23rd December 2009

Conservatism and Wisdom in Cosmetic Rhinoplasty

My goal in rhinoplasty is to achieve the very best result possible for a patient based on what they want.  This has to be tempered by what is possible.

Frustrating though it may be we have to understand that there are limitations on what it is possible to achieve.  These limitations particularly relate to how small we can make a nose whether removing a bump, making a tip more refined or making the whole nose smaller.  There are limitations because skin will not limitlessly shrink.  In fact, if we make the nose too small under the skin and the skin does not shrink completely to fit the new size, a thick layer of scar tissue will form in the gap between the size of the nose underneath and the skin overlying the outside.  This will create a poorly defined putty like nose.  This is particularly true of thick skin.  In thin skin if we remove too much bone and cartilage underneath the skin will shrink and distort the smaller underlying cartilage causing buckles and irregularities.

It is also true to say that there is a price to pay for every step of a rhinoplasty.  We can make for example a tip look slimmer from the front and narrower but in the side view this might cause a nostril rim to lift up or notch.  We are therefore always weighing up the pros and cons of every step to achieve a good balance.

Wisdom is acquired from “the school of transactions”.  Experience tells me that in surgery if we can keep it simple we should.  This does not mean not trying our very best but it means experience has taught that we should limit risk.

There are times when only complex surgery will offer any chance of improvement and in these circumstances the patient must clearly understand that risks might be higher and make their own informed choice based on this knowledge.

Generally speaking I feel that being conservative in cosmetic rhinoplasty means being wise and very carefully understanding the risk versus benefit relationship.