"AS PLAIN AS THE NOSE ON YOUR FACE"       

That expression certainly suggests that its author recognized what all of us probably appreciate, the importance of the nose to our facial identity, particularly given its central location. To a great extent the nose defines the face and - in the eyes of some people - the person, given the tendency of those people to associate certain nasal shapes with certain racial and ethnic backgrounds. Rhinoplasty, or nose reshaping, continues to be one of the more popular cosmetic surgical procedures which I undertake. And probably the most challenging as well, owing to the complexity and intricacy of the nasal framework and the sometimes unpredictable behavior of the skin and other "soft tissues" which must conform to an altered nasal framework if the results of Rhinoplasty are to be apparent.


An understanding of the anatomy of the nasal framework, described easily in thirds, is essential to an understanding of what Rhinoplasty can/cannot achieve. The upper third consists of the paired nasal bones which are fused to each other, the frontal bone above and the malar (cheek) bones to either side. The middle third consists of the paired upper lateral cartilages which straddle the nasal septal cartilage or the "wall" which divides the nose into right and left halves. The lower third consists of the lower lateral cartilages which, like collar stays in a shirt collar, determine the "spread" and "stiffness" of the nasal tip.


Many of my Rhinoplasty patients are focused upon only one aspect of their noses, for example, a nasal hump or bulbous nasal tip or nasal asymmetry (keep in mind that no one's nose is perfectly symmetrical), and think that a little snip here and a little snip there will solve their problems. What few of them realize is that, because of the interrelationship of the components of the nasal framework to each other, a change in just one aspect of the nose will alter, perhaps detrimentally, the overall appearance of that nose. Removal of a nasal hump by shaving upper lateral and nasal septal cartilages may produce a more pleasing profile but also will produce a nose which appears flat and wide, necessitating fracture of the nasal bones to narrow the nose. Reduction of a bulbous nasal tip, by reduction and repositioning of the lower lateral cartilages, may produce a very elegant nasal tip but one which looks too small for the remainder of the nose, necessitating further nasal reduction to insure a pleasingly proportioned nose which fits the face upon which it sits. The key to successful Rhinoplasty surgery is careful attention to proportions. Think about the noses you like and you'll realize that, whether big or small, long or short, wide or narrow, they all share a common denominator: pleasing proportions.


While Rhinoplasty surgery is very challenging, the surgery can be undertaken on an outpatient basis under a variety of anesthetics (I normally employ general anesthesia to insure total patient comfort and cooperation) and usually is followed by minimal pain. Most of my patients experience nothing more than a dull headache, much like a sinus headache, for a few days. I normally remove any splinting and packing employed at surgery three or four days afterwards and permit my patients to return to non-strenuous physical activities at that time. Discoloration of all four eyelids, particularly the lower eyelids, and nasal swelling normally follows surgery, especially if surgery involves fracture of the nasal bones, but usually disappears within 10 to 14 days. Consequently, most patients are very "presentable" shortly after surgery. The final result of surgery is apparent only after the skin and underlying "soft tissues" which drape the nasal framework contract to the new shape of that framework. Complete contraction, particularly in individuals with thick nasal skin, may not be apparent for as long as 12 to 24 months following surgery owing to persistent swelling, usually in the nasal tip. Given, as I explained earlier, the unpredictability of nasal skin contraction and the potential for distortion of the final result by under-contraction in some areas and over-contraction in other areas, as many as 1 in 10 Rhinoplasty patients may require, anywhere from 6 to 24 months following surgery, a minor surgical procedure to refine the results of surgery.


When is Rhinoplasty surgery "covered" by health insurers? When either (1) the undesired appearance of the nose is a result of injury to the nose or (2) the nasal framework contributes to an impairment of normal nasal function. While nasal function is limited primarily to filtering and humidifying the air we inhale, it is a very important function. Disturbance of that function can be particularly unpleasant and disabling. A deviated nasal septum (whether the result of abnormal growth and development or injury) which intrudes into one nasal air passage compromises airflow through that nasal air passage which results in more airflow through the other, unobstructed nasal air passage, leading in turn to drying, cracking and even bleeding of the mucous membrane lining that unobstructed air passage. Obviously, if "cosmetic" improvement of a patient's nose is undertaken in conjunction with "functional" improvement of that nose, then the cost to that patient of that "cosmetic" improvement is reduced considerably by virtue of the "participation" in the overall cost of surgery by his/her health insurer.


For more information about this and other cosmetic and non-cosmetic procedures, please call The Pittsburgh Institute of Plastic Surgery at 1-800-321-7477 or The Plastic Surgery Information Service at 1-800-635-0635.





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Dr. Richard T. Vagley, a Board Certified Plastic Surgeon, is Medical Director of The Pittsburgh Institute of Plastic Surgery and a Contributing Editor of Outpatient Surgery Magazine.

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