Mr Rowe-Jones's Rhinoplasty Blog

Reflections on the Fifth Biannual International Milan Masterclass

It was a pleasure and honour for me to have been invited by my great friend Professor Pietro Palma to be one of the masters on his fantastic course this year. The other masters were Abel-Jan Tasman from Switzerland, Rollin Daniel from California, Steve Perkins from Indianapolis, Roxana Cobo from Columbia, Yong Ju Jang from Seoul South Korea, Joseph Wong from Canada, Dirk Jan Menger from Amsterdam and Gilbert Nolste Trenite from Amsterdam.

I find it extremely rewarding and stimulating to be in the company of international world field leaders and to be able to discuss common difficulties, experiences and potential solutions for the future.

One area we all seem to have difficulty with is the bulbous nasal tip in which the tip cartilages are mal-positioned. This has been called the parenthesis tip in the past. It is my feeling that tip stitches alone can lead to loss of normal contour. Grafting to the tip can help but this can lead to increased tip bulk at times. I discussed with Rollin whether or not repositioning the tip cartilages might help but we both felt this could lead to disruption of the dome area. There are many capricious aspects to aesthetic rhinoplasty!

The Regensburg Course in Facial Plastic Surgery.

It was a pleasure for me to visit Regensburg as an invited speaker. Regensburg is a beautiful city on the Danube that has recently been elevated to World National Heritage status.

This was the first time I had performed rhinoplasty on a patient for a teaching course in another country. Previously my experience of performing rhinoplasty “live for the surgical audience on TV” has been at the London Rhinoplasty Course at the Royal National Throat Nose and Ear Hospital. It was a particular challenge operating in a new environment with some instruments that were different from my own at home and operating for an audience with external and intranasal cameras. The experience concentrates the mind magnificently! I think live surgery is a fantastic challenge and undoubtedly such tense circumstances help one develop as a surgeon. I look forward to visiting Regensburg next year.

The Third International Congress of Rhinology, Otology and Skull Base Surgery Current Concepts

I travelled to Athens earlier this month, having been invited to give a lecture entitled “Rhinoplasty – The Demanding Patient”.

I took a lot of time to prepare for this lecture as I had not given it before. It also gave me an excellent opportunity to reflect on my own ideas and goals in treating the aesthetic rhinoplasty patient. It is my feeling that any patient who has visited me for a consultation or has undergone surgery should at the completion of their care with me feel happier than when they arrived whether or not we have agreed to proceed with surgery. There are instances in all aesthetic surgery when surgery would be inappropriate and not in the patient’s best interest. There are times when although a patient thinks that rhinoplasty is a solution to their problems it is not and their unhappiness stems from something other than their perception of their nose. In such circumstances surgery even when technically successful may not lead to the patient feeling happier and more self-confident and it is important to detect this in advance. I think it is of vital importance that when a patient sees me for rhinoplasty they are attending for a medical opinion not only on what is possible for them but most importantly on whether rhinoplasty is right for them or not. Rhinoplasty can have a fantastic effect on the self esteem and self confidence of well chosen patients but it is important to understand that rhinoplasty is only the vehicle for the journey to feeling happier and occasionally it may be the wrong vehicle and this has to be sensitively and carefully explained.

Reflections on the Seattle Rhinoplasty and the European Academy of Facial Surgery Meeting in Portugal

One of the lectures I gave and one of the topics for discussion at both meetings was treatment of the saddle nose. It is clear that all of us find this a difficult procedure. Unfortunately currently there is no perfect material to use. Artificial grafts risk infection and extrusion and patients own tissue for grafting requires surgery to borrow cartilage from the ear or the rib and involves difficulties of carving to the right shape. I and other speakers agree that in most cases surgery requires reconstruction of the nasal septum and for the severe cases use of rib cartilage. Often patients with saddle noses have loss of the normal angle between the nasal tip and lip and I presented my thoughts explaining as to why this is not a problem with the bone of the upper jaw but loss of septum length. I think the caudal extension graft is very significant in reconstructing this area. The use of rib cartilage I feel is appropriate for when tissue loss is severe only.

