I have a many rhinoplasty patients who consult with me in my Los Angeles plastic surgery office, who have shopped around for their surgeon before making their very important decision on who will perform their rhinoplasty. One surprise that I enjoy is the relief on the patient’s face when they ask about how the scar from surgery will look, and I tell them that there won’t be any scar. “But Dr. So-and-so told me that he had to cut between my nostrils to do my rhinoplasty,” they reply. What they are referring to is external or open rhinoplasty, where an incision is made in the columella, or the skin between the nostrils, which allows a surgeon to flip the skin back so they have a better view and access to the cartilage and bone of the nose. It’s the technique that most surgeons trained in the last 15 years learn in their training, because you can see what the teacher is doing.
But there is a problem with open rhinoplasty: the scar. It is usually acceptable, but occasionally it is noticeable. I can usually see some trace of it in almost everyone who has open rhinoplasty, especially if they have thicker skin. How do you avoid this telltale scar? I perform scarless rhinoplasty by making all my incisions inside the nose. This is the original way that rhinoplasty was performed, but less experienced plastic surgeons shy away from it because it is more difficult, and it is hard to learn. From a patient’s standpoint, however, it is very reassuring not to have a scar on their nose that might draw attention, especially since many patients seeking rhinoplasty because they are self-conscious of their nose already.
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.