Rhinoplasty: The Art & Science of Shaping a Nose

Rhinoplasty may involve multiple, often subtle, adjustments to reshape the nose. Shown: before and after a 19-year-old’s nose reduction surgery.

CYNTHIA GREGG, MD
FACE & BODY SPECIALISTS

Blending art and science is at the heart of Dr. Cynthia Gregg’s work as one of the area’s most accomplished facial plastic surgeons. An admitted perfectionist, she observes that “rhinoplasty—surgery to reshape the nose—is both among the most challenging and among my favorite procedures, because nothing has a greater impact on how a person looks than the size and shape of their nose.”

Dr. Gregg calls rhinoplasties “my millimeter surgery—because simply changing the shape or moving the nose as little as one to three millimeters can produce a striking difference in appearance. When someone’s nose looks as if it’s the product of a surgical procedure, it’s usually because it’s been altered too much. That’s one example of the art of facial plastic surgery.

Form and Function

Rhinoplasty is about more than simply changing appearance, emphasizes Dr. Gregg. “Of paramount importance is the need to respect and maintain functionality. The goal—for everyone—is to make the nose look natural, while still preserving breathing. Furthermore, we need to be sure that the things we do in a rhinoplasty will maintain themselves so the patient’s breathing will not be compromised as they get older—10, 20, or 30 years down the road.

“So, the first part of an initial assessment,” she says, “is to understand any functional issues: are there problems breathing? Allergies or a history of sinus infections? Has the nose ever been broken? And, while nasal obstruction and breathing issues may be related to trauma, genetics, or allergies, they also could simply be due to the aging of the nose. Because, as we age, the cartilage in the nose weakens and may contribute to breathing problems. So, we need to consider all factors that might impair optimal nasal function.”

But it’s also true that patients seek surgery—not because of functional problems, but because they’re just unhappy with the shape, size, or projection of the nose, explains Dr. Gregg. “It could be that they feel their nose is crooked; or it’s too large; or there’s a bump on the bridge they want removed. Whatever the reason, the goal always is to give them a natural looking nose that fits their unique facial structure and, at the same time, maintains the functionality of the nose.”

Achieving a Shared Goal

“Successful surgery doesn’t just happen in the operating room,” observes Dr. Gregg. “It begins with the initial consultation. We go through the medical part—assessing functional issues—and then get to the critically important question: ‘In an ideal world, how would your nose be different? What would it look like?’ That conversation leads to taking pictures and doing computer imaging. It’s a great educational tool because it allows them to see what a change will look like. Then it’s my job to show them what’s realistic and what’s not.

Rhinoplasty to straighten and reduce the size of a patient’s nose.

Analysis of a Nose

“The foundation of a successful rhinoplasty,” notes Dr. Gregg, “begins with a scientific analysis of facial structures. In a face that looks ‘normal’ and balanced, nose and eye widths are equal and each of them is approximately one fifth of the total facial width. Similarly, the facial profile is divided into thirds with the top third going from the hairline down to the top of the nose, the middle third consisting of the nose, and the bottom third going from the bottom of the nose down to the chin. There are also several angles on a facial profile that we use to analyze balance and proportion between the nose and the rest of the face.

“When we look at someone from their profile, for example, we analyze the balance and proportion of the nose in relation to the forehead and chin. So, if someone has a receding chin and a recessed forehead due to balding, a nose may look huge. But if you kept that same size nose on someone with a strong chin and a strong hairline, the nose may look perfectly fine.”

That “scientific” analysis, Dr. Gregg explains, “is a good starting point. But then you’ve got to look at the nose and the person’s face aesthetically. Everyone’s face is so different, and the real challenge of rhinoplasty is balancing art and science in a three-dimensional analysis of the face.”

“The consultation process is about coming to a place of shared understanding and expectations,” explains Dr. Gregg. “It’s not like I can go in and just shave off a piece of wood; the surgery is a dynamic process, with moving parts to it. So, there’s a lot of psychology that goes along with the rhinoplasty, and a lot of education.

“I need to determine if there are functional issues, but my most important task is to listen to and understand exactly what the patient wants to achieve. From there we can explore the best possible outcomes and determine how they can be accomplished technically.”

Anatomical Challenges

That issue—assessing what can be accomplished technically—is where “science” plays a key role, explains Dr. Gregg. “People have different skin thicknesses and different cartilage strengths. Certain ethnicities have very thin skin and very strong cartilage; other ethnicities genetically may have very flaccid cartilage and very thick skin, giving them a very different nose. These differences may impose limitations on what can be accomplished.”

Age is another important factor, she points out. “Doing a rhinoplasty on someone who’s 28 is completely different than on someone who’s 58. Simply put: our noses age as we get older. The skin thins; the cartilages thin and have more laxity—affecting breathing.

“So, anticipating the changes that come with age is essential. Furthermore, timing is important. We don’t do a rhinoplasty or a septoplasty until a person is mature physically—after 16-18 for girls and 17-20 for boys—because we don’t want to disturb any growth plates that haven’t finished growing.”

Achieving Balance

“The art of rhinoplasty, notes Dr. Gregg, “can best be summed up in the word ‘balance.’ When planning surgery, I look at each patient in terms of achieving balance in their face. There are certain basic guidelines for a ‘balanced’ face, in terms of proportions of facial features (see box). Those ‘guidelines’ are simply the proportions and relationships that we instinctively perceive as normal and natural.

“In addition to helping patients understand what’s possible anatomically, I help them understand an aesthetically balanced face. I don’t tell patients what their nose should look like; my job is to tell them what their options are for achieving their goals. And it can be more complex than simply reshaping the nose.

“For example, some people think their nose is over-projected and want it reduced considerably. But studies have shown that up to 30 percent of people who thought their nose was too large actually had a recessed chin. That’s a question of balance. “What I say in those cases is, “look, I can only bring your nose back this far safely, but we can bring your chin out a little bit.” So, we do the nose and the chin. It’s about giving them a balanced face.”

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