Philosophy and Principles of nose job
Nose job is widely regarded as the most challenging operation in facial plastic surgery. Much of the difficulty lies in understanding the threedimensional configuration of the osseocartilaginous framework and its translation into external contour. While rhinoplasty is a continually evolving operation, the underlying philosophy and principles have not changed much over recent years.
However, a better understanding of nasal analysis, interplay of anatomy and function, and longterm postoperative healing have led to refinement of surgical techniques. All these factors have contributed to improved longterm aesthetic and functional results.
In the advent years of rhinoplasty, most techniques were reductive, focusing on dorsal hump excision and nasal tip refinement. Functional aspects, particularly longterm, were either not known or simply ignored. Endonasal approaches were commonly used, leading to less than ideal exposures with imprecise and often uneven structural resections. Compromised outcomes were hidden behind camouflaging effects of soft tissue edema. Noses began to appear pinched and scooped over time, leading to nasal obstruction.
In recent years, the pendulum has swung toward an emphasis on both: function and form. Finding the right balance between the two is now a priority of the contemporary rhinoplasty surgeon. More emphasis is placed on preservation of key anatomical structures to highlight higher nasal dorsums with complementary tip projection. The increased popularity of external rhinoplasty approaches has allowed surgeons to accurately assess the patients’ anatomical problems and precisely modify the underlying structural framework. Some may argue, however, that the increased exposure afforded by the external approach allows the surgeon to make more radical alterations to the nose, which can lead to more complications.
Inherent histologic tissue changes occur with aging, while constant external forces act on the nose’s structural support system; with each inspired breath, the nose tends to collapse. It is the role of the skeletal framework to prevent the overlying skin–soft tissue envelope (SSTE) from collapsing. In contrast to the common belief that noses enlarge with aging, they tend to become narrower and more pinched over time. The nasal appearance 1 week postoperatively may differ greatly from the appearance at 6 months, 1 year, and thereafter. While the surgeon controls the operative intervention, it is equally important to develop skills in manipulating and controlling dynamics of postoperative healing. The operation itself should be considered the first, and not the last, intervention in altering someone’s nasal shape and function. Maintaining and establishing structural support of the nose is hence critical, withstanding the aforementioned forces that may otherwise lead to suboptimal functional and aesthetic results.
The idiom that no two noses are alike certainly holds true in rhinoplasty. Even among identical twins, variations in nasal anatomy have been observed, likely due to a variety of congenital and environmental effects. It follows that every rhinoplasty presents the surgeon with a wide array of nasal anatomy, contours, and proportions, necessitating a series of organized and interrelated surgical maneuvers tailored to each patient’s needs. The aesthetic judgment of the surgeon, guided by the patient’s wishes, determines the surgical plan. No single procedure or technique will suffice to adequately reconstruct every nose. Many years of experience are required to critically observe, analyze, modify, and perfect surgical results. With the increased popularity of external rhinoplasty techniques, less experienced surgeons may be able to perform more precise maneuvers through improved visualization. Inappropriate and optimistic attempts to create changes greater than the tissues will permit may yield complications from overaggressive resection of supporting structures and should be avoided. Reductive techniques that were popular decades ago have now been replaced by more augmentative, structurally preserving techniques. Proper preoperative and intraoperative analysis with identification of correctable deformities and recognition of surgical limitations is critical to achieve consistently successful outcomes.
