My Rhinoplasty Blog – A Surgeon’s Perspective

I’m Tarick Smaili, M.D., a plastic surgeon certified by the American Board of Plastic Surgery and the founder and medical director of the California Surgical Institute – a plastic surgery group serving California’s Orange County, Los Angeles and the Inland Empire.

Overview:

Rhinoplasty, also known as nose job, is surgery to reshape the nose. It is a very popular
procedure with over 310,000 operations being performed in the US each year. Usually patient requests include making a nose smaller, reducing the bridge of the nose, narrowing the nose, lifting a droopy nose, making changes to the nasal tip, revising a previous rhinoplasty and also to correct any or a combination of the following: Bulbous Tip, Too Wide, Too Narrow, Over projected, Under projected, Nasal Fracture, Twisted Nose, Droopy Nose, Upturned Nose, and other Unique Problems.

As you can see there are many aspects to the nose, and rhinoplasty is the most difficult procedure a plastic surgeon performs. After all it is the main midline and most visible structure on the face. It is a 3 dimensional part of the face with many different tissues comprising it. Including cartilage, bone, skin and most importantly has the function of breathing. In order to get perfect results, a surgeon must first be extensively trained in this field and be a graduate of an accredited plastic surgery program and should be board certified by the American Board of Plastic Surgery.

Philosophy:

My personal philosophy of rhinoplasty is to achieve a result that makes the patient happy without interfering with function. The patient must have realistic expectations to the result which will be determined during the initial consultation. It takes a good surgeon to say no rather than to have to redo a nose due to unrealistic expectations.

Rhinoplasty is an art and I believe that one is born with this innate factor and you develop it with many hours of experience and wisdom. You must have an artistic eye as well as eye to hand coordination without forgetting the healing process and the changes that might take effect after the surgery.

I focus on maintaining structural support, and seek a natural subtle appearance. This must fit well with the rest of the face especially the chin. Like most surgeries, rhinoplasty is both a science and an art, and it is this perfect blend of scientific mind and artistic interplay that makes a surgeon stand out.

The surgeon must also have a detailed understanding of the multiple anatomic variants encountered. Every patient is a different challenge and a different 3D piece of art.

Approaches and technique:

There are two general types of rhinoplasty:

1. The endonasal (“closed” rhinoplasty – all incisions hidden inside the nose) you really have to be trained in this as it is more difficult to perform
2. The external (“open” rhinoplasty – all incisions EXCEPT one small incision are inside the nose.) In open rhinoplasty there is one small incision across the columella, the skin between the nostrils.

I prefer the endonasal closed technique for the following reasons:

• No external scar
• The nose is in its final shape at all times so I can predict the outcome as I do any changes
• Faster healing of the tip and less swelling due to not interrupting the lymphatics
• Less effect on sensation of the tip

I do the component reduction of the dorsum “bump” of the bridge which has the best result expectation and prevents what is called “open roof deformity” which might occur with the traditional osteotomy.

Sometimes I will use cartilage grafts, most commonly taken from inside the nose or the ear to create a better nasal structure to do a revision.