A 21st CENTURY APPROACH TO RHINOPLASTY: A Marriage of Form and Function
By Sam Rizk, M.D., F.A.C.S.
According to the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS.org), in 2012, rhinoplasty was the most popular procedure performed on both men and women under the age of 35. Yet rhinoplasty is also among the most complex procedures to perform well because the surgeon must take into account not only aesthetics, but functional breathing considerations as well.
The nose is the most prominent feature on the human face: even a small change will affect a person’s whole appearance in a big way. A beautiful nose is a natural one that complements and fits harmoniously with the other facial features. There is no universally ideal nose—only an ideal nose for one particular face. The consensus of opinion on the qualities of a beautiful nose has changed considerably over time. In nasal surgery, it is critical to achieve a natural result. Patients today do not want upturned noses, pointy tips, scooped-out bridges, or pinched nostrils that were commonplace in the 1980s. The modern concept in rhinoplasty is to preserve the overall characteristics of the original nose, and make small alterations to straighten or refine the shape and projection as the patient desires.
Every nose is unique since every face is different. Therefore an individualized approach is required to address each patient’s unique goals. My main mission with nasal surgery is to create a natural looking nose that will stand the test of time, based on the structure of the cartilage and the overlying skin. A natural nose should be in harmony with the other features of the face, including the upper lip, chin, and cheeks. An important factor in achieving a natural result in rhinoplasty is to maintain good structural support.
I routinely combine treating the internal structures of the nose with cosmetic improvements. A deviated nasal septum, if significant (greater than 50 percent), can result in difficult breathing and may be treated with a septoplasty surgery. This can be done as an isolated procedure or combined with sinus surgery or cosmetic rhinoplasty surgery. Being able to restore a patient’s ability to breathe, in addition to improving the appearance of the nose by rebuilding previously removed cartilage or bone, provides an additional benefit to the patient. Functional repair can be combined with an aesthetic approach simultaneously, without compromising either, which is what most patients desire.
A delicate framework of bone and cartilage supports the internal structure of the nose. Even a small miscalculation can lead to an unsatisfactory result. The determining factor in assessing whether a patient’s nose has good support is the inherent strength of the underlying cartilages. If the tip has good support, it can be refined by simply removing some excess cartilage. Another important aspect of the nasal anatomy is skin thickness. Thicker skin can often present a greater challenge for the surgeon to achieve definition and to sculpt a newly refined shape. Having a bulbous tip is common with thicker-skinned patients, and it also can appear larger and droopy with advanced age.
During the consultation, it is vital for patients to view photographs of other patients whose noses the surgeon has operated on to determine whether they are in sync with the surgeon’s vision of an attractive nose. In my practice, we offer patients the opportunity to view photographs, and upon request, to speak to other patients who have undergone a rhinoplasty procedure. Patients find this helpful to know what to expect before, during, and after the operation.
After a comprehensive nasal examination, I will evaluate the strength of the cartilage, thickness of the skin, and see if the septum is deviated. In some cases, only one part of the nose may be too prominent. If an unsightly bump is the patient’s main concern, we can sometimes file it down or shave it to create a smoother bridge. If the nasal bones are too wide, the nose can be slimmed down and refined. A crooked nose is a very difficult problem to correct. Although a nose can be made to look straighter, it is not always possible to create a perfectly straight nose.
Bone structure, skin type, age, and ethnic background all play an important role in determining the optimal surgical plan. Cultural differences should be respected in altering the size, shape, and characteristics of an individual’s nose. In many cases, African American, Middle Eastern/Mediterranean, Latino/Hispanic, and Asian patients may tend to have thicker skin that requires specialized techniques to re-sculpt the nasal tip. Rather than the cartilage-excising techniques used on individuals with thin skin, these patients often require more skill and expertise. It is not uncommon to see cases where the nasal tip is quite bulbous or there is a lack of support. Having thicker skin with very little cartilage support, or where the cartilage is weak, creates a more complex operation. These types of rhinoplasties often require cartilage grafts from the patient’s own septum or from behind the ears, and de-fatting the thick skin to achieve good definition.
My overriding goal is to create a natural looking and aesthetically pleasing facial improvement that is tailored to the specific patient’s needs. There is no ideal nose anymore; each procedure is customized to create a nose that is in harmony with the patient’s face. The perception and creation of beauty in a nose is an artistic, innate quality that can be observed by looking at a surgeon's results. Training and experience provide the necessary tools to achieve this goal, but that is just the foundation. There was a time when surgeons had a “signature” procedure or look that was very identifiable. For today’s consumers, that concept is wholly unacceptable. In fact, it runs counter to what they are really looking for. Each surgery I perform is customized to be in harmony with the individual patient's face to complement his or her other features.
A natural looking nose with tiny hidden incisions is certainly possible with modern techniques. Given the choice, patients will usually opt for a closed approach to avoid the resultant visible external columella scar, however that may not always be in their best interest. Among the advantages commonly cited for endonasal surgery are shorter surgical times, reduced postoperative edema, decreased potential for compromised tip support, and shortened recovery time. For decades, many rhinoplasty surgeons have favored the closed approach for these and other reasons, but that philosophy can severely limit results, particularly with ethnic rhinoplasty where direct visualization can be essential.
