What are the Guiding Principles for Rhinoplasty

As one enters practice and begins to learn rhinoplasty surgery in the real world, decisions have to be made and their consequences must be accepted. Hopefully, these principles will guide the surgeon through the challenges of rhinoplasty surgery.

• Rhinoplasty is the most difficult of all cosmetic operations for three reasons:

(1) Nasal anatomy is highly variable

(2) The procedure must correct form and function

(3) The final result must meet the patient’s expectations.

• Few surgeons do more than 25 rhinoplasties a year. Thus, one must maximize the learning experience of each case by careful documentation of the operative procedure and frequent follow-up visits. Only you can teach yourself surgical cause and effect.
• Form without function is a disaster. Most postoperative nasal obstruction reflects a failure to diagnose and treat a preoperative subclinical condition. One must identify and correct preexisting anatomical deformities of the septum, nasal valves and turbinates. There is no excuse for not doing a thorough preoperative internal exam and recording a specific operative plan.

• One must accept in advance that there is no magic operation that guarantees perfect results. Each surgical maneuver within an operation has its learning curve. Within an operative sequence, the individual maneuvers are additive but their interactions and potential complications are geometric. Keep the operation simple – maximum gain, minimum risk.
• Expand what you know from your comfort zone. Do not incorporate every new fad.
• Early in your practice, select nice patients with obvious deformities that you can easily correct using surgical techniques that you know. With experience, begin to add new maneuvers and then take on cases of greater difficulty. Operate within your comfort zone early on.
• The preoperative course is finite, but the postoperative course is infinite, so pick your patients carefully. Postoperative problems are most often confirmations of intra op suspicions.
• If the tip did not look exactly right during the case, it rarely gets better later.
• Once you operate on a patient, it is your result, regardless of how many previous operations were done or how non compliant the patient. Select your patient’s carefully.
• Once you have a complication or poor result, admit it directly to the patient and discuss how it can be improved. Do not pretend that it is not there or shame the patient into accepting a minimal improvement or make it financially impossible to correct the problem.
• Treat patients as family, at worst they will be disappointed but not litigious.
• Understand your own limitations and progress through Level 1–3 primary cases before embarking on major secondaries. Secondary rhinoplasty is technically more demanding and requires greater surgical expertise that can only be gained through operative experience.In primary cases one often takes away the negatives to reveal the underlying attractive nose while in secondaries the surgeon must be capable of rebuilding a destroyed framework using numerous grafts.
• Rhinoplasty is the most rewarding of all cosmetic operations, both for the patient and the surgeon. Few operations can make as great a change in a young person’s appearance or in their self-confidence. For the surgeon, rhinoplasty is the ultimate in artistic three-dimensional sculpturing. It is truly worth the patient’s risk and the surgeon’s commitment.