I decided to come to Louisville for plastic surgery training, largely to learn the art of closed rhinoplasty from one of the masters. I decided to stay because both rhinoplasty and Louisville are very special to me. Rhinoplasty is often considered to be one of the most difficult procedures in Aesthetic Plastic Surgery. Though the reasons as to why are numerous, arguably the most important is an issue of patience, or lack there of. Patience is necessary for not only the physician but the patient as well. One must understand that the changes made in the operating room do not fully manifest for many months.
Many surgeons are uncomfortable with rhinoplasty, as it is difficult to learn and perform. The nose changes over a lifetime. Inevitably, the changes immediately after a procedure are dynamic. Therefore, the changes made in the operating room may not reach the desired outcome for an extended period of time. Experience and judgment are key to an optimal aesthetic result.
There are countless maneuvers to be considered when performing a rhinoplasty. The first being how the nose is approached. Access to the nose may be achieved in an “open” or “closed” fashion. The “open” approach is what the majority of plastic surgeons choose. It is easy to learn and teach, and is often intuitive. You will see results, but due to the invasiveness of the procedure, the patient is left with a scar at the base of the nose. There, an incision must be made in order to “lift” the skin off of the nose, which often takes hours to accomplish. Also, the final result is delayed due to prolonged swelling.
Now don’t get me wrong, open rhinoplasty is not all bad. I still use the technique in certain circumstances, for instance if a large amount of tip work is required. In the majority of cases however, rhinoplasty can be performed more efficiently and directly. By utilizing the “closed” approach, a final result can be established with a faster rate of recovery and a seamless end product. This view is not universal. Many plastic surgeons are only comfortable with “open” rhinoplasty, and would disagree. I am passionate about noses, so I will stand up for what I believe…
“Closed” rhinoplasty is a technique that does not involve external incision, and does not deglove the nose from its underlying framework. Unlike “open” rhinoplasty, it is difficult to learn, perform, and teach. For surgeons who are facile with the approach, and for the proper candidate, the “closed” method can offer less swelling, bruising, and down-time. All without the external scar required with the “open” approach. It leaves all of the scars within the nose and does not require the use of nasal packing. However, it is not for all noses and in some cases the “open” method is best for the patient.
Any discussion of the nose must also include a discussion of the chin. The chin and the nose are intimately connected. A small or under-projecting chin will make the nose appear too large and out of proportion. Addressing only the nose will lead to a poor overall aesthetic result. Oftentimes, chin augmentation is an integral part of reshaping the nose. Rhinoplasty may also be combined with other procedures to improve nasal breathing. These may include opening the airway or straightening of the septum.
Admittedly, there are ways to make rhinoplasty easier, but they come at the price of longer procedures and external scars. Unfortunately, the nose does not take well to scarring or long procedures, hence the importance of efficiency and respect for the nose. This is why patience is important for this procedure. It takes patience to perform the operation correctly, and also to heal. With the nose constantly changing, I do not employ digital or 3-D imaging. It is physically impossible to translate a morphed computer image to a living nose. For this reason, I rarely employ before-and-after images for rhinoplasty. No two noses are the same. They differ in size, shape, bony and cartilage framework, skin thickness and quality, internal nasal anatomy, and relation to the chin. Of all the aesthetic procedures, rhinoplasty is often the most individualized. Therefore, computer imaging in before-and-after photos are not particularly helpful. My approach is to customize the procedure for the individual nose and treat patients as I would someone in my own family.