Rhinoplasty 2011 and Beyond: Aesthetic and functional surgery of the nose--The HYBRID rhinoplasty

Sam Most, MD
Article by
Bay Area Facial Plastic Surgeon

The nose is the central feature of the face.   Along with the eyes, it is one of the first things our gaze is drawn towards when we look at another person.  While we may not realize it, the shape of the nose plays an important role in the unconscious process that allows us to recognize other’s faces, especially in profile.  So it is perhaps not surprising that surgery to change the shape of the nose is one of the oldest procedures in facial plastic surgery, with the first documented attempts dating back a few centuries.
But our noses look the way they do for a reason. Not only are they an essential component of the movement of air during respiration, they also filter particles, provide the sense of smell, help in vocal communication, and regulate humidification of the air we breathe.   Our appreciation of the importance of the structure of the nose in maintaining these functions did not develop until the last century. 
The nose can be thought of as a tent:  the skin and soft tissue of the nose are the canvas that covers the tent, and the bone and cartilage that supports this can be thought of as the poles that keep a tent standing upright.  During a rhinoplasty, most of the changes we make are to the ‘poles’ or bony-cartilaginous skeleton of the tent.  The skin then must redrape over this, to give us the effect we are looking for.  If too much of the structure is removed, the tent may collapse and cause aesthetic deformities and perhaps breathing obstruction issues.  Thinking in this way, it is easy to understand that functional issues must be considered in rhinoplasty surgery.
“Doctor, please remove the bump on my nose”
One of the most common requests in aesthetic surgery of the nose is to ‘remove the bump’ on top of the nose.  In this situation, it is first important to determine if the ‘bump’ is due to too much bone and cartilage on the nasal bridge, or if the ‘bump’ is actually due to a deficiency of cartilage at the root of the nose, between the eyes.  The latter situation is more rare but does occur.  In the more common scenario, there truly is an excess of bone and cartilage on the top of the nose.  What do we do in this situation?  Removal of the bone and cartilage can be achieved with a rhinoplasty procedure.  While this may seem straightforward, few things in rhinoplasty are.  For example, when we remove a dorsal hump (as it is called by rhinoplasty surgeons), it is important to analyze what this does to the overall balance of the nose.  Does it make the nose appear longer?  Does the tip now seem too low, or too large?  Do the bones need to be moved inward (toward the middle of the face) to prevent a ‘flat top’ to the nose (what we call an ‘open roof’)?  All of these questions require experience and a keen eye to answer, which is what makes rhinoplasty one of the most challenging procedures in facial plastic surgery.
“My tip is too large and round”
Perhaps the second most common request in rhinoplasty is to refine the nasal tip.  Often the issue is that the underlying cartilage is too rounded, too large, or too weak to provide adequate structure to the overlying skin.  Remember the tent concept I spoke of earlier?  In this case, we really to strive to alter the underlying cartilage to provide a desired shape the the ‘tent fabric’ or skin as it redrapes over this cartilage and heals.  As you might imagine, the texture and thickness of the skin will make a big difference in the result we can achieve.  Why not simply thin the skin? The skin is a living organ, and over-aggressive thinning can have catastrophic effects. While a minimal amount of thinning of the soft tissue envelope can be done (the tent fabric consists of skin, fat, and muscle), the skin itself should approached with caution.  So to a certain extent we are limited in what we can do.  The good news, however, is that a natural, long-lasting and aesthetically pleasing result can be achieved in most cases. The issue is one of expectation.  Often, if one has thick nasal skin, this matches the rest of the face.  To have a tiny, thin-skinned nose is not only unlikely but would probably look strange.  Again, the idea of facial harmony comes in to play.
“What about computer imaging?”
Digital imaging has revolutionized my approach to rhinoplasty surgery.  I initially approached this tool with some trepidation.   The reason for this is simple:  computer simulation is NOT a guarantee of surgical result.  Using a computer imaging program, we can make a nose look any way we want.  The computer does not take into account skin thickness, bony structure, tissue elasticity, healing properties, or any of a number of other factors that play an important role in determining results.  For this reason, many surgeons refuse to use this tool. 
However, I feel that imaging is an important communication tool for my patients and me.  And communication, for me, is the most important part of the doctor-patient relationship that I’d like to foster.  Ultimately this leads to better outcomes.  Looking at images, my patients and I are able to more effectively communicate to each other what our expectations are. For me this means trying to show what I think is possible.  For my patients, it allows them to visualize what they changes to their nose may look like.  Again, these are never guarantees of results but a communication tool.  As such, it does help us determine is rhinoplasty surgery is the right option for my patients.  In some cases, it is and in some cases it isn’t.  I think it is better to find out without surgery that a rhinoplasty is not a good option.

“I have a deviated septum”
The septum is a piece of bone and cartilage that sits in the midline of the nose.  It extends backwards towards the middle of the head several centimeters.  In very few patients is the septum perfectly straight.  So, a deviation of the septum is very common, and is not an indication for surgical correction.  Only in situations where a septal deviation exists coincident with nasal obstruction is surgery a possibility.  In these cases, it is important to first treat medically before trying a surgical procedure.  Specifically, prescription nasal sprays or over-the-counter anti-histamines can sometimes reduce swelling in the nose enough so that the deviation is no longer an issue.
In cases where a deviation of the septum persistently causes nasal obstruction, a septoplasty can be performed.  This procedure is relatively commonly  performed by an otolaryngologist (ENT), and should not change the shape of the nose.  In some cases, patients ask for a rhinoplasty at the same time, and this can be done.
However, evaluation by an experienced rhinoplasty surgeon can determine if then nasal obstruction is caused by more than just the septal deviation.  One of the most common causes of nasal obstruction is internal valve collapse. The degree of collapse is determined by the angle of the valve to the septum and wall.  Surgery to correct this is called a ‘functional rhinoplasty’, and can also be combined with aesthetic surgery of the nose.
“What about injection rhinoplasty?”
The development and wide use of injectable fillers has now entered the realm of rhinoplasty surgery.  Dermatologists and even non-cosmetically trained doctors and nurses are performing this procedure.  The advantage is that you avoid surgery and the associated risks and recovery period.  However, as you might have gathered from the above discussion, analysis of the aesthetics of the nose is quite complex.  In some cases, an injectable filler may work to fix a deficiency of the nose.  What is important to realize, however, is that (1) injectable fillers can only make the nose bigger. In some cases, this is desirable.  In my experience, these situations are rare.   (2) Fillers in the nose are not without complication.  I have unfortunately seen catastrophic complications from fillers (done by other physicians).  I think that it is important that a determination of the appropriateness of filler injection in the nose be done by an experienced rhinoplasty surgeon.
“How is a rhinoplasty performed?”
Rhinoplasty usually takes between 1-1/2 to 2-1/2 hours.  Patients will be able to go home afterwards.  The nose is taped for one week.  Most people will experience post-surgery bruising for about 1 week, and final results can take as long as one year as the soft tissue and skeleton settle and adjust. 

Final comments
Aesthetic rhinoplasty is about both form and function.  Although ideals are taught with regards to nasal form, there are no ‘cookie cutter’ rhinoplasties in my practice.  Each patient gets an individual analysis that takes into account factors such as overall health, gender, ethnicity, anatomy, and nasal function.  While new techniques are constantly emerging, rhinoplasty still involves adjusting the skeleton of the nose so that the skin contour is aesthetically pleasing.  This takes years of experience on the part of the rhinoplasty surgeon.  However, the end result can be very gratifying for both the patient and facial plastic surgeon.