I just performed an ethnic rhinoplasty on a 22 year old man of Indian descent from Los Angeles. He had come to me with concerns about a downward pointing or drooping nasal tip that made his nose look elongated, and his nostrils appear relatively flared and retracted. In addition, he was concerned about wide appearing lower third of the nose, and a nasal bridge hump. To bring up and refine his nasal tip, I had to remove some of the tip cartilage that were pushing things down and support the weak cartilage on the stronger septum. Weak cartilage and thicker skin are almost always issues in ethnic rhinoplasty. I improved the profile, by taking down the hump, while leaving a strong masculine profile with a subtle convexity. The nose was then narrowed by infracture of the bones. As always, the breathing was optimized with a septoplasty and turbinate reduction.
“Madame X” is a painting by the famous 19th Century American portrait artist John Singer Sargent. This painting has always struck me as an unabashed celebration of the nose. I have enjoyed this painting long before I became a rhinoplasty surgeon, and seeing it again through the eyes of a surgeon, gave me pause. This was painted in a time before cosmetic rhinoplasty. In fact, I think that if Madame X walked in to a plastic surgeon’s office today, they may well tried to persuade her to have rhinoplasty as, according to the modern aesthetic, her nose is prominent.
To be more precise, most rhinoplasty surgeon’s critiques would likely include descriptive terms such as an “overprojected tip,” “too much columellar or nostril show”, or “tension nose deformity.” To my eye, I can see all these “deformities,” but I am still struck with her beauty, as Sargent clearly was. Her nose is prominent, but each feature is beautiful: the undulation of her nasal bridge, the slight visual depression of the profile separating the nasal tip from the bridge, the delicate tip, the forward pointing of the nostril shadow, and the second angle or double break under the tip as the nasal profile returns to the face.
What makes her nose beautiful is how well suited it is to her face: distinctive, detailed and bold. It is prominent, but it is well balanced with her strong chin. It is complex in detail as one might imagine her real life personality might have been. Sargent’s bold and dark strokes of background outlining the fair and delicate contour of her nose declare his confidence in her beauty and suggest that Madame X is fully self-aware and confident of her appearance and uniqueness. She seems to have turned away from the artist in a bit of defiance, while simultaneously and self-consciously highlighting her profile for the artist’s enjoyment.
If Madame X walked into my office today, I would not touch her. Certainly my instinctive critique and analysis of her nose might lead me toward an attempt at some vain, generic perfection. As I tell young surgeons, “Just because you can do something, does not mean you should.” Judgment and appreciation of the multiplicity and complexity of beauty should make us all stop and appreciate how beauty is about cohesiveness and harmony rather than its dissected elements. What “MadameX” reminds me of is the intellectual space between the artist and medical scientist that I live in every day.
In shopping for plastic surgery, buyer beware. The internet is a great place to look at everyone’s wares. Before and after pages are always the most looked at pages for Plastic surgeons. You should like what you see and there should be plenty of examples. Get a feel for the overall site. Is it haphazardly organized or too slick? Is it generic with only models photographs and no real patients? Is there any focus on the nose? Be a good shopper. It is really up to you to evaluate the doctor like you would anyone you might hire. Don’t be distracted by the office decor or a nice suit. You want to connect to the doctor and feel that they are hearing your concerns and ideas. I think that asking for digital image morphing during your consultation allows an excellent opportunity for you to interact with your physician. You can see if you are able to communicate with them about what you want and expect. The surgeon then gets to perform a little virtual surgery that allows you to see if you like his or her aesthetic judgment, an essential component for a successful primary rhinoplasty. Look for results. Ask to see lots of pictures of before and after photos. These should be the “home run” results that the surgeon wants to showcase. If you are unimpressed, you should move on. Ask to talk to former patients. While these patients are hand selected to happy patients, you may get some subtle clues about their unfiltered opinion. Choosing to have rhinoplasty can be a very rewarding experience. Finding the right surgeon requires a clear head and using all your faculties and consumer skills.
As an educator, teaching young surgeons at UCLA, I have a great interest in helping make the situation better for rhinoplasty patients by teaching surgeons the basics, as well as the nuances, of this surgery so that the overall quality of care is improved in the community. Our fellowship in Facial Plastic and Reconstructive Surgery at UCLA has produced some of the finest academic Facial Plastic surgeons I’ve ever seen, who will continue to train a new generation of higher quality surgeons. In the meanwhile, there are some basic tips for patients to help them get their rhinoplasty right the first time.
Above all, find the right doctor. Believe it or not, not all doctors are created equal. Board certification in Facial Plastic Surgery or General Plastic Surgery is a starting point, but does not guarantee that the surgeon has adequate experience, training or talent. Look for a doctor who has a special interest in rhinoplasty. Ask around. Referrals in plastic surgery have traditionally come from word of mouth. Physicians generally get a reputation over time for good (and bad) work. Don’t believe all the hype or negative rumors. The best referral comes from someone you know and trust and preferably has had surgery with the surgeon in question. Ask other doctors as well, as they often know the reputation of their peers. Shop around.