Rhinoplasty describes an array of operative techniques that can be used to alter the aesthetic and functional properties of the nose. Surgical access to the nose can be gained via incisions placed inside the nose (endonasal approaches) or via incisions placed inside the nose combined with incisions placed outside the nostrils (external approach), usually on the columella.
The history of nasal surgery is indeed long. The Edwin Smith surgical papyrus from ancient Egypt outlines the diagnosis and treatment of nasal deformities some 30 centuries ago. In approximately 800 BCE, Sushruta, of India, described a nasal reconstruction approach based on the transfer of a pedicled forehead skin flap. In the 16th century, Tagliacozzi of Bologna, Italy, used brachial-based delayed flaps to reconstruct noses. The science and art of rhinoplasty remained essentially stagnant until the 19th century. Approaches to correcting nasal deformities were used by early plastic surgery pioneers such as Dieffenbach in the 1840s, who used a buried forehead flap to cover the nasal dorsum.
The first published account of a modern endonasal rhinoplasty can be traced to an American otolaryngologist, John Orlando Roe. His original article published 1887 was titled "The deformity termed 'pug-nose' and its correction, by a simple operation" and described the treatment of saddle nose deformities. In 1892, Robert F. Weir, another American surgeon, also published his techniques for correcting the saddled nose.
In 1898, Jacques Joseph, an orthopedic surgeon by training, presented his revolutionary concepts of nasal surgery to the Medical Society of Berlin. Many aspiring rhinoplasty surgeons traveled to Germany to watch Joseph perform his rhinoplasties. His general reputation as the father of modern rhinoplasty can be supported by his influence in shaping many rhinoplasty concepts and techniques. In fact, many of the basic rhinoplasty maneuvers remain essentially the same today as when Joseph first described them. Joseph's concepts and techniques were further disseminated (especially in the United States) by surgeons such as Gustav Aufricht, Joseph Safian, and Samuel Fomon. Fomon's teachings and medical review courses on endonasal rhinoplasty helped in the education of countless early modern rhinoplasty surgeons, such as Maurice Cottle of Chicago and Irving Goldman of New York.
In the relatively short history of modern rhinoplasty, many additional rhinoplasty masters have contributed to the advancement of the field. Countless surgeons continue to advance our understanding of the art and science of rhinoplasty through their scholarly and clinical works. The continued sharing and dissemination of rhinoplasty knowledge has hopefully benefited the patient and surgeon alike.
In general, nasal analysis can be divided into 4 basic components addressing the different areas of the nose. The first is the lower third of the nose (nasal tip and base), the second is the middle third of the nose (middle vault), the third is the upper third of the nose (bony vault), and the fourth is the septum. The typical first steps in a successful rhinoplasty are (1) a careful preoperative analysis of the patient's concerns and nasal deformities and (2) the generation of a problem list. Accurate preoperative diagnosis of both aesthetic and functional problems can then facilitate appropriately targeted rhinoplasty maneuvers.
After a routine (but important) medical history interview and physical examination, the surgeon's focus is directed to the face and nose. The patient evaluation begins with listening to the patient's main concerns and requests. Despite the fact that most patients seek to undergo rhinoplasty for aesthetic reasons, the functional role of the nose must be kept in mind.
Questions about nasal function are paramount, especially in many patients who may have previously undiagnosed functional nasal problems. Most rhinoplasty procedures tend to narrow the nasal airway. As such, a patient with a preoperatively borderline-normal nasal airway may experience postoperative nasal breathing problems. By recognizing functional issues preoperatively, many patients' nasal airways may be improved by nasal surgery. The physician has the responsibility to diagnose and educate the patient about any existing functional deficits. No amount of aesthetic gain is worth crippling the function of the nose. Finally, as with any plastic surgery procedure, the patient's psychological stability, ability to understand the risks and benefits of the proposed procedure, and sense of body self-image must be evaluated.
Aesthetic goals in rhinoplasty are shaped by the patient's requests, the patient's nasal anatomy, and the surgeon's recommendations based on aesthetic ideals. A complete discussion of facial aesthetics is beyond the scope of this article, but a number of salient points are highlighted. Aesthetic ideals and proportional norms of the human face and nose have been well studied and documented by artists, behavioral scientists, and physicians. These aesthetic norms have validity in most white patients, but they may not be as useful in patients of other races. Ideal anthropometric values for a number of facial angles and ratios can serve as a useful guide. Ideal facial and nasal angles are as follows:
- Nasofrontal angle - 115-130°
- Nasofacial angle - 36° (30-40°)
- Nasolabial angle - 90-105° (males), 100-120° (females)
A surgeon's ideal rhinoplasty outcome may not always be congruent with the patient's desires. The surgeon should discuss the rhinoplasty plan and his or her recommendations with the patient during the preoperative consultation. The surgeon should proceed further only when a clear, mutual understanding of the rhinoplasty goals has been achieved. The end product of a well-executed rhinoplasty includes (1) bilateral symmetry, (2) an unbroken brow-tip aesthetic line, (3) a straight nasal contour on frontal view, (4) adequate nasal sidewall shadowing, (5) a smooth dorsal profile, and (6) a nose that is in harmony with the rest of the face.
At the end of the the day, much of rhinoplasty excellence rests on the hands, judgement and experience of the surgeon. Dr. John Vartanian , is a double-board certified facial plastic surgeon with specialized expertise in primary and revision rhinoplasty. More information on Dr. John Vartanian at
