I have had the opportunity to perform Rhinoplasties and a whole variety of nasal septal reconstructions over a 30-year period. This has allowed me the opportunity to closely evaluate my long-term results. Close observation has ingrained in me that conservatism is the key word in cosmetic nose surgery. The nose keeps changing for 10-15 years following Rhinoplasty. Inevitably, it gets slowly smaller, the skin thins, and one can get more retraction of the nostrils and thinning of the tip over time. What might appear to be an excellent result one year postoperatively can often change over time into an undesirable result or at least not as aesthetically pleasing as the one-year result. I have followed many patients over 12-15 years. These patients had a portion of their dome cartilages and lateral crus of the lower lateral cartilages removed to a certain extent through intranasal approaches. One year postoperatively, they looked excellent. When I saw the patients 12 years later, even though they were happy, I personally felt that the tip had thinned too much and I wished, in hindsight, that I had taken out slightly less cartilage. I present this so the younger plastic surgeons in the audience will learn that conservatism is critical in cosmetic nose surgery. The patients always ask for a smaller, smaller nose, and yet they want to look natural. The surgeon tries to please the patient, but he must inform them that, if he makes the nose too small or removes too much cartilage support in the tip, 10-15 years later, the patient could potentially have pinching or too small a tip that could look like a nose job or certainly not aesthetically pleasing.
In addition, I feel that lateral osteotomies are overdone in many cosmetic nose surgery procedures. Often you can remove a large nasal dorsum on a person with a large hump, and yet lateral osteotomies and/or breaking of the lateral nasal bones is not required. Often in crooked noses, you just have to perform a unilateral osteotomy, in which only one side of the nose is fractured, and that alone is a very neat way of making the nose look more symmetrical without actually fracturing both nasal bones, which would make the nose look too thin. Another favorite procedure for me to perform to make a nose straight is by adding cartilage grafts that are trimmed and sculptured individually and placed through a small intranasal incision in an area of indentation or curve which will help give the nose a straighter appearance without having to do any fracturing of any bones whatsoever.
I also find that cartilage often taken from the ear or septum, crushed and pulverized and made like putty, and placed in the tip area gives a very excellent refinement to the tip without any obvious signs of cartilage grafts, which, when not crushed or morselized, can be sharp and noticeable. Another favorite approach of mine is to give the appearance that the nose is elevated by placing a piece of cartilage through a right rim incision into the base of the columella. This gives the appearance that the nose is raised without actually raising the tip. This is a wonderful procedure for those patients that have large nostrils and really could use a raising of the tip but would not be ideal in their particular circumstances because of their anatomy, poor maxillary protrusion and/or inferior migration of the base of the nasal vestibule and nasal nostril. Therefore, bringing down the columella, particularly the base, makes the profile look much better and gives the appearance that the nose has been elevated without truly raising the tip.
Cosmetic nose surgery is considered probably the most complicated of all the cosmetic surgical procedures, and rightly so. I have been doing cosmetic nose surgery for 30 years and, to this day, I still learn on every case. The learning curve never ends on performing cosmetic surgery of the nose and, therefore, every time I operate, I evaluate the case, the patient, their facial features, the size of their whole body, head size, shape size, and 20 other items in order to determine the best result for them. Just looking at the nose alone will never give the ideal result. You must fit that nose to facial features of that individual. This is often missed by many physicians, in that they just truly concentrate on trying to “improve the nose to make it look better” without thought as to whether that truly is the proper fit for that individual face, feature, and body type. I have enjoyed doing noses over 30 years and consider every nose a new challenge, even after performing so many thousands of noses over the years. I find cosmetic nose surgery to be a very satisfying operation and, when done properly, the patients are so very much appreciative. I do feel that the closed procedure is a more appropriate procedure to do because it causes less scar tissue and allows for more leeway if any future revisional surgery is needed.