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Rhinoplasty is well known to be a challenging facial reshaping surgery. This is  because of its many anatomic components and the lack of an exact science as to how their alteration and healing will translate into the patient’s desired aesthetic effect. Considerable debate has existed for decades as to which approach to rhinoplasty, open vs closed, offers the best result. But in reality this consideration is way down on the list as to why rhinoplasty surgery may not produce the desired results.   

In the November 2021 issue of the Plastic and Reconstructive Surgery journal an article was published on this topic entitled ‘Why Primary Rhinoplasty Fails’. In this paper the authors review seven (7) preoperative and intraoperative reasons why this happens which includes poor patient selection, incongruent patient expectations, inadequate preoperative nasofacial analysis, creating a functional problem, wound healing, lack of structural support and dead space closure.


Poor Patient Selection

Good patient selection is obviously critical for any aesthetic surgery and rhinoplasty is no different. Rarely is a ‘poor’ patient so obvious that the so called red flag is literally evident on their forehead during the consultation. The authors have discussed multiple indications that can help identify the more subtle signs of patients that are at higher risks of postoperative dissatisfaction. One of these signs, which has been recognized almost as long as rhinoplasty surgery has been performed, is the disconnect between the magnitude of the nasal deformity and the patient’s concern about it. When the nose shape problem seems way less than the level of the patient’s distress about it one has to be very careful about moving forward with surgery. That is a lot of pressure to put on an operative outcome which the patient hopes will be potentially life changing.  

One of the more contemporary red flags, because of social media, is the younger patient in particular who comes in with many pictures of celebrities noses, other people’s results, and have done their own often unrealistic imaging of what they want their nose to look like. They may well have dozens to hundreds of pictures on their phone of noses, theirs and others, from every conceivable angle. While such forethought is not always bad it can lead to patients assuming that changing the shape of the nose is almost like changing one’s clothes. Surgery is not like Instagram, results are neither immediate or always turn out exactly like imaged pictures.

Incongruent Patient Expectations

While understanding what the patient wants to achieve is important, helping the patient get a handle on what can not be done is even more important. Every rhinoplasty patient needs preoperative imaging but the role of such imaging is frequently misunderstood or misused. Since computer imaging can be used to literally make any digital image change the key to its use in my opinion is to show truly realistic imaging. Or even better underestimate the magnitude of the potential nose shape change. This is the well known underpromise and over deliver approach. It is important to recognize that patients largely focus on the benefits of any aesthetic surgery, which is largely what they have thought the most about, and risks/adverse outcomes are issues that happen to others. As a result it is important to help the patient understand what the limitations of their rhinoplasty surgery is to provide some balance in their thinking.

Inadequate Presurgical Nasofacial Analysis  

Assessing the nose visually from different angles is critical but feeling the outside of it and looking inside has great merit also. Whether the patient has breathing problems or not it is always a good idea to take a speculum and light and have a look inside. While this does not allow for a view all the way back to the choanae it does provide visualization of the mid- to caudal septum, internal nasal valves and the inferior and middle turbinates. Sometimes you might be surprised as to what you find.

The authors lay out a 10-7-5 detailed anatomic assessment system from the front, side and the basal views. This is an excellent guide that can be used as a work sheet that allows the surgeon to not overlook any aspect of the preoperative nasal analysis. When matching this assessment with the patient’s three primary nasal concerns one is largely assured of not missing how on how to a surgical plan that has the best chance for a good outcome.    

Dr. Barry Eppley

Indianapolis, Indiana

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