PRIMARY RHINOPLASTY :
THE BASIC IDEA
The patient who has never undergone surgery has advantages over the patient who has already had several nasal operations. The skin is not scarred, the skeleton is present and easier to examine, and the nasal septum, whether deviated or not, is present and provides excellent building material to reshape the external nose if that is needed. In the primary rhinoplasty patient, the important considerations are to recognize preoperative airway problems, to judge the ability of the skin to shrink or take on a new shape, to diagnose the areas of the nose that are anatomically too large or too small, and to create a safe plan that allows the surgeon to create a shape that is consistent with the patient's wishes.

"A NOSE THAT FITS MY FACE"
Patients and surgeons often talk about "making a nose that fits the patient's face." As desirable as this goal may be, what is more important is that patient and surgeon understand each other in terms of specific aesthetic goals: is the nasal bridge to be straight, slightly scooped, or is a preoperative dorsal convexity to be softened but preserved? Does the patient desire a nose that is more turned up, or not? Does the patient desire a tip that is more sculptured and angular, or one that has good contours but a softer shape? These are the kinds of issues that a patient and surgeon must have discussed together so that the proper surgical plan can be established and so that the surgeon maximizes the patient's chances of achieving his or her desired result.

Some years ago, when I asked a patient what kind of nasal shape she wanted after surgery, she said, "I don't know. Surprise me!" This is not the way I function. My job is to try to understand the patient's goals, explain what is possible and what is not, what the potential is for improvement in one or more stages, and then to do my utmost to create and carry out a safe and effective surgical plan. After surgery, the patient and I continue to visit over the postoperative months to make sure that the patient's goals have been achieved to the greatest degree possible, and to watch for any imperfections that may occur as healing progresses so that they may be adjusted if that is the patient's wish.