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

Lest you think this identification of the nose with things sexual is farfetched, history shows that the connection has been made for centuries. Ancient Romans believed that the size of the nose accurately indicated the size of the penis, and male adulterers were punished by amputation of the nose. Adulteresses in India were punished the same way for more than a thousand years. medical historians have noted that we are indebted to the “seminal role played by the abundance of noiseless females in India” in the development of the techniques of plastic surgery. And it’s no secret that odors detected by insects and animals can affect sexual behavior. Humans who respond to certain perfumes know the attraction of the odor of musk, which is made from the sexual glands of musk deer.

My files contain a few interesting stories with regard to patients who have had trouble dealing with Rhinoplasty, despite the fact that I take special care to screen such candidates for surgery. If anything, these stories illustrate how subtle the variations can be on potential problems. For example, there was the time that, at the behest of his wife, I operated on a fellow who had a real bugle of a nose. She was convinced that his nose was causing him all sorts of problems with his self-confidence. I interviewed them together, then separately, and came to the conclusion she was right. The operation to reduce the size of his nose was a success, and this devoted woman spent a lot of her time helping her husband through the preoperative and postoperative process. A couple of years ago, I found out that he’d gained such tremendous self-confidence that he’d left his wife and gone off with another woman to start a new life.

Then there was the woman who came to me for Rhinoplasty because she had a rather unattractive wife nose with a bump on the bridge. We did the operation - took the bump off, narrowed the bridge, and narrowed the tip - and away she went, happy, with a much-improved appearance. I should add that this woman was in her early thirties, an intellectual, and that she lived at home with her parents. Almost four years after the operation, she was back in my office: she wanted her nose restored to its original appearance, bump and all. I sent her to a psychiatrist.

In my view, this patient had made a highly unreasonable request but the psychiatrist came to the conclusion that she was in a “gray” area, meaning, not necessarily psychologically upset, and that we could probably safely proceed with the restorative operation. After about ten consultations with her, I finally agreed to do the work. The day of the operation, early in the morning, she was sitting in the patient holding area - dressed in a hospital gown - when she changed her mind. Decided against the operation, just like that. To this day, I don’t really know what happened to cause this patient such anguish, though I suspect that perhaps her parents had been exerting some kind of influence.

Dr. Wright has cited studies that show “type-changing” Rhinoplasty is much less acceptable to older patients than it is to younger patients. At least one cosmetic surgeon has stated that he will no longer perform such surgery on patients older than thirty-five. “Type-changing” Rhinoplasty is elective surgery (surgery entered into by choice) that actually alters the appearance of a patient’s face. Younger people, maybe because they are more open to change in general, are usually happy with the results of a Rhinoplasty that makes a noticeable difference. Older people have a more firmly entrenched idea of who they are, based on what they look like. A change in their appearance sometimes causes a loss of identity. This phenomenon could be what was troubling my patient; perhaps her parents reacted to her altered appearance with altered behavior and she wanted to get her “old self” back.

Two other stories from my files serve to illustrate the complex reactions that Rhinoplasty can incite, especially in male patients. The first involves a patient who was seventeen years old when I operated on him. He had seemed reasonable in consultation and knew exactly what he wanted: the width of his nose narrowed and the “dorsum,” or bridge, built up a bit. One year after the operation, he was on the telephone, very abusive to my secretaries, and upset about the work done. But when he came in to see me, he was remarkably polite and I suggested that perhaps he should see a psychiatrist before undergoing any revisional surgery. Soon enough, he was back on the phone, more abusive than before. The personal threats of death became serious, so we had him arrested, and he ended up in an infirmary for a while. Two years later, he showed up again in my office, for a nice, reasonable chat about possible revisions to his nose. “I don’t think I can help you,” is all I said. Something tells me this isn’t the end of the story; time will tell.

The second story is a classic illustration of the perfectionist, though in this case, he ended up going a little bonkers. This fellow had had several operations on his nose by the time he came to me. He wanted me to open up his nose and remove some of the cumulative scarring inside. I put him through a number of tests, and collected all of the operative notes from the other surgeons. I came to the conclusion that he would need laser treatment to break down the scars and gave him the name of a surgeon who had the proper equipment. Within a week, he had taken a shotgun into his previous surgeon’s office and discharged it into the ceiling. Then he burned his girlfriend’s house to the ground.

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