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Key Points
- Straightening a twisted nose is among the most difficult procedures in rhinoplasty
- Surgeons must consider what happens when the depressor septi activates the nose
- Diagnosis comes before technique, surgeon says
According to Robert L. Simons, M.D., rhinoplasty remains the top facial plastic procedure for long-term enhancement of beauty. He is a Miami facial plastic and reconstructive surgeon and otolaryngologist. Based on more than 40 years' experience, he offers the following advice:
PEOPLE'S NOSES AREN'T NEARLY AS BAD AS THEY THINK. Dr. Simons says this quote comes from one of his instructors, Morey L. Parkes, M.D., of Beverly Hills, Calif. Dr. Simons says he embraces this statement because "rhinoplasty should be conservative in nature." When a patient says he or she doesn't like the hump or the thick tip of his/her nose, "It doesn't mean we must excavate the problem by removing the entire hump or getting rid of all the cartilage in the nasal tip," Dr. Simons says.
FACIAL PLASTIC SURGEONS DO A LITTLE TO ACHIEVE A LOT. Rhinoplasty is also a subtle procedure, Dr. Simons says. "It's an operation that often is not seen, or shouldn't necessarily be seen, in the nose itself, but it should be seen in the eyes of the individual." Rhinoplasty should make the patient's features more beautiful, "But in a way that draws attention to the beauty, not to the operation itself."
DON'T BE QUICK TO CRITICIZE — OR REVISE. "When you see a nose to be done or one that's been done, it's a mistake to quickly jump and get your hands on it or make a comment. What happens in rhinoplasty takes time for either the beauty of the refinement, or the stigmata of contractures or complications, to occur," Dr. Simons says. For example, he says four months postsurgery is too soon to tell a patient she needs hydroquinone, dermabrasion or laser treatment to address dark circles under her eyes. "Tincture of time often serves us well. This is something we must remember when we have a very anxious patient before us with perhaps less than her desired result."
Dr. Simons says that even in a case he holds up as one of his best five years postsurgery, the patient eventually returned complaining of a bump on the right side of her nose. "Indeed, she had a little bit of a bossae that she noticed 10 years after surgery — and I considered her one of my best cases," he says.
A TWISTED NOSE DEFIES PERFECTION. Attempting to straighten a twisted nose perfectly is "one of the hardest problems we're faced with," especially for the long term, Dr. Simons says. In one case, he says a 69-year-old woman he treated for a crooked nose and inability to breathe still had satisfactory results 12 years later. In this case, he made septal incisions to straighten out the septum and extended these incisions to the top of the curvature at the dorsum. Along with external rhinoplasty, Dr. Simons says he used a strut and plumping grafts while removing a conservative amount from the dorsum. He used the patient's upper-level cartilage for support (he did this procedure before the advent of spread grafts). Ultimately, he says, her postoperative photos showed a bit of saddling in the supratip area, but the patient liked her results.
Conversely, a 17-year-old boy he treated for a badly twisted nose with a markedly deviated septum and inability to breathe returned two years later for routine follow-up. "Though he was markedly improved cosmetically and functionally, he still had a slight curvature of the nose," Dr. Simons says. "This underscores how difficult it is to obtain a perfectly straight nose postoperatively" when trying to fix a twisted one. In fact, Dr. Simons estimates that in such cases, "Revision rates double, from about 5 percent normally into double figures."
