by Steven M. Hoefflin, MD
To obtain a satisfactory result in the eyes of both the surgeon and the patient, one needs a broad base of knowledge. My goal is to provide some basics that apply to standard rhinoplasties as well as to the more difficult ethnic nose.
In many ways, a successful rhinoplasty is like a successful work of architecture. Both are constructed with aesthetic balance and function in mind, and both require detailed planning before construction begins. Just as a successful architect will first evaluate the land and its foundation before erecting a building, a good rhinoplasty surgeon will thoroughly evaluate a patient’s general physical makeup, psychology, facial contour, and nasal structure prior to surgery. The rhinoplasty surgeon determines not only what is excessive, deficient or in need of modification, but also what is sound and physically possible. A detailed preoperative evaluation and organized surgical plan are as important to the surgeon as preliminary studies and blueprints are to the architect.
Ethnic noses characteristically provide the challenge of managing thick skin. The bulky, thick nasal covering, particularly at the tip, provides the highest number of complaints, the most formidable surgical challenge, and the greatest difficulty in managing secondaries.
Patients presenting themselves for nasal changes usually have a very specific desire in mind. They usually communicate the goal in general terms, and the evaluating surgeon must then press for specifics. Not infrequently, they simply comment that their nose is “too large”. Specifics of shape, balance, width, and projection of the nose should then be evaluated. Twenty years ago rhinoplastic training of the time discouraged showing pre- or postoperative photographs to patients. I find, however, that in addition to its aid in conversation, the practice is actually extremely helpful in discouraging unrealistic expectations.
I make a practice of showing patients basic slides, including both intra- and extranasal anatomy, diagrammatic techniques, and “before ad after” photographs of average results. At the end of the slide carousel are photos of specifically “good” results, as well as complications for when patients wish to see them. After a thorough discussion of the procedure, anesthesia, recovery period, risks, and, specifically, limitations, I will thoroughly examine the patient. I will sit the patient down in front of a three-view mirror and spend an ample amount of time showing the patient those areas I feel I can improve and those that have certain limitations. This examination provides both the surgeon and the patient with a realistic appraisal of the type of results that can be obtained. I also make diagrammatic notes of this discussion. Just before surgery, the same appraisal is given in front of a mirror.
In my experience, the order of importance for most of my ethnic patients is the following:
- A thinner, more shapely tip
- A narrow nasal base
- Augmentation or reduction of the dorsum
- Reduction of the bony pyramid
When elevating and “tenting” the thickened nasal tip to increase projection and definition, this has been the most reliable graft in my hands. I found that mere “add-on” grafts without “tenting” effect from the base of the columella to the nasal tip usually added bulk, and not projection, to the tip.
Advancement techniques with nasal alar base reduction allow one to excise more alar soft tissue. Previous to the “pea-pod” tip graft, larger nasal base excisions resulted in a triangular spreading and flattening of the nose. When cheek skin is advanced medially, a more acute angle is developed and the normal curvature of the nostril is maintained.
The combination of “pea-pod” tip graft and alar base excision techniques has assisted tremendously in solving the problem of the thickened nasal tip, which normally cannot be removed without significant scarring. It is beneficial to excise the alar base to provide a semblance of nasal thinness.
The desired degree of augmentation in my patients has not been significant unless there is an imbalance between the dorsum and nasal tip. As years have gone by, more patients now desire a very slight convexity, instead of a perfectly straight nose. I mention to my patients that there are no straight lines in the human body and that slight curves, particularly in the facial area, are normal. While I am not in favor of “ski-slop” noses, one must be cautious when creating a large nose with a large tip—even if “balanced”, as such patients are frequently dissatisfied. Erring on the side of a smaller nose with a more concave dorsum typically results in greater patient satisfaction. Taking a convex bridge and narrowing the pyramid a moderate, but not substantial, degree provides more balance. This is particularly true when there is a significant width to the bony pyramid.
When dealing with difficult anatomical challenges, we all learn both from our patients’ preferences and surgical experience. I find it most rewarding to sit in the consultation room and present a mirror to my patients while sitting across from them and to ask them what bothers them about their nose.