Conservatism and Wisdom in Cosmetic Rhinoplasty

My goal in rhinoplasty is to achieve the very best result possible for a patient based on what they want. This has to be tempered by what is possible.

Frustrating though it may be we have to understand that there are limitations on what it is possible to achieve. These limitations particularly relate to how small we can make a nose whether removing a bump, making a tip more refined or making the whole nose smaller. There are limitations because skin will not limitlessly shrink. In fact, if we make the nose too small under the skin and the skin does not shrink completely to fit the new size, a thick layer of scar tissue will form in the gap between the size of the nose underneath and the skin overlying the outside. This will create a poorly defined putty like nose. This is particularly true of thick skin. In thin skin if we remove too much bone and cartilage underneath the skin will shrink and distort the smaller underlying cartilage causing buckles and irregularities.

It is also true to say that there is a price to pay for every step of a rhinoplasty. We can make for example a tip look slimmer from the front and narrower but in the side view this might cause a nostril rim to lift up or notch. We are therefore always weighing up the pros and cons of every step to achieve a good balance.

Wisdom is acquired from “the school of transactions”. Experience tells me that in surgery if we can keep it simple we should. This does not mean not trying our very best but it means experience has taught that we should limit risk.

There are times when only complex surgery will offer any chance of improvement and in these circumstances the patient must clearly understand that risks might be higher and make their own informed choice based on this knowledge.

Generally speaking I feel that being conservative in cosmetic rhinoplasty means being wise and very carefully understanding the risk versus benefit relationship.

Revision Rhinoplasty

A successful outcome in rhinoplasty surgery depends on patients understanding what they want from cosmetic nasal surgery, both physically for the shape of their nose and psychologically. It comes from the surgeon understanding what the patient wants and understanding what the patients concerns are. It depends on the surgeon understanding the patients nose and it depends on the surgeon explaining to the patient, from this understanding, what is possible and what the risks are. It also of course depends upon the surgeon performing the surgery well and following a carefully considered operation plan. There are unpredictable elements in rhinoplasty and the final outcome also depends upon favourable healing.

If a patient wants revision surgery it is because there has been a failure of one of the steps above or unluckiness in the healing process.

In considering a patient for revision surgery the surgeon and his team must understand where the failing occurred. It is important for the revision surgeon to be aware that a patient may have had a good result from their primary surgery but that their expectations may be unrealistic and they’re looking for a perfect result which is not achievable. In such circumstances further surgery would be unwise. I see a large number of patients for revision rhinoplasty and generally if I had seen them prior to their first operation and would have felt it was not in their best interests to offer them primary surgery then it certainly is not in their best interests for me to offer them further surgery.

If revision surgery is appropriate then it’s my experience that the majority of patients who’ve had surgery elsewhere and are requesting revision surgery have had too much reduction surgery performed initially. This means that the majority of revision operations require grafting and are complex procedures.

It’s extremely important to understand perhaps even more in secondary than primary rhinoplasty that there are limitations on how the tissues can be reconstructed and how the skin will either shrink to a better new shape or stretch to a more balanced new shape.

Wisdom and experience should help the surgeon to guide and advise on what is or isn’t possible for these difficult cases.

Helping patients to understand what can be achieved is perhaps even more important in secondary than primary rhinoplasty to avoid yet further disappointment.

I have constructed the Rowe-Jones Rhinoplasty Journey™ comprising two modules, The Rhinoplasty Discovery Program™ and the Rhinoplasty Vision Achiever™ to help patients understand what we can achieve and what the risks are and to optimise the outcome when patients do decide they would like further surgery.

Teenage Rhinoplasty

Happiness for rhinoplasty patients is achieved when expectations are met, or even better when they are exceeded. It is therefore so important that patients have realistic expectations. This ideal state can only be reached if the surgeon understands what the patient wants and helps the patient understand what can be achieved for their nose, what the limitations are and what the risks are. Only then can the patient know what to expect and if it is what they are hoping for.

