A recent patient illustrates multiple points necessary to have a successful rhinoplasty.

This gentleman originally had a badly traumatically damaged nose, the result of parental physical abuse.  That is an important point.  He underwent surgery that straightened his nose and profile, removing the bump.  The result seemed good, but the patient was angry and unhappy.

When I first saw him, we discussed the cause of the original trauma.  To the patient, the twisted nose had almost seemed like a badge of honor signifying that he had withstood the abuse and survived.  More important, however, was the fact that the surgery had removed a bump on his bridge that was key to his sense of personal identity.

This is not an uncommon reaction: In a paper that I published in Plastic and Reconstructive Surgery in 2012 (to my surprise one of the 10 most read papers that year in the journal), 15 percent of the revision patients I interviewed wanted another surgery because they thought they had lost identifying ethnic, familial, or personal characteristics that they could not tolerate.

When I saw this man originally several years ago, I told him he needed to wait; I thought he was too angry to undergo surgery at that time and my preference was for him to undergo trauma work.

He returned several years later, a changed man.  Though he had not undergone formal therapy, something in his life and spirit had changed and he now had become a surgical candidate.  I did operate on him and use rolled ear cartilage open his airway and restore the height to his bridge.

He is one of my happiest patients.  Recently his wife wrote a lovely note that said, in part “[My husband] is in a different place after the surgery … He has no shortage of words to express his happiness … From the first time we visited, your focus was primarily on [his] overall well-being … It never felt like a business transaction … Your team was on our side, working with us to figure out the best way to help [him] heal, no matter how many consult hours it would take.”

There are several takeaway points here.  Personal identity is individual, even if it means having a bump on the nose instead of a straight profile.  Each patient’s human story is important to consider.  Function and appearance go together: restoring the profile also opened this man’s airway.

Finally, many surgeons would have rejected this patient because the appearance of his initially corrected nose was good.
That is not what is important.  What is important is the way patients feel they need to look.  That is the intricacy of body image and the complexity of plastic surgery.