Rhinoplasty — what you need to know

Dwight V. Galloway M.D.

Rhinoplasty, or cosmetic nose surgery, is one or the first plastic surgery operations, started over one hundred years ago by Dr Jacque Joseph in Berlin. He was well known and many came to learn from him but he was very secretive and did not show what he was doing or explain it. Although the techniques are now well known “closed Rhinoplasty” is still an art and must be learned over several years after being taught by an expert. Most present surgeons use the open technique as it is much easier to understand but takes almost twice as long to perform and leaves much more scar tissue in the nose. I was taught the closed technique in residency at the UCLA medical center in the 1960s when that was the standard method. This leaves much of the delicate tip structures and the character of the nose intact and addresses only the undesired characteristics. Both the open or closed technique can be done either under local or general anesthesia and I have done well over 500 under local anesthesia. However with present medical system in either the hospital or surgicenter, the price and risk is the same for general or local anesthesia so now you will have no pain and less anxiety and I can concentrate only on the operation without worry that I am hurting you. My intention is to fix what you do not like about your nose and for the result after 2 years to look natural and not like a “nose job”. A perfect nose is not my goal.
Rhinoplasty if considered one the most difficult operations to master and there is a whole society of “experts and wanna be s” that meets at most of our national meetings where only that one operation is discussed year after year. Many text books have been written on the subject. The steps of the operation are not hard to teach or learn but deciding what to do and how much in each nose, takes about 5 years to learn. The biggest problem is that you need to reexamine the patient after about 2 years to see how the skin, bone, cartilage and scar have healed and matured in relation to what you started with and what you did. The other factor to consider is that it is well known that about half of the rhinoplasty candidates have a fixation on their nose and fixing the physical part of the nose does not eliminate the psychological part. If you decide to do rhinoplasty you have to accept the unhappy patient even when you think you have done your best. Most plastic surgeons just “do not do noses”. The other half with the improved self image and happy smile makes it all worth it, at least to me.
The nose is in the center of your face and you cannot hide it. The most common complaints are (1) the hump, (2) the bulbous and wide tip, (3) too big and (4) the tip “pulls down when I smile”. Some are so self conscious they cover it with their hand or do not smile and are considered a sourpuss or an unhappy person. Curing that is what it is all about.
After the surgery there will be a tape and aluminum splint on the nose for about a week to hold the bones, cartilage and skin in place until they are stuck together. It takes about 16 days for the bones to get solid and I have you push them together for about 3 weeks to be sure they do not spread apart. You will be instructed how to do that on the day the splint is removed.
I take many before and after photos to help me decide what to do and record the results at various stages after surgery. I usually use the computer and Photoshop to help me decide how much to take off and change the angles and do a “choice 1” and an over do “choice 2” to emphasize what I am proposing, so that you can have some input into my decision, and also to check how we came out at 2 years after the operation. About 10 percent of noses, like most cosmetic operations, could stand a revision when fully healed. Sometimes it is the patient and sometimes me that feels a further touchup is warranted. But you never know if you don’t look and good photos are a must. Healing and judgment are not always perfect and if a second operation can make a significant improvement the time and effort to check and get the photos is worth it. The nose and the chin are related to facial balance and I do very few initial chin implants compared to some surgeons, feeling that I can always come back if fixing the nose is not enough. I initially do only about 5 percent chin implants where some surgeons do 90 percent.

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