The Art of Rhinoplasty

All of us have heard the following statement… “It was better in the old days.”  Well perhaps that statement is true about a lot of things, but believe me, the statement does not apply to Rhinoplasty.

Every physician who has performed a functional Rhinoplasty (to improve breathing), a cosmetic Rhinoplasty (to change the appearance of the nose), or a combination of the two can attest to the fact that Rhinoplasty is the most difficult of all facial plastic procedures.  One of my mentors, Dr. Jack Anderson, once said that of all the Rhinoplasties he performed, being the consummate perfectionist, he only got it to perfection a handful of times.  He was a gifted surgeon and was always tweaking his skills to reach a greater standard of success.

At an early age all of us imprint on our facial appearance, and the nose is the centerpiece of such.  I have done numerous Rhinoplasties, and in 35+ years of practice I have tried to emulate Dr. Anderson’s attempts to achieve the ultimate Rhinoplasty.

There have been times when I have witnessed a young patient’s ground swell of confidence and poise when I changed his or her nasal appearance.  Their personality blossomed, perhaps they changed their hairstyle, and their complexion received better care.  It brings a smile to the patient’s face and mine when observing these changes.

Surgical Rhinoplasty is reported to have begun in ancient Egypt and India.  The Indian physician, Sushruta, first described nasal reconstruction in a text dated circa 500 BC.  Indian society considered the nose to be a symbol of dignity and respect throughout antiquity.  As punishment for adultery, nasal amputation was performed and the practice of Rhinoplasty was started to reconstruct the external nose.  Reading some of the techniques used in nasal reconstruction boggle my modern thoughts as to how they operated and were able to prevent infections and complications.

From those early roots, Rhinoplasty surgery has arisen, and we now have a modernized and civilized approach that is used to correct breathing and nasal impairment, as well as change the contours of the nose in a refined manner.  Current statistics suggest that over 300,000 Rhinoplasty procedures are done annually in North America.  Rhinoplasty is commonly accepted by all ethnic and religious disciplines as a way to change function and appearance.  With the possibility of nasal fractures ranking as the most frequently broken bone of the body, it appears the facial plastic surgeon will always have job security.

Well, how is the procedure performed?  When seeing a patient for a “nose job”, I assess all sense facets of the nose to determine my approach to their needs.  I follow a premise of determine your overall approach to nasal deformity and learn to perfect your approach for consistent results!

As an Otolaryngologist (ENT physician), I determine a need to correct nasal respiratory impairment, as well as simultaneously correct visible deformities within the facial rules of harmony.  In other words, a short nose would not be appropriate for a long and slender face on a tall person.  I have my staff take a series of photographs of the person and their nose in varying views, then I offer the patient the ability to view my proposed nasal changes.  I enjoy sharing the before-and-after photographs with the patient after healing is complete.  Interestingly, many patients seem to suppress memories of their former nasal appearance.

An experience comes to mind with a former female patient whom I performed a Rhinoplasty several years ago.  She confided that before the surgery she would shield her nose from view by placing her hand on her cheek.  The person seated in the adjacent car to the traffic light wouldn’t see her nose.  After the surgery eliminated her self-consciousness about her nasal appearance, she faced the person in the next car and smiled with confidence.

There are occasions where insurance coverage will apply to nasal deformity related to breathing impairment.  We always strive to help the patient if this is an option.  There are also occasions where insurance may cover only the repair of breathing and the patient pays for cosmetic changes.  A personal consultation with my staff and me can be obtained to give one a cost analysis.

The Rhinoplasty is performed typically under a general anesthetic in an outpatient setting.  Every effort is made to make the surgery as comfortable as possible and to minimize bruising.  Medications are placed within the nose to constrict blood vessels and anesthetize the nose. Blood loss is very minimal and many patients have little or no bruising.  My approach is with an “open” technique.  A delicate W-shaped incision is made across the columella, the tissue between the external nostrils, and combines with a small incision within the nostrils’ interior. Through these incisions, the structural supports for nasal shapes can be sculpted to give the appropriate changes.  The incisions are closed with dissolving sutures about the size of a human hair.  Correct technique almost always eliminates nasal packing, which formally was placed in outdated techniques.  Total nasal obstruction from the packing made it impossible to sleep and one was uncomfortable during the first week after surgery.  Splints were frequently used in nasal surgery to secure nasal tissues and prevent bleeding.  Seldom do I use them anymore.  At discharge from surgery with no packing in the nose and no splints within the nose, patients can breathe while recuperating and they are not as uncomfortable.

Patients are requested to refrain from anything that may increase nasal pressures, such as blowing the nose, for one week.  They are also asked to sleep with their head elevated for one week.  Most all return to work and can be very presentable within one week.  Many patients can likely return to participating in sports and exercise in one month.

If you have an interest in having a “nose job”, consult with us to determine what is needed.  You will be well cared for should you choose to have surgery and no, we will not go back to the “good old days!”

Call us at River Region Facial Plastics and let us help you breathe better, remove a “bump” or straighten your twist.


All the best,

Dr. Thomas H. Cawthon


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