Rhinoplasty

According to the American Society of Plastic Surgeons, nearly 45,000 rhinoplasties were performed in the United States (US) in 2022, making it the third most popular facial plastic surgical procedure after blepharoplasty and rhytidectomy (2022 ASPS Statistics). Since its first description by John Roe in 1887, both the technical and philosophical approaches to rhinoplasty have evolved substantially. Current indications for rhinoplasty vary widely, including aesthetic enhancement, improvement of nasal airflow, gender affirmation, and oncologic or traumatic reconstruction, each requiring different techniques. Early rhinoplasty was exclusively cosmetic and relied predominantly on reduction maneuvers. As understanding of nasal anatomy advanced, a more proportional approach to the operation developed, incorporating cartilage grafting and suture refinement. Among the pioneers of rhinoplasty are Jacques Joseph, Maurice Cottle, Samuel Fomon, and Jack Sheen, whose techniques remain in use today to varying degrees. Joseph, a German surgeon at the turn of the twentieth century, emphasized the importance of correcting the nasal septum while reducing the dorsal hump and strongly advocated for the positive psychological effects of aesthetic surgery. Cottle, the founder of the American Rhinological Society in 1954, invented the dorsal preservation technique for hump reduction and recognized the critical role of the nasal septum in shaping the external nose, famously stating, "As the septum goes, so goes the nose." Additionally, Cottle co-founded the American Academy of Facial Plastic and Reconstructive Surgery in 1964 with Goldman and Fomon. Fomon, who served as a US Army Medical Corps officer during World War I, began his career as an anatomist and brought his expertise and passion for teaching to facial surgery. He made education in rhinoplasty theory and technique widely available in the United States during the mid-twentieth century. Sheen is perhaps best known for his seminal textbook (1978 1st ed), but his insights opened doors to considering nonCaucasian/ethnic rhinoplasty and revision rhinoplasty. The latter has greatly benefited from the spreader graft technique he described in 1984. As rhinoplasty techniques have evolved, so has the understanding of the complex interplay among aesthetics, breathing, smell, and psychology, all of which are intricately connected within the small confines of the nose. An adverse outcome in these areas can mar the patient's perception of the result, while a good outcome can provide multifactorial benefits. The nose is the central landmark of the face; its proportions and symmetry are directly linked to the overall perception of facial beauty, making the stakes very high when attempting significant modifications. The broad range of nasal appearances among genders, ethnicities, and ages, coupled with anatomical variations from trauma and prior surgery, along with the myriad described operative techniques and the preferences of each patient, makes achieving consistent results challenging even for very experienced surgeons. The nose continues to change shape over time, especially after surgery, and predicting its appearance 20 years in the future is more art than science. For this reason, it has been said that rhinoplasty surgeons can only truly appreciate the extent of their surgical skills as they prepare to retire. Assessing outcomes in rhinoplasty is complex and challenging, requiring subjective and objective input from patients and surgeons. Surgeons typically rely on physical examinations and comparisons of preoperative and postoperative photographs within the context of normative nasofacial proportions to evaluate a surgery's success. They may also review their revision and complication rates, which are typically reported to be up to 15% and 3%, respectively, and track patient satisfaction. Patient-reported outcomes include validated instruments such as the Standardized Cosmesis and Health Nasal Outcomes Survey, Rhinoplasty Outcomes Evaluation, and Nasal Obstruction Symptom Evaluation questionnaires. These tools seek to quantify postoperative quality of life changes and are arguably the most important measures of a surgery's effectiveness. Consequently, patient selection is considered the most critical predictor of operative success and the most effective means of avoiding litigation or the need for secondary surgery, which is notoriously complex. Planning revision surgery, whether for cosmetic or functional reasons, must account for the difficulty of meticulous dissection through a previously operated and scarred field, the potential lack of available cartilage for grafting and structural support, injury to the vascularity of the nose and its impact on healing in the septum and skin-soft tissue envelope (SSTE), and the psychological impact on the patient, which may affect rapport and reasonable expectations. These factors, among others, must be considered when performing what is widely regarded as the most complicated of facial plastic surgical procedures.