Mr Rowe-Jone's Blog

4th Mar 2010 - Teenager 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. 

1st Mar 2010 - 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.

23rd Dec 2009 - 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.

11th Sep 2009 - 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.

6th May 2009 - 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.

28th Apr 2009 - 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. 

29th Mar 2009 - 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!