"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.