Rhinoplasty: Structure and Surface

One of the biggest challenges of rhinoplasty is the complex three dimensional nature of the nose.  A natural, attractive nose is a soft, rounded, triangular pyramid which should reside in the center of the face.  Symmetry, smoothness, and a rounded triangular shape are the outcomes surgeons generally strive for with surgery.  The problem is that each nose is different, with a multitude of possible imperfections.

Given the  three dimensionality of the nose, it is understandable why some people liken rhinoplasty to sculpting.  But the thought process and mechanics of the surgery are quite different from working with clay, marble or wood.  The key issue is that the medium of the nose is bone, cartilage and flesh and these components together create a delicate infra-structure.  One cannot simply “carve” or “whittle down” the nasal anatomy into a more favorable shape because this weakens the nasal framework and makes it unstable.  After surgery, forces of scar contracture and healing cause a “shrink wrap” effect on the skin covering the nose.  If the structure is weak, this contraction will lead to collapse of the nose.  I see this all too often in patients who come to me for revision rhinoplasty.  Unfortunately, many patients have undergone a predominantly reductive surgery which leads to the typical revision deformities: the pinched tip, upturned nose, ski slope bridges, and over-exposed nostrils.

I believe rhinoplasty is like the construction of a house.  A structural foundation must be secured prior to executing the surface finishes.  For this reason, I rely on cartilage grafts to reinforce all changes I make to each nose.  The septal foundation is often altered to smooth a bridge or change the position of the tip, but these alterations are reinforced with cartilage grafts to ensure strength and stability.  I approach tip work similarly – instead relying only on reductive measures such as removing, dividing or narrowing tip cartilages,  I prefer to control shape by reinforcing what is already there through cartilage struts.  Shape changes are created though addition of cartilage rather than removal.  These changes can result in the nose looking smaller and more refined by causing bulges or prominences to flatten – but this is accomplished by adding support rather than taking it away.

Only after the underlying structure of the nose is favorable and stable will I then put the fine tuning, finishing touches on that structure to ensure the surface contour and appearance through the skin is ideal.  I find I go back and forth from a left-brain, engineering, structural mentality and a right brain, artistic, surface mind-set.  Only in this way can I be sure I create a nose that looks good but is also strong a stable.