I think this is especially true for teenagers wanting rhinoplasty. The opportunity to have surgery may be a present, perhaps offered at the ideal time after leaving school and moving on to a first job or university and a new group of friends. Such an opportunity is associated with all the excitement that a gift can bring. Furthermore, expectations may be inflated due to pressure in the body conscious, beauty driven world of celebrities and media manipulation. A sense of entitlement may be present in some teenagers and there may be areas of emotional upset that the teenager thinks can be resolved by achieving a new nasal shape. Of course this may not be the case.

I think it is also true that teenagers may not appreciate that rhinoplasty is serious surgery and that the operation is considered probably the most difficult of all the cosmetic facial plastic surgery operations. I have seen many patients who rushed into rhinoplasty in their teens without researching the operation first and who later greatly regretted their rush into surgery and its results.

I also think that surgery should err on the side of conservatism in teenagers. Surgery should certainly not be performed before the age of 16 as the nose is likely to still be growing up until this age. Skin also tends to be thicker in teenagers so greater refinement of the nasal shape may occur with age anyway. It is important that surgery is predictable in the long run and so rhinoplasty should concentrate on reshaping and maintaining support rather than removing too much tissue in pursuit of a little nose that lacks balance and harmony. Good qualities in a nose should be recognised and maintained and a standard approach based solely on removing tissue should be avoided.

None of us can predict fashion change either. The small Barbie doll noses of the 1960’s are not considered fashionable now so again I think it is better to err on the side of conservative rather than radical surgery.

To compliment our rhinoplasty surgery I have put together a rhinoplasty discovery programme™. The components of this programme are all about providing patients, absolutely including teenagers, with all the information they need to understand what they want for their nose and what is possible. We also think it is extremely important that patients are fully informed of the risks of surgery. Only then are they able to make a decision with the help of their family and friends and with our honest advice and support as to whether they would like to proceed with surgery.

Rhinoplasty in the USA

I recently returned from the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) meeting in Florida. It was great to catch up with international friends and to make new friendships. Those of us who have a particular interest in Rhinoplasty form strong bonds and friendships sharing experiences both high and low received from this most demanding of operations. There can be few if any other operations that can dominate a meeting programme in terms of hours dedicated to the subject than Rhinoplasty!

I lectured on surgery to de-project the nasal tip. My philosophy is to take a very analytical anatomical approach to diagnosing the problem and then a step wise graduated surgical approach to correction. I do think it’s important to be aware that there’s a limit to how much the skin will shrink to a smaller nose and therefore at times it’s better to maintain a little more projection than one might ideally want so that a slim nasal tip can be maintained from the front. Too much de-projection might lead to the nose looking bulbous from the front. This can be quite difficult to explain to patients at times.

I travelled from Miami to California for 5 days after the meeting. It was my great pleasure to be able to spend time in the operating theatre with Rollin Daniel in immaculate Newport Beach and Paul Nassif and Jay Calvert in Beverly Hills. Rollin has reflected on rhinoplasty as having essentially three levels of difficulty and complexity in the cases that present. As surgeons, those of us who look towards operating on the most difficult level 3 noses know we must really expand the envelope and push ourselves out of our comfort zones. It was therefore great for me to see colleagues I respect operate on revision cases, which are certainly level 3 and to swap ideas and thoughts.

I am sure that highly precise, accurate reconstruction of the nasal skeleton to restore support and contour to the nasal skin envelope is the right way to go and my experience leads me to feel now that often ear cartilage is inadequate for this reconstruction and that rib cartilage is the best way to proceed. I saw two very interesting rib cartilage cases with Rollin and Jay and saw Paul use injectable diced cartilage to finesse the nose.

