(Excerpted from Dr. Adamson’s book Fabulous Faces, available on Amazon.com, and edited for our blog. Be sure to read parts 1, 2, 3 and 4!)

Part 5: The Process Of The Modern Rhinoplasty
So the nose bears a huge load of emotional and psychological baggage for its owner. The goal of rhinoplasty is to make the nose blend in. It may be the most prominent feature on the face, but it shouldn’t be distracting. It’s all about first impressions—what you see when you first set eyes on someone. It takes one-sixth of a second to scan a face. In that fleeting moment, the gaze shouldn’t stop at the nose but go straight to the eyes. That means creating a nose that looks balanced, proportional, and feminine or masculine, as the case may be—a nose that people just don’t notice.

That makes the nose tricky and delicate terrain for the plastic surgeon. It’s always approached with great caution. Rhinoplastic surgery involves dozens of basic steps, each affecting all the others. Imagine a watch that’s two centimeters in diameter. Suppose that you want to make a watch that looks the same, but 18 millimeters in diameter. Every little wheel in that entire watch has to be changed and fitted appropriately. That’s what rhinoplasty is like. You’re dealing with complex anatomical structures.

First, the septum (the midline wall) usually has to be straightened. Most of us are asymmetrical to varying degrees, up to and including our noses. One study showed 97 percent of patients undergoing rhinoplasty had asymmetrical faces.

Then there’s the tip of the nose. It may be too long or too short. Changing that can involve cutting and shortening the cartilage arch, but it may also mean taking cartilage from the nose, and sometimes from the ear or even a rib, to use as struts to support the arch.

The dorsum, the bone at the bridge of the nose, may have to be reduced. A misstep here can result in a nose that looks great in profile but oddly flat when seen from the front.

When all that’s done, the skin has to once again rest easily and naturally on its reshaped foundation.

For all these reasons, rhinoplasty is the most difficult cosmetic facial surgery procedure to get just right. These are the things a surgeon thinks about when assessing a prospective rhinoplasty patient. There’s a lot of planning. By the time I take a scalpel to a patient’s nose, I’ve gone over the case four times, first in the initial consultation, then in more detail in the follow-up consultation. I then plan the operation, writing down what we expect to do during surgery. The fourth time I go over the operation is the night before or the morning of surgery, when I review my plan and consider the various things I intend to do. The fifth time is the surgery itself.