Tony Raymond Bull – Beauty, Form or Function?

Written by Hesham Saleh

Nasal plastic surgery is an interesting and important branch of our speciality and concerns surgery of an anatomical part which is very readily apparent, and not easily concealed. A nose can certainly be conspicuous and ugly, and deformity is frequently associated with airway obstruction. Those not particularly interested in rhinoplasty must occasionally sympathise and feel that some correction is called for with a patient requiring septal surgery whose nose has an obvious, marked external deformity. An ugly nose therefore is readily apparent, but a beautiful and aesthetic nose is less obvious and definable. In the endeavour to reach beauty, the surgeon will often encounter a conflict between form and function. One should not be favoured over the other as it is the surgeon’s goal to achieve a balance.

Rhinoplasty usually presents, in both Ear, Nose and Throat and Plastic clinics, and the common complaints are specific. The nose has a hump, or there is a saddle deformity, or a deviation: it may be too wide or too large. In women, more commonly finer complaints may be made about deformities of the nasal tip. One must be very suspicious of males who present with nasal deformity, particularly when minor, for a number of grossly disturbed psychiatric patients are concealed in this group.

The very large nasal deformity may not prove as easy to manage as it would appear.

The attitude that the nasal deformity is ‘so severe that it can only be improved’ may be expressed, but the gross deformity is more difficult to correct than the moderate deformity for an ‘operated appearance’ and nasal obstruction may result in the same way that a gross deformity may present problems, the very minor deformity may be equally awkward. Not infrequently a patient listed for correction of the septum asks as a Parthian shot whether a small nasal deformity can be corrected at the same time. The request is made as if little if any extra effort or expertise is required and that the operation can easily be combined with the operation on the septum. The minor deformity, however, particularly with thin skin, is not easy, for the exact small amount of the right tissue must be removed so that irregularities and a deterioration in the appearance of the nose—particularly with a ‘surgical look’—is to be avoided. One therefore has little to gain with these patients, and a lot to lose if the operation is not very precise. The moderate deformity therefore is the easier aesthetic nose for operation and one that is likely to lead to the least complaints from the patient and hence the least problems for the surgeon.

A request for rhinoplasty is frequently accompanied with a request for improved breathing and vice versa. External nasal deformity should be noted before proceeding with correction of the septum and perhaps commented upon pre-operatively in case the patient is reluctant to mention it. A standard sub-mucous resection, although a good operation, is unsatisfactory if it is to be followed by a rhinoplasty. Separation of the upper lateral cartilages from the septum in these cases predisposes to a saddle deformity, so that a submucosal resection preceding a rhinoplasty prejudices a good result.

Septoplasty techniques aim to preserve as much septal cartilage as possible and involve fracture and reposition of the nasal bony structures—vomer, ethmoid, maxillary crest and also, the nasal bones, with excision of any projecting portions of bony septum. This is coupled with minimal cartilage removed and a number of maneouvres employed to persuade the deviated cartilage to take up and maintain a midline position. Although the septum and turbinates are the important and commonest structures influencing the airway, the nasal obstruction is not infrequently at the inlet or valve. The columellar portion of the septum is commonly dislocated into the nasal vestibule causing an ugly deformity with nasal obstruction. This may be associated with a fracture of the nasal spine which is not in the midline and on which the cartilage rests. Providing the columella is not retracted, it is better to excise this cartilage. Cartilage morcellising and other cartilage incising maneouvres, to persuade twisted cartilage to take up a midline position, at the best give a thick columella and at the worst results in the cartilage taking up its previous position. The problem, however, with excessive removal of the columellar septum may be retraction and more uncommonly loss of tip support. If a considerable portion of cartilage is excised, replacement in a separate pocket anterior to the base of the medial crus as a ‘filler’ to the columella prevents the appearance of columellar retraction. The feet of the medial crura may also cause an ugly deformity often accentuated by telangiectasia as well as airway obstruction. Providing there is no tip deformity these feet can be excised.

Airway obstruction at the nasal vestibule due to narrowing in the region of the latera crus of the alar cartilage and the junction with the upper lateral cartilage—sometimes called the nasal ‘valve’—is difficult to manage. There is no one simple operation available, whether the narrowing is congenital, traumatic or a complication of nasal surgery. Before considering the techniques available it is important to make sure that no further room can be achieved either by thinning or further correcting the septum, by reducing the base of the medial crura, or the anterior end of the inferior turbinate. If none of these factors are relevant there are several alternative methods to be considered.

After three or four revisions the likelihood of significant improvement and a patient satisfied with rhinoplasty is poor. If a dictum is difficult to follow. After rhinoplasty a residual or new deformity presents obvious pressures to revise early. A premature operation before the nose has fully healed may well lead to a spiral of repetitive and unsatisfactory operations.

Perfection in rhinoplasty may seem to be the obvious aim at the outset of the operation.

Paradoxically, striving for such a result may in some cases achieve the very opposite. Improvement in appearance is the aim of the operation, providing that the technique does not give an operated appearance and impairment of the function of the nose. A balance between form and function is, therefore, what really defines beauty.