HOW DIFFICULT IS RHINOPLASTY
So here I am, sitting with a new patient chatting..I chat a lot. It’s always a good thing. We were talking about her face, and what might be needed to polish… the “o” is soft.
OK DEFINE “NEED”
“Need” in cosmetic surgery – that’s what I do – has various meanings, as in I need a new suit, and such. While she had the floor, she asked me, among other things, what was the most difficult operation I do. Not the most difficult case, but operation itself. Intentionally missing a beat, so it looked like I was actually thinking about it, which I wasn’t, it’s the rhinoplasty, I say. Oh a “nose job” she said.
DON’T TRIVIALIZE MY WORK
Ok listen, this may be a “nose job” to some, but it’s my work and I get a little straighter in my chair. It’s not a nose job it’s a rhinoplasty. They are not “boobs” , they are breasts. Don’t get me started! Ok so why is the nose the most difficult operation? That covers a wide range of items, but here only a few for discussion.
For one thing the nose is asymmetric. The whole human body is asymmetric. Humans show merely a versimiitude of symmetry, a perception, if you will. Most folks believe they are symmetric; but don’t really have a reason to examine themselves. Well some do…
It usually takes some incident, an injury (surgery) or accident or something else to draw attention to the injured part and any other part in the vicinity. Even when I point this out to my patient, he/she still asks whether I am going to fix it. So it comes to this: the nose is “made” different from side to side. Even if you go to the mirror to check, you won’t see the same nose that everyone else sees. The image in the mirror is reversed…go look at a photo, but don’t get crazy.
NORMAL NOT FIXABLE
No, the asymmetry is, not only not fixable, it should not even be attempted..usually – a weasel word of great utility. Our asymmetry is really one of the engines of our recognizability. It is how other humans know it is us – Pogo’s enemy. Try and fix the asymmetry and you will likely ruin the face. And it’s not only the nose but the same trouble happens when I do a blepharoplasty..look it up.. Or a browlift, or when I work around the mouth. They are all uneven, and supposed to be. I better stop there before I beat this to death. It is probably why humans with more symmetry in their faces are more attractive to other humans…you could look it up.
A second reason is that the nose is the central feature of the face, and it has projection out from the face. Everything else besides the ears and a cigar, are flat on the face. In that projection are many different views seen by everyone else in the world, but not by the person wearing the nose. In each of those views the nose looks slightly different. All this comes down to this: the nose has an infinite capacity for change. And if that weren’t difficulty enough the usual patient expects the nose to look great in all views. Just thinking about that gives me a headache.
Ok one last reason for today. Self Perception: This is a subject that has been beaten mercilessly by academics, presumably because it is really interesting. Everyone has something to say about how we see ourselves, and they’re all probably correct. But for me as a plastic surgeon, It’s kind of like talking about the weather, and doing nothing about it, yet still needing to know what it is.
Getting a handle on how someone sees himself (generic, don’t get pissy), is important. I have to figure out what he/she wants me to do, let alone how I am to do it. So each of us have our own private way of seeing ourselves, and it’s secret. Not stopping there, most humans could not describe how they see themselves. There’s more. Most people don’t even understand how we appear to others, and neither do they. It’s all bound up in growth and development. We never really examine ourselves, without a little pathology going on. It’s all very confusing, but for me and the nose it’s critical.
THE FAILURE OF LANGUAGE
So, if I’m going to operate on a nose, or anything for that matter, it’s a good idea for me to know what the outcome should look like. In getting the esthetics of the nose, language, words, are no good tools at all. It takes pictures of all sorts of noses including those of the patient, for me to figure out: not only what the patient wants; not only what looks good or would look good; but whether the limitations of surgery and healing will allow me to actually do what it is I am agreeing to do. Possible disaster awaits if I don’t. Add to all this the heightened awareness, for the patient, of his/her nose after operation. More - the human eye can pick up a millimeter that’s “off”. You gotta love this work.
There are more reasons for the difficulty in rhinoplasty. For later.
Thanks for listening