As otolaryngologists and facial plastic surgeons, we are fortunate to have the opportunity to perform many challenging operations of the head and neck. Many would agree that rhinoplasty is one of the most complex facial plastic operations that we perform. Why is this operation so complex? First of all, whereas many of the other operations performed in otolaryngology have uniform, predictable anatomy, every nose has different anatomy, which is reflected by different nasal contours and deformities. For example, when performing a mastoidectomy, paranasal sinus operation, or neck dissection, the anatomy is predictable. This allows the surgeon to use a more uniform surgical approach to correct the underlying problem. When performing a rhinoplasty, however, no two patients have identical anatomy. This requires the surgeon to modify his or her technique based on the anatomical findings. The surgeon must choose a technique that is appropriate for the given anatomy and proposed aesthetic and functional goals. When a single technique is used for all rhinoplasties, the surgeon is not recognizing the variance in anatomy that should dictate how the structures of the nose are managed.
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November 2006
The other unique aspect to the rhinoplasty operation is the aesthetic component. Most procedures performed by otolaryngologists do not have an aesthetic consideration. Aesthetics have a significant subjective component and require a right-brained approach. Most operations in otolaryngology have well-defined outcomes. Hearing loss, tumor ablation, and incidence of infection are examples of more concrete outcome measures that can be used to measure the success of an operation. Success in rhinoplasty, though, is not easily defined. Patient satisfaction and functional outcomes can be measured, but success in the aesthetic outcome of rhinoplasty is not easily defined. This is another major reason why rhinoplasty is such a unique operation in otolaryngology.
Once the operation is completed, healing must occur in a favorable manner to attain a good long-term outcome. The healing in rhinoplasty continues throughout the patient’s entire lifetime. An outcome at one year can be drastically different from the outcome at 20 years. Rhinoplasty is one of only a few operations in otolaryngology with such variability in results over time.
Skills for Success
Success in rhinoplasty requires three major skills to reach a high level of competence. First of all, the surgeon must be a very good diagnostician. Analysis in rhinoplasty is critical to success because one must be able to correctly identify the problems in order to plan the correct surgery. One can be an excellent technician, but if the incorrect procedure is performed, the outcome is likely to be suboptimal. The surgeon also must be able to execute the operation properly. If the proper diagnosis is made and one has chosen the correct operation but failed to execute it properly, then a suboptimal outcome is more likely to occur. Finally, the surgeon must be a good clinician. This requires a person to be a good communicator and empathetic to the patient’s needs. Being a good clinician also requires one to be able to select good candidates for surgery and identify those who have unrealistic expectations or misguided motives for undergoing surgery. The surgeon also must be able to identify patients that have deformities that are beyond his or her level of expertise.
In order to elevate oneself to a high level of competence, any surgeon interested in performing rhinoplasty must make a commitment to study the rhinoplasty operation. This begins with substantial exposure to rhinoplasty during residency training. Residents should receive basic lectures on aesthetic and functional rhinoplasty focusing on principles of rhinoplasty. They should also learn how to analyze the rhinoplasty patient. In my practice, I see many patients who require secondary rhinoplasty, and most of the poor outcomes are due to errors in judgment or inaccurate analysis. Such problems can be avoided but require refinement of ones diagnostic skills. It is the responsibility of the training programs to provide substantial exposure to rhinoplasty during residency, as this is the most common aesthetic operation performed by otolaryngologists in practice.
More advanced training can be achieved through course work or an observational period with a busy rhinoplasty surgeon. Numerous rhinoplasty instructional courses are offered at our annual fall meetings. These courses provide the participant with a broad range of topics related to rhinoplasty analysis and surgical management.
Fellowship training is an excellent means of gaining exposure to rhinoplasty. Spending time in the office with busy rhinoplasty surgeons will be helpful because the fellow is able to observe the healing process from rhinoplasty in a number of patients. The fellow will also be able to see how the surgeon handles the occasional suboptimal outcome or the difficult patient. By sitting in on a consultation, the fellow can see how the experienced surgeon educates the patient and may also see how computer imaging can enhance the educational process.
It appears that there is a shift in rhinoplasty referral patterns with the Internet becoming a more prominent source for patients to gather information. This is also resulting in fewer rhinoplasties performed by less experienced surgeons. Unfortunately, this makes it even more difficult for these surgeons to sharpen their skills. The otolaryngologist and facial plastic surgeon have the unique opportunity to see many patients who are seeking correction of a functional problem or post-traumatic nasal deformity. I have seen numerous patients who were seeking correction of a functional problem and were left with cosmetic deformity as well as worsening of their functional status. As otolaryngologists and facial plastic surgeons, we must work very hard at correcting all functional problems and never compromise function for aesthetics.
Lifelong Learning
How can we enhance our level of rhinoplasty expertise? I believe expertise in rhinoplasty is based not on years in practice or the number of rhinoplasties performed, but rather on one’s ability to apply objectivity to this operation. This requires making associations between cause and effect. By following one’s own rhinoplasty patients long-term, the surgeon can make associations between specific techniques and outcomes.
When performing rhinoplasty, as with any aesthetic procedure, one must have an effective means of performing preoperative photographic documentation of the patient. Special care must be taken to create only the highest quality photographs as a preoperative record. After surgery, very precise rhinoplasty operative diagrams should be completed to record the details of the operation that was performed. The more precise this record, the more helpful it will be in the follow-up of the patient.
With good records (pre- and post-op photographs, rhinoplasty worksheet, and operative report), the rhinoplasty surgeon can see the patient in the office, assess the outcome, and learn by correlating the patient’s records with the results. The surgeon is encouraged to engage himself or herself in a mental exercise with every patient by trying to figure out what was the direct cause of every suboptimal component of every rhinoplasty done.
Learning rhinoplasty is a lifelong process, and we all can learn from every rhinoplasty that we perform. The educational process begins as soon as the patient’s cast is removed. Every time you see the patient in the office for follow-up, this represents a single point on a continuum of healing that extends over the lifetime of the patient. It is unlikely that the contour noted at one year will be the same as the outcome at 10 years. In fact, in some cases these changes are dramatic and influenced by the forces of scar contracture that act on the nasal structure over time.
It is time for otolaryngologists and facial plastic surgeons to further develop their rhinoplasty skills and, as a result, provide an even higher level of care to our patients. This begins with elevating our expectations on rhinoplasty and intensively studying the operation to improve our outcomes. As a specialty we have the opportunity to establish ourselves as the rhinoplasty specialists. This is not given to us by default. We must earn this status.
©2006 The Triological Society