In order to prevent excessive narrowing of
the middle vault in my patients, I tend to over-correct the
width of the middle vault in patients who are at higher risk of
middle vault collapse. These tend to be patients with thinner
skin and shorter nasal bones. This intentional over-correction
will make the middle vault portion of nose a couple of
millimeters wider than ideal in anticipation of the contracture
phase that tends to narrow noses. With this approach, patients
are less likely to have collapse of their middle nasal vault and
tend to improve in appearance over time.
Many patients want an ideal nose
immediately after surgery.
Every nose swells after surgery, so if the nose is
swollen, it only makes sense that it will look wider than ideal
Once the swelling subsides, the nose will
This desire for
immediate results is one of the primary reasons why many
secondary rhinoplasty patients end up undergoing multiple
The surgeon is trying to
please the patient and provide immediately-visible refinement
after surgery instead of compensating for swelling and long term
changes that will occur over the patients lifetime. This is a
short term answer to the problem and is not wise unless a
patient does not mind having revision surgeries every 5 to 10
years. Some patients tell me that they want their nose to look
good now and do not care what it looks like in ten years.
Unfortunately, most would think differently if they were unable
to breathe through their noses or needed splints or external
nasal strips to hold a pinched nose open in order to sleep at
If you have had previous nasal surgery, you
can likely see the long term effects of this narrowing and
contracture in your own nose. With high quality close up photos
of your nose, you can compare your early postoperative photos
with your present photos. If you have thinner skin and shorter
nasal bones, it is likely that your nose has narrowed over time.
This narrowing will tend to continue over your lifetime and is
more pronounced in some patients with certain anatomy. Every
time you breathe in, you create negative pressure in your nose
that also tends to pull in the cartilages of the middle nasal
vault. The combination of the scar contracture and negative
pressure can create tremendous change over ones lifetime.
Remember that your nose will be with you forever.
I can assure you that it
will tend to narrow and contract over time and not get wider.
My goal is to create an improvement in
ones nasal shape that will continue to improve over the years.
These changes tend to be slow in coming and relatively subtle. I
tell patients preoperatively that their nose will be wide and
ugly early on due to swelling and overcorrection. This is a very
difficult time for patients, especially those who disregarded my
preoperative counseling and instead believed that their nose
will look good early postoperatively. What you see at one month,
one year or ten years is not the final outcome. This is the
toughest part of the recovery period and is another reason that
patients need to come back for follow up, as I can provide
instructions for nasal exercises or taping that can help
decrease the swelling and width in a symmetric fashion.
Once I operate on a patient, I expect them
to come back for follow up for their lifetime. This obviously
fills my office with patients on whom I have already operated. I
want to see my postoperative patients long term to insure that
their noses are moving in the right direction toward the proper
narrowing and proper contour. A more profitable approach would
be to just see new patients to add more surgeries and shorten my
new patient waiting time. Instead I spend at least half of my
office hours seeing postoperative patients, which limits the
number of new patients that I can see. My intent is not to be
more profitable. My intent is to provide patients with the best
long term outcome, and that requires long term follow-up.
With the long term follow-up I am also able
to see what happens to my patients over time. I frequently see
patients that I operated on 10 to 15 years ago and critically
assess their outcome. I correlate suboptimal outcomes with my
very precise rhinoplasty operative diagrams that show what was
done at the time of surgery. This information allows me to
modify my techniques to better insure a long term favorable
outcome. Using this constant critical analysis of my results, I
can fine tune my approach and constantly improve my results. I
am always changing my techniques based on this follow-up. If you
look at books such as the "Rhinoplasty Dissection Manual" and
papers that I have published in the past and look my more recent
articles on nasal tip contouring and rhinoplasty philosophy, you
will see that I have dramatically changed how I perform
rhinoplasty over recent years. These changes are based on long
term follow up of my patients and allow me to constantly improve
at this operation. Once a surgeon feels that he or she is good
enough, the surgeon will not improve.
In contrast, I know there is always room for improvement.
If I could get the nose to reach a certain
size and shape and then freeze it at that ideal shape, then I
would not over correct any noses and instead make each nose the
exact size desired.
fact, it is not difficult to make a nose look good early
postoperatively. The real difficult part of rhinoplasty is to
make a nose that will heal well, look good, and function well
over the long term.
Having such a result is dependant on many years of experience
and long term follow-up.
years of practice and intense study of many patients long term
after rhinoplasty has led me to my present philosophy of
rhinoplasty. I will always do whatever is best for the long term
good of the patient. The problem with this approach is that many
patients think I want to give them a big nose or that my
aesthetics reflect a goal in making big noses. I can assure you
that I can make the nose very small.
However, I must also take
into account a patients skin and anatomy when determining what
is really the right size of a nose.
This is the question that
eludes many surgeons.
I frequently see patients in my office who have had
surgery to make their nose smaller that resulted in deformity.
Patients with thick skin and a large nose are the most
problematic. At the time of the consultation I will perform
computer imaging and digitally manipulate the image to show a
larger nose on profile view. This is to increase the likelihood
that the frontal view image is good. If you make a large nose
with thick skin smaller it will tend to become a mass of thick
hanging skin and create what we call a pollybeak deformity. The
only way to correct this deformity is to make the nose bigger on
the lateral view to stretch the skin and create definition. This
is the reason why I make some noses larger in length and
projection. Trust me I do not like to make these noses long and
projected. However, my goal is to make the frontal view look
better by making the nose larger.
The patient below had a wide nasal tip and
very thick skin. In order to make her nasal tip look narrower on
frontal view I increased her nasal tip projection and made her
nose larger. I demonstrated this change on the computer imaging
preoperatively. Postoperatively she looks much better on the
frontal view due to better balance and expansion of her thick