This week I worked on two patients who really illustrated the interface of cosmetic and reconstructive rhinoplasty. One patient had been asssaulted and had his face smashed with a baseball bat. Having completed restoration of his upper jaw and teeth it was time to rebuild his nose. Unlike routine rhinoplasty where there is bone and cartilage to reshape, everything had been smashed and crushed leaving little to work with. After adding in the resultant scar tissue it left the patient with a collapsed, shapeless and nonfunctional nose. The challenge was met by going to one of our natural spare parts boxes, in this case the patient’s rib cartilage. After harvesting this new supply of firm, supportive cartilage all the building blocks to create an aesthetic and functioning nose were carved and shaped and then implanted and grafted. This is one of the most diificult of all challenges in rhinoplasty. The second patient presented with what is often called “finesse” rhinoplasty. An attractive young woman who only desired modest refinement of her profile and nasal width. The challenge (and sometimes trap) for the surgeon here is to resist the temptation to do to much. The over zealous surgeon who wants to use all the great (or usual) techniques he knows or does on every patient ends up altering a pretty face when only subtle refinement is needed or has been requested. Such a result can be devastating for a patient. Each of these cases represent polar opposites in planning, approach and execution to achieve the desired result.The sum of these two cases together remind me why I love doing this procedure-even after twenty years you still are challenged by every patient. It is never routine. You can’t do the same procedure on every patient. You have to be skilled in a wide variety of techniques but only use what’s needed for each individual case. The results will be right out there for everyone to see, not hidden under clothes or makeup. It can only come from you, it’s not an implant or a technology that anyone can buy. Nothing is more rewarding or humbling then being trusted by patients with this responsibility and being able to help them meet their goals.
