About Face

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About Face

Chapter Eight The Nose The Psychology of Rhinoplasty Patients Expectations Initial Surgery Making the Nose Smaller Saddle Nose Columella Deformity Revisional Treatment Recovery

Expectation

I’m sure by now you must be wondering why on earth a cosmetic surgeon is at all willing to perform the Rhinoplasty procedure. Well, for one thing, the level of dissatisfaction following a Rhinoplasty can range from the sensational stories I’ve related above to a transient depression lasting a couple of days after the operation (mostly due to the patient’s reaction to an unwholesome, bruised appearance during the early stages of healing). So not everyone is out for revenge with a shotgun, and modern preoperative counseling has been enormously helpful in weeding out the truly disturbed candidate.

Something else to consider is the fact that a huge number of rhinoplasties are performed every year. Consequently, even a small percentage of dissatisfied patients translates into a seemingly high number. Rhinoplasty is the most popular facial plastic surgery procedure, followed by eye surgery. In Ontario alone, where I practice, I would estimate that over 15,000 rhinoplasties have been performed within the past five years. (Roughly double the amount covered by the provincial health care plan.) Of these, perhaps 2,000 patients are dissatisfied with their results, to one degree or another.

The truth about rhinoplasties, however, is that they are practically irresistible for the surgeon, no matter the risks. They incorporate all of the things that a cosmetic surgeon loves most: aesthetic judgment, technical complexity and challenge. Without quest, a Rhinoplasty is the most difficult of all cosmetic operations to perform. There are at least fifty-five different maneuvers that can be applied to the nose, and the combination of ways to use them is as unlimited as the variety of work to be done. The nose is the true Rubik’s Cube of cosmetic surgery; it can be rearranged from side to side, up and down, and back and forth.

To give you an idea of just how fascinating Rhinoplasty is, I’ll tell you a tale straight out of the 1960’s when things were different and almost every medical resident at the University of Toronto was a guy. For four years, we met across the street for a beer or two after grueling days of training and practice. Each year, there were special courses devoted to training in Rhinoplasty and whenever those courses were conducted, we’d come out of the pub and realize that all we could remember about the gorgeous woman at the bar was what her nose looked like. This might not mean a lot to female medical residents, but for us, in those days, our fixation was a revelation.

The technical complexity of Rhinoplasty is something that can be mastered with continual training and time and assessment of the results, but aesthetic judgment is another matter. Patients sometimes ask if there is a kind of “universal” nose, a nose for all time that will forever be fashionable. I suspect they might be thinking about the turned-up “French” nose that was popular in Hollywood when cosmetic surgery began to gain acceptance in the late 1960s and early 1970s. It may have been a fashionable nose in Hollywood, but I would quickly have gone out of business if I’d tried to impose it on my clientele, then largely Italian-Canadians and other people of Mediterranean extraction. This is the first lesson of aesthetic judgment: make the nose fit the genetic background. Don’t give a cute button nose to an Italian male, unless you’re looking for trouble.

Height is another basic aesthetic consideration when it comes to Rhinoplasty. I’ve had patients who are six feet tall come into my office, looking for a shortened nose. A shorter nose is generally more upturned, and my first question is: “Would it bother you if your next date spent the whole evening looking up your nose?” That’s exactly what would happen, of course; the tall patient must be counseled to consider the overall harmony of body shape and facial features.

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