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

Roughly speaking, harmony exists in the face if it can be divided into equal thirds from the hairline to the top of the brows, from the brows to the bottom of the nose, from the nose to the bottom of the chin. Within each of these thirds, there are other, measurable equations to determine if facial features like the eyes, nostrils and lips are evenly distributed. Overall, a harmonious blend of features should produce a balanced, pleasing profile.

The nose is one of the most important parts of a good profile. Most of the people who approach a cosmetic surgeon for rhinoplastic work have come to the conclusion that their nose does not harmonize with the rest of their face: it is upsetting the balance of features. Perhaps the nose is too big, or too small or misshapen in some way. Only some of them have taken into account how the nose is affecting their profile. I suppose this is partly because most people don’t bother with a three-way mirror in the bedroom or the bathroom. All they are concerned with is the view that others have of them face-to-face. Some are shocked when they initially see their face in profile, or in a profile photograph. But the first thing that a cosmetic surgeon will do is analyze the profile. A profile reveals how balance will ultimately be achieved.

On profile, the nose, chin, lips and forehead are the key features. If the chin is “weak”, or what we call “retrodisplaced” (meaning, backward from its usual place), a well-proportioned nose, even after cosmetic surgery, will not solve the problem of facial disharmony. It could be that further work is needed by an orthodontist or an oral surgeon to correct the problems of bite alignment. Or a cosmetic surgeon might be able to balance the chin by bringing it forward visually. This can be done, simply enough with a bit of “mentoplasty.”

“Mentoplasty” (from mentum, the Latin word for chin), usually involves an implant underneath the soft tissues of the chin, next to the bone. The pocket it sits in within the soft tissues holds it in place. This implant is made from medical-grade solid plastic called Sialastic and it looks like something you might find in a fisherman’s lure box, a flexible, sinewy strip of plastic that is wider in the middle and tapered to either end, like the shape of the rind on a wedge of lemon. It is slightly hollowed on the inside so that it cups the chinbone perfectly. A cosmetic surgeon has a variety of implants to choose from, depending on the existing shape of a patient’s chin.

Chin augmentation adds only about half an hour to a rhinoplasty operation, and it can make all the difference in the world. Likewise, a too-large chin can be corrected by removing excessive bone. Or the profile might be improved by liposuction; vacuuming out excess fat to eliminate a double chin. At least one-quarter of the patients who arrive at a cosmetic surgeon’s office looking for a rhinoplasty would benefit greatly from another, secondary form of profile work as well.

The frustrating thing is that often patients cannot be convinced of the value of a chin implant or other technique. They remain totally focused on their nose and don’t understand that part of the problem stems from the chin, or one of the other profile features. As a result, a rhinoplasty can be disappointing; the surgeon knows full well that the job could be better done. It’s especially upsetting if the new, perfectly balanced nose ends up making the secondary problem even more apparent.

With regard to the nose itself, there are many interesting variations on what a cosmetic surgeon might be asked to correct. I’ve had families bring in their children because the combination of features between a husband and wife has produced genetic restructuring that is aesthetically unpleasing. For example, the husband might have a magnificent nose that suits his large face perfectly, and the wife might have a delicate little chin that suits her face. Together, they have produced a child with a big nose and a tiny chin: a rhinoplastic challenge.

Another common scenario is when parents bring in a young child who has suffered a nasal injury. The accident might have been a long time ago: I’ve seen a child up to three years after any injury, when his nose appeared to be growing in an odd shape, ever though the accident itself hadn’t resulted in any fractures. The cartilage of the nose was injured at the time of the accident, so it stopped growing. The bone, however, continued to grow. When the doctor who saw the child after the accident took X-rays, only the bone was revealed and it showed no damage. (Cartilage doesn’t show up on an X-ray.) Often, the family is amazed when I point out the cartilage, which may have bowed out into an airway. This same problem often causes breathing problems in young children.

Careful palpation - feeling with the fingers - of the framework of the nose and its envelope of skin is an important part of the preparatory work before a rhinoplasty operation. Fingers are a cosmetic surgeon’s antennae. They relay vital information about the upper and lower cartilage’s, the septum (a membrane inside the nose that separates the nostrils), the nasal bones, the premaxilla bones that connect to the upper jaw, and the skin inside and overlying the nose. Palpation would reveal a great deal about the extent of the problem with cartilage in a child’s nose, for example.

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