I am on a mission to revive my passion; the almost extinct art of closed rhinoplasty. Everybody talks about plastic surgery as an artistic endeavor, but not much is taught about this in our surgical training. The emphasis is mainly on anatomy, technical skills, and surgical techniques but I want to seriously inject art into this discipline. Artistic vision is critical is this going to be your career. After years of attending many rhinoplasty conferences, I have observed the lack of emphasis and conversation about the design element in rhinoplasty. Absence of this artistic philosophy just leaves rhinoplasty as a basic surgical procedure that lacks the beauty element and leads to rhinoplasties that look technical or mechanical. The nose is the center of the human face and the feature perhaps most closely associated with what we call “character.” Any alteration in its shape must be handled with great care, subtlety, and artistry, for no form of cosmetic surgery will so influence that way a face is perceived. In my 33 years of rhinoplasty experience, after performing over 6,000 closed rhinoplasties, my experience has been that overwhelming majority of patients, approximately 90% want subtle refinements to their nose with a desire to preserve the natural character. As restoring a Rembrandt does not require major alteration, neither does the beautiful nose that simply needs subtle refinements. Most noses have attractive features which should be identified and left untouched. Even if there were such a thing as a “perfect nose” it would be of no use in practice. A well executed rhinoplasty is simply a series of subtle brushstrokes leaving the patient a more refined version of herself or himself. It is one which fools the human eye, where no one is able to discern the specific alteration, yet can appreciate the enhancement. Appropriate selection of patients with compatible vision of the final outcome is paramount. I urge you not to impose the reconstructive mentality of revision rhinoplasty and inflict it upon a beautiful nose. My desire is that all students of rhinoplasty should once again consider and re-evaluate this almost extinct art of closed rhinoplasty, despite its difficulty teaching and its longer learning curve.
Rhinoplasty is about finesse, NOT change. During consultation, I review the nose in 9 categories:
- Breathing
- Septum
- Internal Nasal Valves
- Turbinates
- Length of nose
- Tip configuration
- Projection
- Width and asymmetry of nasal bones
- Width and contour of nostrils
Upon my review, I normally discuss which of the above categories are in harmony and which ones need some refinement. Preserving parts of the nose in its original form keeps the integrity and character of the nose. This is an extremely important concept to fully comprehend. Amongst rhinoplasty surgeons, there is a wide range of techniques, philosophies and surgical results. Most surgeons employ an “ideal nose strategy” for rhinoplasty. These surgeons have a vision of a perfect nose and focus their rhinoplasty efforts toward creation of their ideal nose for every face. Unfortunately, the “ideal nose strategy” has a few flaws. First of all, this strategy assumes that all parts of the nose which do not meet the criteria if this ideal nose need to be changed. I contend that there is a wide range of features which may be attractive and must be considered in the context of the remainder of the face and nose. Surgeons who ascribe to the ideal nose strategy will often employ more extensive radical procedures with extensive grafting in an effort to impart more dramatic changes to the nose. While the surgeon may be able to achieve his goal in changing one aspect of the nose, it often comes at the expense of unintended changes in the remainder of the nose. Another downside of the one nose fits all strategy is that it may lead to imbalance between nose and the corresponding facial features. A successful rhinoplasty operation is a marriage between the face and nose so that not only is the appearance of the nose improved, but the remainder of the facial features are enhanced.
During the initial consultation, an understanding between the surgeon and patient is necessary to see if the patient and surgeon have a shared goal of what can be achieved. Patients are prepared with Vitamin K 5mg twice daily and Arnica Montana preoperatively for 1 week. Patients are forbidden to take Aspirin, Motrin, or any blood thinning products for two weeks prior to surgery. Caffeine, alcohol, and smoking is also limited during this time. One hour of preoperative icing is performed on all patients. Ice acts as a natural and powerful vasoconstrictor of the nose, which significantly reduces edema and bruising. All surgeries should be performed under general anesthesia as this allows greater control of the patient’s blood pressure, which is a direct contributor to the amount of intra-nasal bleeding.
A vasoconstricted, bloodless tissue plane is needed for appropriate visualization and methodical, rhythmic execution of all steps. To accomplish this, one should hydro-dissect the septal mucosa from the bony and cartilaginous septum and the whole skin envelope from the framework of the nose. Approximately 10-15cc of ropivicaine and lidocaine is injected 25 minutes before the 1st incision is made.
A left hemitransfixion incision is made 5 mm posterior to anterior edge of the cartilaginous septum. Through this incision a full thickness mucosal flap is elevated to access the cartilaginous and bony septum. The obstructing portions of cartilaginous and bony septum are removed to straighten the airway. Approximately 3 cm long and 4 mm high septal cartilage will be needed for spreader grafts. This is harvested from the floor of the cartilaginous septum, embedded in the vomer. We as surgeons must work extremely diligently to have 100% patent nasal airway on both sides.
