By its very nature, Rhinoplasty is one of the most personal of facial plastic surgery procedures. Many people define the way they look and reflect their ethnicity on their noses and any changes anticipated must be fully discussed pre-operatively. To do this the patient must have a firm and unwavering commitment to facial change as well as an honest and realistic expectation about the nose they wish to have. This may start with a look through today’s fashion magazines to see what the “beautiful people” look like. While it is rarely possible to recreate another’s nose, it does provide a starting point and does give the plastic surgeon a general idea of what the patient wants. The process can then begin to alter the patient’s expectations to something nearer to reality. Every patient should expect to have a more attractive nose that also breathes well, but not every patient can have the perfect little turned-up nose seen in so many of our current movie actresses. Once the Plastic Surgeon gets a general idea of what the patient desires, then he/she can begin discussion of the details of the operation and what may or may not be possible. During this part of the consultation, drawing expected results on the pre-operative photos or utilizing computer imaging is essential. The only caveat regarding computer imaging is that it is always better if the operating surgeon does the imaging so that the imaged results are as close to realistic as possible.
Explaining the details of the procedure is important as the possibility of complications is hidden in these details. For instance, describing a dorsal hump reduction should lead to the possibility of a small elevation at the bone-cartilage junction and in large reductions leads to a discussion of osteotomies and supra-tip problems. We usually perform a septoplasty as straightening the outside of the nose can incur septal deviations that cause breathing difficulties if no septoplasty is performed. Additionally, the sub-mucous resection of the septal cartilage can be replaced (banked) for possible future use or used to help define a nasal tip or to open an internal valve or straighten the cartilaginous dorsal septum.
The thickness or thinness of the skin needs to be addressed as each can affect the visualized result; thick skin will camouflage tip contouring while thin skin may show the tip architecture created in the finest detail. Therefore, in a thin skinned patient more discussion of tip detail is crucial. Explaining planes, cartilage breaks, and light reflexes may then become important.
The most important pre-operative information that must be understood clearly by the patient is that it takes at least 6 months and usually up to a year before the final result is realized and that any necessary revisions should wait at least 6 months in most circumstances. It is important to not over-sale the cosmetic rhinoplasty.
From the Plastic Surgeon’s point-of-view, reconstructive and even cosmetic rhinoplasty is challenging and has a “steep learning curve” which means it takes a lot of cases to become facile with the instruments and the operation. I personally was trained by one the best rhinoplasty surgeons ever (see: Rhinoplasty Tetralogy by D. Ralph Millard, Jr., MD). My early practice encompassed a lot of broken noses due to automobile or physical trauma. Then I gained a reputation for cleft lip and palate as well as the most difficult rhinoplasties on infants and children. After 20 years of experience I now only concentrate on teenage and adult cleft lip rhinoplasties, complex rhinoplasty due to trauma and most cosmetic rhinoplasty. After an extensive 26 year experience, I still find rhinoplasty to be the most taxing and the most rewarding operation that I perform.
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