Richard E. Davis, MD FACS - The Center for Facial Restoration in Miramar, Florida

Eyes Wide Open

After nearly two decades of performing both reconstructive and cosmetic nasal surgery, I am still amazed by the large number of rhinoplasty patients who experience complications from sub-standard nasal surgery. Although one might be inclined to blame a small handful of incompetent surgeons, surgical ineptitude is not confined to any particular specialty or to any specific geographic region — it exists in every community and fundamental treatment errors continue to ruin a surprising number of rhinoplasty cases nationwide. In fact, even cosmetic surgery hotbeds like Los Angeles, New York, or Miami fall victim to faulty surgery. Ironically, while most consumers would carefully comparison shop for a high-ticket item of similar value, cosmetic surgery is often given a pass when it comes to consumer scrutiny and verification. Frequently, the unsuspecting patient never thinks to question the surgeon about his or her training, experience, or success rates. After all, most of us trust the medical profession. Yet, there’s no law against poor artistic judgment or surgical mediocrity, and thousands of patients have learned this lesson the hard way.

In actuality, rhinoplasty is widely regarded as the most difficult of all cosmetic procedures. Even a modest change in nasal contour requires a sophisticated understanding of nasal anatomy, precise surgical technique, and familiarity with the myriad pitfalls that can lead to potential complications. For most surgeons, near total dedication to the study and practice of this demanding operation is needed to achieve mastery. For this same reason, rhinoplasty is also perhaps the least commonly mastered of all cosmetic procedures, and naïve or misguided surgical strategies often result from under-appreciation of this exacting and complex operation. And while your local surgeon may have a justifiably stellar reputation for other types of cosmetic surgery, his or her mastery of this highly specialized operation may be far from cutting edge. In fact, surgical findings at the time of revision rhinoplasty suggest that fundamental surgical errors, not unfavorable tissue characteristics, are the most common cause of the failed rhinoplasty.

Although malicious negligence is seldom involved in the unsatisfactory outcome, the consequences of naïve and misguided rhinoplasty techniques can be just as devastating and just as difficult to reverse. While scar-prone tissues, poor tissue strength, or unfavorable wound healing can ruin the efforts of any rhinoplasty surgeon, most bad rhinoplasty outcomes appear to be the result of technical errors that could be avoided with adherence to sound surgical principles. Unfortunately, some surgeons are apparently unwilling to dedicate the time and effort necessary to achieve mastery of this complex operation, and many shocked and disappointed patients bear testament to this unfortunate reality.

Although my fascination with rhinoplasty has been rewarded with a successful surgical practice, like all rhinoplasty surgeons, I am also confronted with a disappointing surgical outcome from time to time. While disappointing outcomes are far less common in the hands of an accomplished surgeon, technical excellence alone does not guarantee a favorable outcome. And although most disappointing results can be remedied with further treatment, the limitations of poor tissues, unfavorable wound healing characteristics, and/or previous tissue damage may be insurmountable in some patients. Even though the media, popular culture, and even the surgical community itself tend to hype the benefits of cosmetic surgery and downplay the risks, not all outcomes are successful. For a small minority of patients, a beautiful nose is a medical impossibility regardless of who performs the operation.

Fortunately, for the overwhelming majority of potential rhinoplasty patients, the prospects for a satisfactory outcome are excellent as long as sound surgical principles are combined with artistic and skillful execution. In summary, rhinoplasty seldom succeeds without genuine surgical competence, and the importance of choosing an experienced, talented, and knowledgeable surgeon cannot be over-stated. By the same token, even the consummate surgeon cannot account for the inadequacies of poor tissue, and surgery is best avoided in such circumstances. A careful assessment of the surgical risk is an essential component of responsible rhinoplasty surgery and should not be disregarded or downplayed under any circumstance.