When addressing the nasal tip, the intercartilaginous incision in the vestibular skin is made at the level which will facilitate the entry and then the removal of the excess cephalic strip of the tip cartilage. In order to prevent any post-operative pinching or collapse, no more than 50% of the cephalic strip should be removed. Here, comes the dilemma and limitation in an extremely bulbous tip. Delivering the tip cartilage, trimming and suturing the domes, can be accomplished through the closed approach, yet may have a better access through the open approach.
The nasal dorsum is skeletonized through the same intercartilaginous incision. Cartilaginous dorsum is adjusted with a 15-C blade. The bony dorsum from rhinion to nasion is addressed with a Rubin chisel to lower the bony dorsum as well as to open the roof of the bony vault. This cortical nasal bone has to be gouged because using the Rasp, not only fails to reduce the bony profile but also does not open the roof. The space thus created by opening the roof is absolutely mandatory to accomplish complete lateral osteotomies. The ease with which the nasal bones can be aligned in a more medial position is a direct result of creating this gouged open roof. This averts the need for medical osteotomies and transcutaneous transverse osteotomies to accomplish complete medialization of the nasal bones.
Lowering of the bony cartilaginous junction disrupts and tears the fibrous connections between the nasal bones and the upper lateral cartilages, often leading to medical migration of the upper lateral cartilages. This results in a cosmetic mid third pinch and functional crowding of the internal nasal valve. To avoid this unacceptable outcome, an appropriate placement of the Spreader Graft is the answer. Septal cartilage harvested earlier during septoplasty is straightened, sliced and carved into 2 spreader grafts. They vary in length, height, and thickness according to the individual need for correcting this mid third deformity and restoring the patency of the internal nasal valve. More than 1 spreader graft on the same side could be utilized to wedge and skew the cartilaginous nasal septal pyramid for further straightening. The spreader grafts, once positioned to accomplish the desired results are immediately fixed into its desired position using a 3.0 chromic in a through and through mattress fashion.
Lateral osteotomies are performed in a LOW to LOW fashion from base to the top to medially displace the right and left nasal bones to recreate the nasoseptal pyramid. The ease with which the nasal bones come together is a direct result of our previously created space from gouge osteotomy on the nasal dorsum. Very rarely, if one or both bones are resistant to medialization, a quisling osteotome is used. This is placed lateral to the reluctant bone and tapped into place for completion.
The dorsum is revisited for smoothness and finessed with sharp Maltz rasps if so needed. Once completely satisfied with the dorsal projection and smoothness, a small strip of gelfoam is introduced into the dorsum between the skin and the dorsal bony cartilaginous framework of the nose. The intercartilaginous incision is closed. The nose is taped and casted with moldable cast.
Please do not try to impose your vision of what is beautiful and in effect, take away natural features of the face. Alar grafts, batten grafts, radix grafts may have a place in secondary rhinoplasty, but in primary noses, they bulk up the nose. Furthermore, most grafts add a certain rigidity to the nose taking away its natural feel and look. Although they may be able to achieve this desired amount of projection of deprojection, they do so at the expense of the rest of the nose.
Knowledge of the nasal anatomy and steps performed in a closed rhinoplasty is critical to a successful operation, and during residency, we are taught exactly this. But we are NOT taught the art of rhinoplasty. We spend countless hours memorizing the ideal facial angles, ideal proportions of the nasal tip, and performing multiple surgeries using these concrete measurements as out measure of a successful outcome. But there is so much more that goes into rhinoplasty that cannot be taught using the standard textbook. Each patient is different and only when we look at the patient’s nose in the context of his/her face can we better understand this artistry. In fact, this skill of injecting art into your work is something that takes time to develop and I think that we need to start developing this skill in our training, while our minds are more fresh and malleable, before rigid dogma has stamped its imprint on our way of thinking about rhinoplasty. Every face and every nose is beautiful in its own way. As a true artistic surgeon, our job is to bring out those beautiful features even more while refining those areas that are not in congruence with the rest of our face. Subjecting every patient to an “ideal” nose is absolutely wrong. Given the entire context of a face, some noses look better with a silver of a dorsal hump or with an alar width larger than the “ideal” intercanthal distance. These artistic decisions are made based on preserving the natural beauty in a person’s face. As a cosmetic surgeon, it is important to understand and see beauty in all aspects of life as this will better allow us to inject artistry into our craft of rhinoplasty.
- Raj Kanodia, M.D.