News & Features



Nose Jobs: Art and Science


CosmeticSurgery.com Staff Report
Medically reviewed by Angelo Cuzalina, M.D., D.D.S.,

A nose job (Rhinoplasty) is plastic surgery’s most difficult procedure because the nose is a three-dimensional part of the human body. A nose job first requires a sturdy supporting architecture under its skin. So even a small sliver of removed cartilage can make a huge difference. Consequently, botched nose jobs are often redone by specialist surgeons. And while a pleasing nose job requires an artistic eye, the practitioner must also keep uppermost in mind the nose’s basic purpose– to assist its owner with breathing.

When Brian P., a 29-year-old stock broker, had his first nose job in New York City, he chose a high profile surgeon who routinely appeared on television talk shows.

Unfortunately, the surgeon botched the procedure and left Brian with a nose that caused him breathing problems with the tip of his nose pointing down toward his upper lip. Brian tried to have the nose fixed but a second New York surgeon only eased the breathing problems somewhat while doing nothing at all to improve its appearance.

“You have no idea what it’s like to be literally paralyzed by your appearance,” Brian told PlasticSurgery.com.

Unfortunately, according to Jeffrey Rawnsley M.D., an assistant professor at the University of California, Los Angeles, and director of the U.C.L.A. Facial Aesthetics Center, about ten percent of rhinoplasty patients nationwide require major or minor revision.

1000 Procedures

Moreover, when Paul Nassif, M.D. a facial plastic and reconstructive surgeon in Beverly Hills was going through rhinoplasty fellowship training, his director told him: “Surgeons have not learned anything about rhinoplasty until they have performed at least 1000 procedures and followed their progress for many years.”

The nose can be so challenging for a surgeon because removing even a small amount of cartilage, say, to remove a bump to make a large nose smaller, can cause breathing and aesthetic problems after surgery. Common woes include irregularities in cartilage or bone that can be felt or even seen, loosing cartilage support for the tip of the nose, causing its collapse and narrowing of the internal nasal valve which creates the breathing problems.

“Every time a nose is opened, more scar tissue is formed,” says Dr. Rawnsley. “Revision operations are very difficult and can only be done so many times on one nose before it just becomes impossible.”

Perhaps the best way to make sure a rhinoplasty is done correctly the first time is to take great care selecting a surgeon. Brian, for instance, says he should have seen red warning flags flying over the office of his first surgeon because the physician did not listen to what facial changes he, Brian, wanted, was very cocky, took offense when Brian asked about his training and had in his office only a few before and after pictures of previous, satisfied rhinoplasty patients.

Before and After Photos

“With two bad experiences behind me, I did things differently the third time out,” Brian says. “I interviewed three plastic surgeons and even drew pictures of what I wanted my nose to look like. I looked carefully through the physicians’ before and after photos. I looked for a physician who seemed confident and one who listened.”

Says Brian’s surgeon, Stanley Jacobs, M.D., a board certified surgeon with offices in San Francisco and Santa Rosa, California: “Brian had a lot of scar tissue in his nose from past operations in which too much cartilage was removed. So we took cartilage from one of his ears to rebuild and lift the tip of his nose.”

Adds Dr. Rawnsley, who yearly performs about 200 rhinoplasties, half of which are revisions on previously botched surgeries: “Starting about a century ago, a rhinoplasty consisted of sawing down a hump on a nose and that was about it. But in the last 25 years, plastic surgeons have refined the ways to make noses look less bulky.”

For instance, Dr. Rawnsley is fond of -- and teaches to junior surgeons -- “soft touch,” a procedure that uses not surgery, but permanent stitches in some critical nasal cartilages to create more eye-pleasing changes. The stitches pull some essential cartilage together.

But it often may take a year for all the shrinkage to occur following rhinoplasty. Thus, a bad result may not become obvious for several months when it becomes clear that too much tissues was removed or that abnormal internal scarring has occurred. That long delay is why experienced surgeons require years to master rhinoplasty – because their true artistry may not really be known until they can see their patients’ results – which sometimes appear only after many years.

Over resected noses are also sometimes rebuilt using tiny pieces of the patient’s ribs, hip or pieces shaved from the top of the skull where it’s the thickest. Cartilage harvested from behind the ear or from the nasal septum is also a very common location to obtain tissue to reconstruct a bad nose job. Occasionally, tissue from cadavers or synthetic materials may be necessary, but most surgeons think those approaches are less than ideal compared to working with the patient’s own tissue.

While shopping for a good doctor, there are several telltale clues patients can easily look for, say experts.

Forget Marketing

“A good surgeon is reflected in the people around him,” says George Orloff, M.D., an L.A. area, board-certified plastic surgeon who does many rhinoplasty revisions. “The first good sign is when the office receptionist does not rush nor ignore you on the phone and communicates well with you. Another thing to watch for: make sure all the people in the office like the physician and speak well of him.”

Dr. Orloff’s third tip: forget about any marketing or advertising you may have seen or read about the surgeon and concentrate on his ability to communicate. Of course, before you arrive for the first consultation, you should have read something about the surgeon’s training and practice, which is usually available on the Internet. Also check for his hospital privileges.

“Second or third rate physicians are not granted hospital privileges,” says Dr. Rawnsley. “But excellent surgeons have multiple privileges.”

Adds Dr. Rawnsley: “It is also entirely appropriate to ask a surgeon exactly how many times he has done a particular operation.”

The combination of a patient who does his homework and an accomplished surgeon’s art and science can easily be worth it. Just ask Brian who once lost faith in plastic surgeons and just let his nose go for ten years.

“For the first time in a decade, people do not notice my nose first and give me compliments about my large eyes,” he says. “And I no longer feel embarrassed just by walking into a room.”

Like most good plastic surgery, Brian’s new nose doesn’t draw attention and fits his face.




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