Rhinoplasty is a very difficult operation and one has to be prepared to put huge effort in to get the best results out. This effort must extend into every aspect of surgical care from the analysis through the planning to the final actual surgery. It was interesting for me to see that we all share in common the need for unstinting energy and enthusiasm in focusing on attention to detail. This is important in all areas, including taking photographs during surgery and recording meticulously the surgical steps used to allow later reflection and comparison with the final result. We shared laughs too remembering it is also about enjoying the challenges of this great area of facial plastic surgery with great teams.

On my return I was also honoured to have been invited to give a lecture at the AAFPRS meeting in Chicago 2011. I will start preparing ideas now!

Reflections on tip mal position

I performed a secondary rhinoplasty last week for a male with a bulbous tip and nasal nostril collapse and weakness. The nostril weakness was making breathing difficult during exercise.

At surgery although I noted he had particularly large tip cartilages they were positioned too far up the nose away from the nostril edges. This causes unnatural, bulbous curvature in the nasal tip and is associated with weak support to the nostril margins particularly when breathing in. I therefore used an open approach freed up the tip cartilages and swung them down to lie along the nostril rims. I strengthened them with struts of cartilage taken from the nasal septum. Rollin Daniel and I have discussed this technique before and recognise that it must not be considered lightly as a change in one part of the nasal tip cartilages can lead to abnormal changes in other areas which have to be counteracted with stitches and grafts. I saw Rollin use this technique in California 3 weeks ago which helped me think about my own technique more and it was good to have such a case to do when I returned home. I think the key is to fix the dome areas and the medial crura first before repositioning the lateral crura. After repositioning the lateral crura the infra tip lobule position must be reassessed as there is a tendency for the tip to rotate and turn up. This may need to be balanced with an infra tip lobule add on graft.

Modern Rhinoplasty – Staying Current

Lecturing and teaching both at home and abroad on rhinoplasty is a very rewarding part of my professioal life. I have just lectured on the use of rib cartilage for the saddle nose and the twisted nose in Geneva. Not only do I enjoy communicating my thoughts and ideas with others but I also find extremely stimulating the feedback and discussion I have with other invited members of these national and international panels. Putting together lectures and teaching videos also helps me reflect and crystallize my own thoughts as well as giving me the impetus to research the thoughts and ideas of others with whom I share rhinoplasty symposia and sessions. I particularly enjoy discussions and sharing ideasand surgical difficulties and solutions with my colleagues from Europe and America. Some of our most stimulating conversations are over a drink outside the lecture halls!

When I was training in rhinoplasty over 15 years ago much surgery was performed through a closed approach and favoured a philosophy of re-contouring the nose mainly through removal of tissue. Whilst very good results can be achieved for some noses using this approach I believe things have moved on since then and I have moved away from widespread application of closed surgery.

My travels to other surgeons and my time spent lecturing on panels with other surgeons from across the world since has led to me using the open approach for many of my rhinoplasties. I believe this does reflect a different philosophy and approach to surgery where structural grafts such as columella struts, spreader grafts, alar support grafts and lateral crural strut grafts along with stitches and sutures are used to reshape and support the nose. This minimises the amount of cartilage and bone that needs to be removed. I feel this leads to a more balanced nose which is more harmonious with the face in general terms and in which long term outcome may be more predictable and the affects of healing less left to chance than they might be when removal of nasal framework alone is relied on. A good, contemporary rhinoplasty result should look natural and not “done”.

My current practice reflects these thoughts and moves beyond what I experienced in my early years learning rhinoplasty. This contemporary approach to re-building the support framework of the nose and in severe cases using rib cartilage has I believe really advanced surgery particularly revision surgery for the over-reduced nose.

As I have discussed in my previous blog on wisdom in rhinoplasty though there is always a balance to be drawn between complex surgery to maximise the result and a desire to keep things simple so as to limit risk – a difficult equation.

Staying current and contemporary to me means travelling, visiting and lecturing, reflecting, listening and sharing thoughts and ideas with others who are also passionate about rhinoplasty. Amongst this quite small group of surgeons I have joined internationally, many have become great and valued friends.