I employ both the open (external) and closed (endonasal) surgical techniques to reshape the nose. Typically, the closed approach is more often used when the surgical objective is to reduce a bump or straighten the bridge. An open rhinoplasty may be more appropriate when the skin is very thick, or if there is significant asymmetry in the nasal tip, or when implants may be required. Since there are specific advantages to both, I have adopted a graduated approach to endonasal tip surgery versus open nasal tip surgery. The endonasal approach can progress from less invasive to more invasive. Less invasive endonasal approaches can be classified into either non-delivery approaches to the lower lateral cartilages, or delivery approaches to the lower lateral cartilages. Of course, the more aggressive open approach is a last resort but may be indicated in situations where major tip support and definition is needed. This is especially the case with revision rhinoplasty patients where the anatomy may not permit an endonasal approach. With this method, I can address all issues involving the bridge, including refining a bump, with a closed technique, and then address tip correction through a partial open incision, if needed.
With rhinoplasties, where a few millimeters can make a big difference in the result, I have incorporated a 3D high-definition approach, which increases precision and results with minimal trauma. Instead of rasping over soft tissue, muscle, and blood vessels and getting bruising, I am specifically reducing cartilage and bone under direct visualization with a high-definition 3D telescope system.
The use of this system basically provides a precise view of the interior nasal area by inserting a telescope that is connected to an imaging system. With this enhanced view, I can avoid disrupting blood vessels, muscles, and other sensitive tissues so there is less bruising and swelling, which promotes a quicker recovery. But the advantages go far beyond rapid recovery. Because of increased visibility, the surgery is more direct and allows for greater precision, as tissue is not distorted by swelling during the procedure. In addition, I have moved away from using nasal packing in favor of using only tissue glue to insure a faster and more comfortable recovery. This is a clear benefit to patients as well.
While older rhinoplasty techniques may have yielded nicely shaped noses early on, these results often changed over time as cartilage grafts became resorbed and shifted and airways collapsed. I now routinely employ the use of suture reshaping techniques for cartilage sculpting. By employing a micropowered diamond machine to soften and refine the edges of all of my cartilage grafts, I can achieve a more finessed result. I see a large number of revision rhinoplasties, so I am always searching for ways to get a smoother outcome with cartilage grafts. Having had experience using diamond burr high-powered units to smooth out the bone during reconstructive ear surgery, I decided to apply this technique with cartilage grafts to create a rounded edge. This has worked extremely well and I have been able to achieve the round edges for cartilage grafts consistently.
One of my recent innovations is to avoid closing all incisions inside the nose completely, which allows blood and fluid to come out through gaps so it does not collect under the skin of the nose. These incisions close on their own during the first five days after surgery. I tend to perform rhinoplasty by sculpting deeper under the muscle layers of the nose, which is a clean plane of operating with fewer blood vessels. I have found that this method results in a more natural look because the muscle layer on top of the cartilage and bone acts to soften the shape of the nose, eliminating any potentially harsh edges. Finally, I use a combination of fibrin sealants and herbal supplements to achieve a speedy recovery so patients can look presentable within a week after the procedure and experience minimal discomfort, swelling, and bruising.
In performing revision rhinoplasty, it is not only about getting a good cosmetic result—there is an important functional component to consider as well. Many patients coming in for cosmetic rhinoplasty operations also have significant breathing deformities. Their noses may have been collapsed after previous surgeries. In revision rhinoplasty, it is even more likely that both the functional and the cosmetic issues need to be addressed. The surgeon must keep an open mind and change the techniques and instruments used to adapt to each new situation encountered and to achieve a more superior result.
Patients who have had a previous nasal operation, and are unhappy with the outcome, require more time and attention during the consultation. In most cases, a poor result can be improved with a secondary procedure. It has become exceedingly common to perform secondary and tertiary nasal operations, especially if there was a miscommunication or the original surgeon was not very experienced in rhinoplasty techniques. Secondary rhinoplasty is almost always more difficult than a primary operation and requires a more detailed surgical plan to address all the components of the nose. The most common problem is overly aggressive surgery, where too much cartilage or bone was removed, which necessitates grafting of cartilage, rib, or other materials.
A natural angle between nose and forehead and nose and upper lip as well as a natural transition between profile and tip are important features of a natural nose. A soft tip, which is not overly pointy, and a bridge that is not overly narrow, also contribute to the appearance of the nose. Achieving an appropriate length of the nose to fit the face and that does not expose a great distance between the tips of the nose and upper lip is also critical. Natural looking nostrils should not appear to be pinched or collapsed. A natural nose also must fit harmoniously with the rest of the face, and in particular, the chin angle and projection. Additionally, although there are certain standards for the size of the nose in relation to the face and eyes, rhinoplasty presents a combination of science with artistry. In the end, to achieve optimal results means selecting the right technique for the right patient.
Sam Rizk, M.D., F.A.C.S. is a double board certified facial plastic surgeon in New York City, and Director of Manhattan Facial Plastic Surgery, PLLC. www.drsamrizk.com