Rhinoplasty

Above all facial plastic procedures, rhinoplasty is the most intimately tied with the otolaryngologic field. The historical roots of modern aesthetic rhinoplasty may be traced back to the late 19th century with the pioneering work of John Orlando Roe. Roe accomplished the remarkable feat of the first entirely intranasal rhinoplasty to correct what he termed the ``pug-nose deformity'' in 1881. Prior to Roe's seminal thesis, Dieffenbach among others performed his cosmetic nasal work via large vertical incisions across the external nose, leaving noticeable scarring and disfigurement. Roe's innovative techniques antedated even that of Jacques Joseph by 11 years. Besides his contribution to rhinoplasty, Roe, an otolaryngologist, had already published numerous scholarly articles (over 30) on various head and neck ailments, including many on functional nasal problems.

What distinguishes the art of rhinoplasty from many other facial plastic procedures is the paramount importance that the nose plays in both form and function. Above all, the nose is a respiratory organ that is chiefly responsible for humidification and airflow exchange. The rhinoplasty surgeon must be cognizant of this vital function of the nose at all times so that he may either correct a preexisting functional impairment or avoid the potential pitfall of creating one. Many rhinoplastic maneuvers destabilize the nose and contribute to structural collapse, so attention must be paid to restore the violated tip-support mechanisms to preserve functional integrity to the nose. The opening article of this journal addresses the fundamental, practical anatomy of which the rhinoplasty surgeon must be in command before embarking on any rhinoplasty endeavor, with attention paid to both the aesthetic and functional aspects of nasal anatomy. The functional nature of aesthetic rhinoplasty is further emphasized in the elegant article on structural grafting by Dr. Quatela.

Currently, rhinoplasty surgery appears to be divided into two factions, the endonasal and the external camps. Some rhinoplasty practitioners and scholars dogmatically argue on behalf of their approach. Both techniques are valid and merit discussion herein. Endonasal rhinoplasty permits reduced operative time and less surgical dissection, which may promote faster recovery and limit the variability due to scarring over time. External rhinoplasty offers an unparalleled view of the exposed nasal architecture to permit correction of less apparent structural or aesthetic anomalies and to provide the ability for suture fixation and sculpting. The second article in this journal attempts to approach rhinoplasty in a graduated, systematic fashion, in which the full arsenal of nondelivery, delivery, and open techniques is judiciously exploited on a case-by-case basis. By this reasoned approach, the surgery may be tailored to the individual characteristics of the anatomy and aesthetic and/ or functional concern of the patient.

Before Jack Sheen, revision rhinoplasty was an unthinkable project. The already mutilated nose was a terrain that was deemed verboten to the surgeon. Revision work is always fraught with risk. The unsatisfied patient may be harboring resentment to his prior surgeon and may be untrusting to his current choice. The admonition that the last surgeon who touches the nose owns it in the public's eye should always be remembered, especially by the novice rhinoplasty surgeon who may try to tackle a problem better left for his more experienced colleague. The operative bed may be excessively scarred, planes of dissection obliterated, and grafting material deficient. Dr. Adamson has skillfully addressed many important points concerning this difficult subject.

Our aesthetic ideals have been largely founded on the Caucasian model. Oftentimes we approach the nose with our predetermined rules of aesthetic principles based on Caucasian proportions and fail to grasp the subtleties that are unique to the ethnic nose. Not only are the skin envelope and underlying cartilage of the non-Caucasian nose completely different from the Caucasian counterpart but also any attempt to match the Caucasian nose may leave the patient looking unnatural and may fall short of desired expectations. Dr. McCurdy has published numerous monographs on the Asian nose and face and lends his expertise to the reader in this burgeoning field of ethnic rhinoplasty with his article on the non-Caucasian nose. As the world continues to shrink with technological advances multiplying rapidly and multi-ethnicity becoming more the norm than the exception, the rhinoplasty surgeon should endeavor to learn more about the unique characteristics of the East-Asian population to enhance his understanding and his practice.

The cleft-lip nasal deformity has a long history of many failed attempts due to the complexity of the problem. Besides all the orthognathic, otologic, and psychological issues attendant to the cleft-lip patient, the surgeon must encounter a varied anatomy (depending on the extent and bilaterality of the disorder) and must individualize his approach perhaps more so than with traditional aesthetic rhinoplasty. Dr. Sykes is a renowned contributor to the field of cleft-lip nasal surgery and has written a masterful dissertation on the subject in this issue.

The editors thank all of the authors for their scholarly contributions and for donating their valuable time and energy to this project. We have striven to provide a balanced, authoritative, embracive, and current representation of rhinoplasty in this edition of Facial Plastic Surgery. We hope that we were able to meet some of these objectives.