It is rare that any individual’s nose can be categorized into a neat “cookie cutter” type of operation that is done similarly on all patients. There are many factors that dictate what would render an optimal nose for each patient. Despite this, it is convenient for the purposes of discussion to “name” these operations as if they were separate entities. It is important to note that there is probably a surgical technique to handle any issue (no matter how large or small) that someone might complain about.
Historically the most common method for performing rhinoplasty was to reduce it’s overall size (reduction rhinoplaty). While this is still often the case, today more emphasis is placed on achieving a well-balanced nose that fits harmoniously with the other features of the face, ethnicity, and size of the individual. The most common complaint in people who wish to undergo nasal reshaping is that their nose is too ‘big’. More accurately, the size of their nose is disproportionately too large for their face. Specifically, one or more of the following may be too large: nasal length, nasal width or nasal projection (how far the nose sticks out from the face). In addition many people with big noses tend to have a ‘hump deformity’ of the nasal bridge. State of the art reduction rhinoplasty aims to reshape the nose rather than simply remove underlying structure so that it does not change drastically over time and become pinched or non functional. During reduction rhinoplasty it is important to pay attention to other unattractive features that need to be improved such as asymmetry, nostril shape and tip definition.
The ideal nose has subtle features which make it attractive. Even if the length, width and projection are acceptable, other elements will influence nasal aesthetics. Important considerations include tip definition, contour irregularities, asymmetry and the brow-tip nasal aesthetic line. A well defined tip is adequately narrow with properly positioned tip-defining points and has appropriately shaped and sized lobules with smooth contours. A poorly defined tip is either too wide, boxy or bulbous. A poorly defined tip is usually the result of thick skin or weak underlying cartilages. In such cases it’s best to create a more robust framework that can “push out” against the skin to provide greater definition.
Revision rhinoplasty refers to nasal reshaping surgery performed in an individual who has undergone one or more previous rhinoplasty procedures. Revision rhinoplasty can range from a simple procedure to remove some residual excess bone or cartilage in the nasal bridge to a very complicated complete overhaul of the nose. Revision rhinoplasty in an individual who has had the misfortune of having too much tissue removed and has severe residual deformity is generally considered the most difficult type of rhinoplasty. Such surgeries are usually long and complicated affairs that require the use of tissue grafts harvested from the ear, rib or temple region to restore the necessary cartilage, bone and fascia that may be necessary. In addition the skin and soft tissue envelope is often a significant limitation on the outcome due to scarring, resistance to expansion and surface irregularities. In major revision rhinoplasty cases, one needs to be realistic about the result that can ultimately be achieved.
Following surgery to remove cancer or occasionally following facial trauma, the nose may be left severely disfigured due to the lack of tissue that has been removed or lost. Reconstructive rhinoplasty refers to surgery required to restore tissue that is absent or has been damaged beyond repair. Tissue replacement is usually thought of in terms of replacing the three layers of the nose: 1) the outer skin-soft tissue envelope including skin, subcutaneous tissue and fascia, 2) the middle foundation layer or bone-cartilage framework and 3) the inner mucosal lining. Surgical repair requires the use of grafts and flaps from various parts of the body to restore the missing component tissues. The overall reconstructive process typically requires multiple staged surgical procedures. Again, both the surgeon and patient need to understand the limitations in the final outcome that such deformities are associated with.
Each ethnic background has characteristic nasal features. People from the Middle East typically have longer noses with less distance between the base of the nose and the upper lip. People of Asian or African descent tend to show a wider nose with less projection than Caucasian noses. Hispanic individuals fall somewhere in between. Ethnic rhinoplasty involves modifying the non-Caucasian nose to improve the overall appearance while retaining the features unique to each ethnic background. Years ago people often desired a nose that looked more “caucasian” so that they could assimilate. That behavior has changed and in more recent times people tend to want to retain their ethnic look. The surgeon and prospective patient need to carefully consider the impacts that specific changes in the nose will have on the overall facial appearance and how they will affect the ‘ethnicity’ of the final look.
The human body continues to grow until adolescence is complete, usually 15-16 years in girls and 17-18 years in boys. If nasal surgery is undertaken at a point in time when substantial growth has yet to occur, then the remaining growth may adversely affect the outcome or worse yet, the surgery may stunt remaining growth. For these reasons, it is recommended that nasal surgery be postponed until after growth is completed. However in many young teens an unattractive nose can be the source of significant anxiety and self-consciousness. This is a time when their social networking is of paramount importance and they wish to look their best.
A closer look at facial growth relative to overall body growth shows that it proceeds at a more rapid rate than other areas. Specifically, growth in the midface region where the nose is located is usually 95% completed by age 12 in girls and age 14 in boys. IT IS THEREFORE POSSIBLE TO SAFELY PERFORM RHINOPLASTY IN GIRLS BY THE AGE OF 13-14 AND IN BOYS by 15-16 YEARS. Several controlled studies have demonstrated the safety and predictability of rhinoplasty in adolescent individuals. One safeguard is to wait until at least two years following a girl’s first menstrual period before performing surgery. Perhaps a more important factor to consider is that adoescents may not truly know what they want for an outcome. At such a young and impressionable age they might ask for a result that they later find to be unsuitable. For this reason adolescents should be compelled to sit with their desire for some time before embarking on surgery.
The aging process results in typical changes in the nose similar to other areas of the face. These include a drooping tip, a more bulbous and less defined nasal tip and a more prominent hump over the bridge of the nose. The goal of aging rhinoplasty is to reverse these time-related changes. Aging rhinoplasty can be combined with aging face surgery of the eyelids and face as well such as blepharoplasty and face lifting.