Thursday, September 18, 2008

Regrettable Rhinoplasties

oes seem as if young Hollywood starlets all share a common gene pool? The ubiquity of the narrow bridge, defined tip, straight dorsum– something distinctly American and that you won't find on screen in foreign films– isn't due to the great melting pot, it's the surgeon's knife.

Like diamonds, rhinoplasties are forever. Once you've purchased it, you'll be wearing it for the rest of your life.

The nose doesn't grow back or stretch with time. The very best of the rhinoplastic surgeons (and there are fewer of them than you think) can improve on a bad result, but revision surgery will never restore your original nose to your face.

As they say in the business: "you want to hit a home run the first time you're up to bat."

So what makes for a poor result?

First, an anatomical primer. Surgeons identify the supporting structure under the nasal skin by its anatomical parts:
From the apex or nasal tip, the columella projects inferoposteriorly toward the center of the superior lip, adjacent on either side to the nares. Encompassing the border of the nares are the alae of the nose superiorly and laterally, and the floor of the nose inferiorly. At the posterior aspect of the base of the nose is the piriform aperture, bordered superiorly and laterally by the frontal processes of the maxilla and the nasal bones. The inferior portion of the cartilaginous nose, otherwise considered the base of the nose, includes the lobule, which consists of the lower lateral cartilages, the tip, the alae, and the columella. In the midline, the posterior aspect of the medial crura of the lower lateral cartilages articulates with the caudal membranous septum. Anteriorly, the medial crura are enclosed within the columella. The lateral crura of the lower lateral cartilages project superiorly to overlap the inferior aspect of the upper lateral cartilages in the midline. Laterally, these crura loosely attach to the piriform aperture....
And now to illustrate. Double-click on any of these images to get a close-up. Take a good look.

The nose falls apart over time, ie, the underlying architecture of the nose is so compromised that the look (and function) can't be maintained. Repeated surgeries become necessary. Michael Jackson (50) is the poster child for what is termed a 'crucified nose.'

Alternately, the surgical result may stay put but it's a look that doesn't appear in nature ala LaToya Jackson (51). Closely related to this phenonmenon is the 'operated look,' a nose that is plausible but clearly the result of surgery, distracting even to the untrained eye. Calista Flockhart (43) has just such a rhinoplasty. Her skin is thin and her resected greater alar cartilage on one side almost pokes through the tip, like a knuckle.

Scarring and overly aggressive resection of the cartilage causes a 'pinched tip' (thinning of lateral cura) and/or 'notched nostrils' (lateral crus). That girl, Marlo Thomas (70) has both.

Her first cosmetic surgery was way back in 1965. Joan Rivers (73) was actually much prettier than she ever thought she was and her initial surgeries made her only slightly less so. But her nose has been, for some time now, the classic example of too much, too often. The net result is a 'putty nose,' one which looks as if it was fashioned out of silly putty and stuck on her face.

Now you see it, now you don't. Onlay grafts to build up the dorsum are always tricky. Alloplastic grafts (eg, silicone, gortex) tend to become infected and extrude; allografts (eg, cadaver donor tissue) reabsorb over time. Only autogenous ones (eg, the patient's own septal/ear cartilage, rib, iliac bone) tend to last. Just ask Lil' Kimberly Jones (33).

Polly want a cracker? No. The pollybeak deformity is a disproportionate fullness in the supratip which evolves postsurgically. It can be cartilagenous or soft tissue in nature and is often the result of a misjudgment on the surgeon's part. Furthermost left is a 1983 preoperative photo of Meg Ryan (46); the next two date from '01 and '08.

Excessive 'columella show' can cause the operated nose to have the appearance of a long, drooping tip. And seeing inside someone's nostril can provide fodder for embarrassing rumors about what's up inside there. Here are three postoperative views of Paris Hilton (27).

Correction of the twisted nose poses one of the greatest challenges in septorhinoplasty. "My face is full of imperfections and it is what it is." Easy to say when you're Dr. McDreamy and have landed gigs as the face of both Versace and Avon campaigns this year. Patrick Dempsey's (41) rhinoplasty took place sometime around 1991-1994. Symmetry is defined by an imaginary line drawn equidistance between the medial canthus (inner corners of the eye) through the middle space of the two front teeth/cupid's bow.

Perhaps the most incongruous mistake is when a perfectly natural-looking result simply doesn't suit the wearer. Jennifer Grey's (48) new nose so disoriented her fans that her career faltered. Twenty years postoperatively, it still hasn't recovered.

To hear more, tune in to hear Anne discuss it all with Kevyn Burger on FM107.1 at 10am Thursday.


Anonymous said...

If you don't use photos of celebrities where their face is held in the exact same position, you can't make these judgements, sorry!

ANNE said...

Clinical pre- and postop photos are of great value to surgeons in helping to diagnose and evaluate surgical technique. Our comments are just observations of unintended aesthetic outcomes in some very public faces.

Anonymous said...

Anne, keep up the observations, they're welcome break from all of the "hard" news tales of today.
Dan Idrather.

martinkorben said...

this is my favorite blog.

ANNE said...

Oooooh, flattery will get you everywhere.

nosy said...

septorhinoplasty is performed to correct a deviated septum, not a "twisted nose." It is not a cosmetic procedure and does not change the appearance of the nose in a cosmetic way.

ANNE said...

You are referring to a septoplasty, an operation on the nasal septum, the bony-cartilaginous structure that separates the nasal airway in to left and right passages. Surgically correcting a twisted septum can indeed affect the external appearance of the nose. Both the American Society of Plastic Surgeons (ASPS) and the American Academy of Facial Plastic & Reconstructive Surgery (AAFPS) have published papers on this very subject. A septorhinoplasty is combined surgery on both the septum as well as the framework (and sometimes nostrils) of the nose.

Plastic Surgeon said...

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