The art and science of achieving a natural rhinoplasty result

Rhinoplasty surgery should always be bespoke. It’s a balance of understanding what patients want from their operation and telling them what is feasible and functional. For the surgeon, it is the case of putting all those together and then understanding the patient’s anatomy, such as skin thickness, strength of the cartilage, or previous trauma, which will affect what we can deliver.

When we train in rhinoplasty surgery, aesthetics in terms of angles and lengths are based on a Caucasian ideal, if you like. There is a way of doing the same operation and employing the same techniques each time to essentially get the same result, particularly if it is the primary surgery.

However, I steer away from that. First, I listen to the patient and understand what they want from surgery to deliver a natural rhinoplasty result. I’ve had several patients who will say I would like to retain some form of dorsal hump (slight hump on the bridge of the nose) as it reflects their identity and ethnicity. Others would like a flatter profile which can also look very natural.

You must also consider the difference between male and female aesthetics. Over-rotating the tip and shortening the male nose can feminise the nose. Initially, this isn’t apparent when the nose is swollen, but at one year, it becomes noticeable.

Secondly, we have to consider function and tailor the patient’s aims to what we think works functionally and harmoniously with the rest of the facial features.

Understanding rhinoplasty patient expectations

Most patients do not want a dramatic alteration. In fact, some patients will only want a very minor refinement which is possible with thin skin and delicate cartilage but for patients with thicker skin and cartilage, this may not be possible.

Patients might bring pictures with them that they want to aim for. Sometimes, that’s appropriate because the person they’ve compared to has similar facial proportions. But at other times, I have to explain that that person’s face is very different from yours, and putting that type of nose on your face may not fit. However, this helps me understand what their aims for surgery are.

I also use morphing software to help me understand their expectations and ensure we’re on the same page regarding their goals.

Sometimes, they may ask to see what it looks like even more refined using morphing software. I’ll explain to them that this is not something I’d necessarily advise in their case, but interestingly, if you narrow the tip further or lower the dorsum more, it will cement in their mind that they don’t want that.

Every patient heals differently, but I only morph images that are achievable. Although the morphed image won’t look exactly like the post-operative outcome, it will be approximate, and usually, I’m able to achieve it within reason.

I explain to the patients that the nose is a 3D living tissue structure. It’s not an inert substance that you can mould and guarantee the final result. Many different things will affect the outcome and that is taken into account in the planning for surgery. Predictable results are more consistent with primary operations, whereas they are always more unpredictable with revision rhinoplasty.

My approach to facial aesthetics

At Great Ormond Street Hospital, I see paediatric patients with syndromes that can influence facial features. Their faces grow and change over time, which also has to be accounted for. I am also part of the Craniofacial team at UCLH, where I work alongside maxillofacial and plastic surgeons in the management of complex craniofacial presentations.

There, patients will have significant distortion of the facial features, either as a result of trauma or congenital conditions. Understanding what works for each individual patient is important. As a result, I feel I understand facial balance and proportions, such as the distance between the eyes or the position of the chin.

The chin plays a significant role. If the chin is very receded, the nose will look more prominent, but it’s not necessarily the nose that is the problem. Conversely, a very prominent chin can give the nose a more hooked look in some cases. I can refer to my colleagues if chin augmentation procedures are required.

I work with many cleft palate patients, and sometimes, there is an underdevelopment of what we call the pre-maxilla or the middle part of the face, which impacts the nose as well. So, I may use grafts within the midface to build up the base of the nose to give it a better foundation.

Lastly, most patients don’t have a completely symmetrical face, and in some cases, it’s important to tell patients that straightening their nose might actually make their eyes or mouth look slightly crooked. Every action has a reaction.

Delivering a natural rhinoplasty result

There is a saying that an excellent rhinoplasty result is a nose that’s not particularly noticeable. An aesthetically pleasing nose is not the fact that the nose is beautiful, but it fits with your other facial features, and you respond to that sense of harmony.

Most patients I see clearly understand what they would like to aim for, and we make a shared decision together. If I don’t feel that I can achieve the results they want, though, or I don’t think that surgery may be in their best interests, I may advise them that I may not be the right surgeon, or it may not be the right operation. We must work together for a shared aim and goal to ensure we get an excellent result that they’re satisfied with.

To discuss how you can achieve a natural rhinoplasty result, call +44 (0)203 627 2918 to arrange a consultation.