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PST 007: Rhinoplasty Myths and Facts — Read the Transcript

March 29, 2018

Listen to the full audio here

Welcome to Plastic Surgery Talk with Dr. Stephen Mulholland, brought to you by SpaMedica. Welcome to our podcast today on rhinoplasty. What is a rhinoplasty, commonly known as a ‘nose job’? It is an operation performed by a certified specialist like a plastic surgeon, a facial plastic surgeon, on the nose to even out the craniofacial nasal balance, making the nose look like it fits the face. Nose jobs, or rhinoplasties, can be reductive in nature, which is the most common, taking a big nose and making it smaller, more delicate, more balanced, and proportional to the face or taking a very small nose and making it larger.

Then, there’s other varieties and variants of nose jobs and rhinoplasties, crooked noses, bulbous tips, noses that may have indentations or traumatic irregularities. These are the common reasons why we, as plastic surgeons, operate on the nose and why nose jobs and rhinoplasty are one of the top three procedures year after year in the world. Rhinoplasty, nose jobs, one of the most challenging procedures performed by plastic surgeons.

Most surgeons do not specialize or perform rhinoplasty. A lot of plastic surgeons will perform breast augmentation, tummy tuck, facial soft tissue surgery, such as facelift and eyelids, but many do not focus their skill on rhinoplasty because it does take a lot of experience, expertise, and artistry. The nose is a collection of bone, of cartilage, and of soft tissue. It’s the centerpiece of the face, really. It is the centerpiece of the face that we often look at as our eye flows around the facial features, and it takes a lot of artistry and skill to shape the nose to be perfect for the face that owns it.

One of the problems with rhinoplasty and nose jobs, typically, is some surgeons make one nose that fits all. The key to successful rhinoplasty surgery is taking the face and balancing the nose so there’s a pretty, refined, or handsome nose that matches the face. As a double-certified physician, a surgeon trained in both head and neck oncology, and ENT, ear, nose, throat, as well as a plastic surgeon, it’s one of the most common things I perform because I enjoy the artistry and the challenge of making the nose and face look attractive, balanced, proportional, and compelling.

I’m often asked, is rhinoplasty more science and technical or art? It is really one of those procedures where it’s both. The art and the science come together. It takes science to understand the techniques and strategies to break the bone, to shape the cartilage. The technical skills involved and instrumentation in rhinoplasty are complex. However, you can be a great technical surgeon and end up with bad rhinoplasty results because the artistic component, the understanding facial shape and balance, the beauty proportions, what angles and what curves and what structure would look good on any given face, that’s the art of rhinoplasty surgery. It is true that the best rhinoplasty surgeons can combine the art and the science into an excellent outcome every time.

What is the difference between a septoplasty and a rhinoplasty? A septoplasty, or plasty coming from the greek plastos (“to shape”) is shaping of the septum. The septum is the middle partition in the nose, right in between, that ends in the soft tissue down here and then divides the nose into right and the left nasal passage. The septum is often deviated, or injured and shifted, so the septum can cause obstruction of breathing.

That obstruction could occur prior to the nose job when patients present for just a septoplasty or septorhinoplasty or during the rhinoplasty procedure by making the nose smaller. We can often result in the airway on either side being obstructed if we do not perform a simultaneous and preventative septoplasty. Septum is for breathing and, as a certified surgeon in plastic surgery and head and neck oncology, ear, nose, throat, I do a lot of septoplasties combined with rhinoplasties because it’s in my core training, understanding, and in the benefit of the patient so they can breathe, as well as have an attractive nasofacial balance.

What’s the difference between a tip plasty and a bump reduction? A bump reduction, typically, is part of the rhinoplasty that deals with the bridge bump, or the bony anatomy, the upper part of the nose where the bone is either wide or raised, thick, and disproportionate, and that involves the delicate and scientific aspect of saws and rasps and breaking the bone. Occasionally, just a bridge bump is reduced but, quite often, you need to combine the bump, the tip, and the nostrils to make the nose perfectly balanced.

A second kind of nose surgery is the tip plasty. You’re just performing work on the soft tissue portion of the nose, the tip, and the nostrils. Occasionally, in my practice, I’ll see patients who need just bridge reduction or just tip surgery, however, the vast majority of patients benefit from a bridge matching a tip which matched the nostrils so, often, you have to perform all three maneuvers in a well done and executed rhinoplasty.

