People seek out Dr. Cynthia Gregg, one of the Triangle’s premier facial plastic surgeons, for a variety of reasons. “But whether they are considering a face lift, rhinoplasty, or some other procedure,” observes Dr. Gregg, “basically they want to alter and improve how they present themselves to the world. And most often, that’s because there is a significant disconnect between how they feel on the inside and how they look.

“For that reason, there’s an emotional component in all the work we do,” she says. “People want to feel better about how they look. But, in some cases, the changes we make have an especially powerful emotional impact. It could be removing scars from the face of a domestic violence victim; pinning a child’s protruding ears; or altering a large nose. For these patients, there’s often a painful history of self-consciousness and of being teased or bullied. Alterations can be more than just pleasing; they can be healing.”

Rhinoplasty

Dr. Gregg considers rhinoplasty—surgery to alter the shape and appearance of the nose—among the surgeries that have such a powerful emotional component. “It is perhaps the most challenging surgery I do,” she says. “You are transforming a face; and the new nose needs to fit the face naturally and subtly, as well as meeting the patient’s expectations. And because we breathe through the nose, function is always a paramount concern of. You can’t compromise function for appearance.

“One of most significant challenges of rhinoplasty,” notes Dr. Gregg, “is achieving a natural appearance. I want people to have the result after surgery where their faces don’t look different; they just look more refreshed. I want them to look like they were born with that nose, not that it’s a nose that they had operated on.”

And, in fact, even small, subtle alterations can be transformative,” she says. “For example, I call rhinoplasties my ‘millimeter surgery,’ because changing the shape or moving the nose by as little as one to three millimeters can produce a striking difference in appearance—a difference that looks natural. That is always the goal. When someone’s nose looks as if it’s the product of a surgical procedure, it’s because it has been moved too much. That’s the art—the ‘magic’—of facial plastic surgery. It requires not only technical skill but an artistic-aesthetic sense of proportion.”

Transforming a Nose: One Patient’s Story

“Last fall I met Morgan—a 22-year-old who wanted to correct defects caused by trauma—and performed her rhinoplasty in January of this year,” says Dr. Gregg. “Her experience beautifully illustrates how subtle changes can make a powerful difference. (see photos) It also describes the process involved in designing and planning for the surgery, to ensure optimal outcomes.”

The first step, Dr. Gregg explains, was to learn what brought Morgan in—what she wanted to change. “She said she had had an accident when she was about five or six, when a TV fell off a shelf onto her face. That trauma was likely the cause of some of the issues she had with her nose.

“The main thing she wanted was to straighten her nose, and to correct a little bit of obstruction from the deviation so she would be able to breathe a little better. She also told me she wanted her nose to look ‘less masculine,’ and wanted get rid of the bump on the bridge.

“So at the pre-op visit, we spent a lot of time on computer imaging—altering her photographs in different ways to show how changes would appear. And one of the things that we talked about doing was altering the tip of her nose. She told me she felt that the tip stuck out too far from her face and she wanted to get rid of what she called a bulbous tip.”

Form . . .

“My goal for every surgery I do,” says Dr. Gregg, “is to make changes that look natural. This is especially challenging with rhinoplasty, because the ‘new’ nose needs to fit the face—and each face is unique. This is where art and science meet. The science of rhinoplasty involves strict mathematical guidelines for analyzing the face—considering the lines, angles, and positions of eyes, nose, lips from front and sides. And you also have to take into consideration that none of us is exactly symmetrical. We’re actually two halves that come together. So one eye is different than the other, one side of the mouth can be different than the other.

“I always tell my patients, the problem with the nose is that it sits right in the middle of two sides that don’t match, so it needs to blend well. And that’s where the aesthetic part of it comes in. The altered nose needs to look natural, like it belongs on that particular face.”

. . . And Function

In Morgan’s case there were also functional considerations. “Morgan wasn’t having much breathing obstruction now from the deviations,” says Dr. Gregg. “However, my concern was that this could become a serious issue later in her life. With aging, the cartilage gets weaker. So if you’ve already got a deviation, even if it’s not bothering you in your 20s, it probably will bother you in your 40s, 50s, and 60s. To address this, I put in a spreader graft—which is a cartilage material from her septum—which not only helped straighten the left side of her nose, but will make it less likely that she’ll have a breathing problem when she’s older. You have to think long-term, not just short-term.”

Other Challenges

Rhinoplasty is a complex surgery for many reasons, notes Dr. Gregg. “For example, there are certain physical issues that will affect and perhaps limit your surgical options. One is the thickness and type of skin the patient has. Very thick skin does not reveal as much definition; very thin skin may reveal too much. That’s actually neither good nor bad, we just have to accept that there are some limitations.

“Trauma also can affect what you can and can’t do. It can sometimes make it difficult to straighten a nose. And, because you’re dealing with cartilage and bone that’s already broken or cracked, it’s already a little weaker to begin with. So, some options may not be possible.”

Outcomes

“Morgan’s experience demonstrates the power of subtle changes, planned carefully to achieve a natural look,” says Dr. Gregg. “The photos here were taken three months after her surgery. And while they show a remarkable improvement, she will still see more definition and more improvement in the months to come. Rhinoplasty can take up to a year or year and a half—particularly at the tip area—for all the swelling to go away and to get final definition. Nonetheless, even at three months, Morgan was thrilled. Her reaction that touches me most is that she said: ‘I have more confidence now.’ That, ultimately, is the best measure of success.”

For Each Patient:
Powerful Healing for
Their Unique Challenge

“I see the impact—the healing power—of the surgery I do every day,” says Dr. Gregg. “For the patient whose broken nose is straightened or whose protruding ears are pinned back the emotional, the personal benefits are clear. But in South Sudan, that impact is magnified, because of the cultural factors that punish those with cleft lip and cleft palate.”

For many years, Dr. Gregg has joined a surgical team sponsored and supported by Samaritan’s Purse that provides cleft palate and cleft lip surgery to patients in many parts of the world. This spring, the team worked in South Sudan where, she says: “Two of my patients illustrated the transformational power of a relatively simple surgery in an especially moving way. In both cases, it was the harsh social stigma attached to cleft lip that makes the surgical change so important, and the extent of that transformation is hard to measure. For the 23-year-old cattle herder pictured here, a cleft lip meant ostracism, poor work prospects, huge and lifelong limitations. At age 3, it was decided that he would not go to school but could only be a cattle herder. Now, life has options he had only dreamed of. This photograph—of him staring—for a long, long time—at his new face is incredibly poignant.

“The young boy in this second picture didn’t yet understand what difficulties were in store for him because of his cleft lip. But his grandmother understood. He had been abandoned by his mother because of his deformity, so his grandmother took him in and is raising him. Her determination to get him this life altering surgery is extraordinary—involving three long days, sleeping on the road between eight-hour bus trips just to bring them to the surgical center.”