Winning by a Nose

Created on 15th May 2009

Rhinoplasty: leading surgeon Mr James McDiarmid of McDiarmid-Hall Clinic talks us through his surgical philosophy

The nose occupies an inescapably central position in the face. It represents a symphony of cartilage, bone and skin and even minor deviations from the expected norm can produce displeasing aesthetics or functional problems.

Most patients presenting for surgery in my practice have always had a nose they have not liked. Occasionally they present with nasal deformity following trauma, sometimes they present requesting secondary surgery.

Inferences of youth and beauty can be subconsciously taken from the size and shape of the nose; boxers and rugby players often have characteristic pugilistic nasal shapes. Additionally a shorter, more turned-up nose alludes to youth, whereas a longer one hooking downwards goes with an older face.

There are male and female gender differences in the ideal nasal proportion with the male nose having a higher radix (root), thicker skin and a more acute columello-labial angle (angle between the upper lip and the bottom of the nose in profile view) compared with the female.

Important ethnic differences also occur in the desirable nasal aesthetics of Caucasian, Middle Eastern, Asian, Oriental and African patients.

The relationships between the nose and surrounding structures such as the premaxilla and the chin are also vital to recognise. Around 10 per cent of my patients choose to undergo concurrent chin augmentation or reduction in order to maintain a harmonious aesthetic relationship between the nose and chin. I have excluded discussion of chin augmentation and reduction from this article; suffice it to say that a normal-sized nose can continue to look big in the context of a retrusive chin and a strong chin can masculinise an otherwise feminine face.

Recognition of the functional role of the nose is of vital importance for the aesthetic surgeon and it is important to not only assess the status of the nasal airway preoperatively but also to plan to reinforce both internal and external nasal valves during surgery if these structures are to be involved in the operative plan.

Just as every patient is different every rhinoplasty is also different and presents its own unique challenges and demands to the operating surgeon.

My rhinoplasty practice has evolved from initially performing almost every rhinoplasty closed (with the endonasal approach) to carrying out almost every procedure open. The reasons for this can be summed up in one word - predictability. There is no better way of ensuring a predictable outcome in this surgery than by being able to recontour, reduce and reinforce the cartilage, skin and bone of the nose under direct vision. Furthermore the open approach affords incomparably good access to the nasal septum and in my opinion enables far safer and more effective straightening of a deviated nasal septum.

The most important aspect of planning is the preoperative consultation where parameters of what constitutes an acceptable goal are agreed between patient and surgeon. Any limitations should be mentioned at this stage and it important to share a realistic goal. I find using morphing software invaluable at the consultation - it helps to articulate the proposed surgical changes to the patient (nose and chin) and also helps the surgeon with operative planning.

In surgery, preparation and positioning of the patient are vital as well as hypotensive (low blood pressure) anaesthesia, so the surgical field is virtually bloodless with an uninterrupted excellent view of the delicate nasal structures.

My website has an animation which I made explaining my personal approach to this surgery by means of a cartoon (don't worry - it is not gory and there is no blood on display!) and it also demonstrates ten pre- and postoperative case series of my patients.

For the purposes of this article I would like to illustrate my rhinoplasty philosophy by means of six cases. These cases illustrate straightforward and complex primary and secondary rhinoplasty and correction of nasal septal deviation.

Case 1: This pretty girl had a very large dorsal hump which was predictably reduced restoring her facial aesthetics. At the same time she underwent narrowing of the tip and bridge of her nose. She was a straightforward case and had a predictably good outcome.

Case 2: Another attractive girl whose mother had undergone rhinoplasty under my care several years previously. She had a small dorsal hump compounded by a slightly low radix (root of the nose), a broad tip and nasal bridge.

She is a very good example of a patient who benefited from open rhinoplasty, removal of the hump, narrowing of the nasal bridge, radix augmentation, and tip reshaping with grafting. Her mother's nasal anatomy was almost identical and she had undergone a very similar rhinoplasty. You don't need to be a plastic surgeon to realise that nasal characteristics can run in families.

Case 3: This male patient had very challenging preoperative anatomy: large asymmetric bulbous nasal tip cartilages. He had not previously had any surgery or trauma. The greatest challenge in any rhinoplasty is correction of the tip and his tip cartilages were successfully refashioned at surgery by correcting the biplanar convexity and reinforcing their straightness with cartilage grafts.

During the same procedure he also underwent removal of his nasal hump, augmentation of his radix and narrowing of his nasal tip and bridge. He was left with a less obtrusive nose and gained significantly in confidence following surgery.

Case 4: This pretty lady felt her nose was deviated and excessively bulky in comparison with her facial features. She underwent open rhinoplasty with correction of a deviated nasal septum using reversed spreader grafts (see animation on my website for details). Postoperatively her septum was straight and her nasal tip and bridge were narrowed. A more delicate sculpted tip was created using cartilage grafts.

Case 5: This attractive girl had undergone rhinoplasty abroad. She was dissatisfied with the result of this procedure and elected to undergo secondary rhinoplasty. She had the nasal dorsum lowered, the tip tilted upwards, debulked and refashioned and a small radix graft placed. Following this surgery she was very happy with her final result.

Case 6: This young man had undergone two rhinoplasties elsewhere prior to requesting improvement of his nasal shape. As his dorsum was excessively low he underwent augmentation of his nasal dorsum using ear cartilage wrapped in a padding layer called the temporalis fascia.

Additionally he had rim grafts placed to lower his retracted nostril rims and had his hanging columella (the part of the nose between the nostrils) sutured upwards to his nasal septum.

In conclusion
Technical finesse makes all the difference in rhinoplasty surgery.
In my opinion the enhanced degree of predictability conferred by the open rhinoplasty approach is vital for reducing the risk of reoperation and surgical complications.
CS&AM