I firmly believe that successful rhinoplasty should result in a nose which looks like it belongs on one’s face—a nose which that person could have been born with. This does not mean that every outcome must result in the same shape. In fact, noses of a variety of shapes and sizes can look attractive and natural on a person. But there are two important characteristics which a nose must possess to look “real” and not “created”.
First, the surface contours should be smooth. Unevenness, undulations in surface, or protuberances or depressions are features which draw attention in a negative way. From the profile, these irregularities are easy to spot as the eye can quickly recognize even small interruptions of a smooth, straight surface. From the front, these imperfections create inconsistencies in how light reflect and created highlight and how shadows sit and create outline or definition. One of the most telling signs of poorly performed rhinoplasty is the presence of knobs or small bump and deep, unnatural shadows. A good nose is even, consistent in surface, and soft in feel!
Second, the proportion of the nose should be one of a rounded, triangular shape. This is true from any angle the nose is viewed. Rounded triangle means that the angles of the triangle are not sharp but instead are soft and rounded to maintain smoothness. The bridge should be straight or close to it (women can look good with a slight inward slope and men can look good with a slight outward slope). The position of the tip should align with the bridge so the tip surface is on the same line as the bridge. From the base the nostril contour should be close to straight as it transitions for the tip to the base. This rounded triangularity is the normal form of the nose and what we expect to see. If the shape of the nose deviates from this significantly after surgery, it may look unnatural and artificial. Most commonly, this occurs with aggressive reduction rhinoplasty in which the bridge is lowered too much to scoop the nose, the tip is over-elevated, and the nostrils pinched inward.
In order for a surgeon to create a natural appearing nose, he or she must possess a natural aesthetic sensibility. Some surgeons prefer to create more stylized or “sculpted” noses. I have observed, however, this preference is becoming less popular as time goes on. The critical requirement is that the surgeon must possess the ability to precisely control the changes to the shape of the bone and cartilage of the nose and be able to maintain stability in those changes. My strong belief is that a structurally based approach using reinforcement from cartilage grafts is the best way to ensure this. After all, a natural nose is also strong and stable!