What makes somebody a candidate for a rhinoplasty? First and foremost, they need to be of the age of adulthood. They need to understand the complexities of appearance and image, and they have to reach skeletal maturity. There’s no point performing a rhinoplasty while you’re still growing, so adulthood and skeletal maturity. Number two, realistic expectations. You need to have expectations that are realistic, that the surgeon can achieve. Number three, a patient is a good candidate who is truly appreciating the risks and the benefits involved in the surgery and is allotted enough time for recovery.

Number four, a good candidate for rhinoplasty surgery has had a consultation, which included computer imaging. I’ve done this for many, many years. I sit down with a patient. I go through the problems that bother the patient with the bridge, the tip, the nostrils, the front view, the side view, and we go through all the problem list and the options and then perform simulated computer surgery, actual simulated changes on the computer that represent what I know after nearly 25 years of doing nose jobs and rhinoplasties can be the outcome. A properly selected patient who has had computer imaging of adult and skeletal maturity, with realistic expectations, who understands the risks and benefits, those are the best candidates.

Is it true that the nose continues to grow throughout your life? The answer is no and, occasionally, yes. One of the urban myths I didn’t include in the urban myths part of the podcast because I want it to have its own separate home was this issue of the nose continually growing. In general, skeletal maturity, the bone stops growing, so 18 or 19. The cartilages stop growing.

There is, however, a very small group of patients who get the skin continuing to grow as they get old, particularly when they have rosacea and they get something called rhinophyma, which is pilosebaceous  hyperplasia or a giant potato-nose. Sometimes, the skin can thicken and grow, but the bone and the cartilage does not. What happens is, when women, particularly, age and the face deflates, air comes out of the balloon, the cheeks get hollow, the face gets more skeletal. As that occurs, the nose, which hasn’t changed, continues to look bigger and bigger as your face gets smaller and smaller. There is a relative increase in the portion of the nose without the nose actually growing because the face is shrinking.

As a cosmetic plastic surgeon, one of the busier plastic surgeons in Canada, I see a lot of nose jobs. I do a lot of rhinoplasties and nose jobs, but the vast majority are cosmetic. Patients were born with a hereditary tendency of overgrowth of the bridge, overgrowth and bulbosity of the nose, wide nostrils, over-projected, or too long. Sometimes, patients were born with a hereditary underdevelopment, the weak bridge, the weak projection. These are the most common variants of nasofacial balance that present to my office for surgery.

There are some patients who have had trauma and, sometimes, the trauma, a baseball injury, a volleyball injury, a fall in the school yard that hits the bridge contributes to overgrowth of the bony bridge, or deviation, or irregularity, and that can be combined with underlying skeletal and soft tissue overgrowth issues. Very rarely are hereditary irregularities of nasal development, particularly from cleft lip, cleft nose, and cleft lip palate.

You can be born with these tendencies of under- and over-development or you can acquire them through injury or sometimes in culmination. Either way, by the time you’re seeing me and you’re a young adult, you don’t like the balance between the nose and the face, and my job, together with you, is to provide a beautiful nose that has perfect nasofacial balance and proportional architecture.

I very much enjoy performing rhinoplasty. It’s one of the most common things that I do in my practice. I was trained in both head and neck oncology and anatomy and cancer and trauma of the nose. I transitioned to cosmetic plastic surgery about 22, 23 years ago, and nose has always been a big focus of my practice. I enjoy the soft tissue and boney interface of noses, the technical challenge and artistry it requires, and I really enjoy the fact that I’m very good at it. I look forward to seeing you. If you come in for rhinoplasty, we’ll sit down in front of the computer and do a mock surgery, simulated surgery, that will help you as a potential patient decide is a nose job right for you.

Thank you very much for joining me today. Dr. Stephen Mulholland here in Toronto, Canada on Plastic Surgery Talk for our podcast on rhinoplasty. If you found it interesting, educational, entertaining, and/or informative, please share it with everybody on your social channels.

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Dr. Stephen Mulholland
Posted by Dr. Stephen Mulholland
Dr. Stephen Mulholland has been practicing Plastic Surgery for over 20 years. He is one of Canada’s most renowned and best plastic surgeons in Toronto with his wealth of experience, artistry, and humbleness towards his patients.

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