Serving the Boston and Manchester Areas and Beyond

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. When assessing a primary rhinoplasty patient at my practice in the Boston/Manchester region, 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.

The Problem with the Traditional Rhinoplasty Procedure

Traditional rhinoplasty surgery relies on the concept that the preoperative nose is too big, too wide, too bulbous, or too long. It logically follows, therefore, that if the surgeon reduces the skeleton, and the skin shrinks to take on the shape of that new skeleton, the nose will be smaller and prettier. Unfortunately, it doesn’t work out that way. Nasal skin can shrink to some degree, but much less than we have believed. Further, as it shrinks, the nose gets blunter and rounder and generally has less shape, not more shape. Nasal anatomy is so interrelated that changes in one area produce changes in other areas that may or may not be desirable and that can decrease the airway and affect the nose’s appearance.

Both patient and surgeon must remember that a good nasal shape is not the shape of the skin itself; it is the shape that the underlying cartilage and bone impose on the skin. When viewed this way, rhinoplasty becomes more understandable, controllable, and predictable. The surgeon and patient must think in terms of reducing the areas that are too large and supporting or recontouring the areas that are too small to create the best possible shape and nasal balance, while improving or preserving the airway, all in the background of a safe operation and the patient’s own aesthetic goals.

“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 rhinoplasty patient at my practice, near Boston and Manchester, 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.

The Hardest Operation

Most surgeons who perform rhinoplasty say that it is the most difficult operation that they do, for different reasons. Some say that the operation is hard because the incisions are so small, which has led to increased popularity of the “open” rhinoplasty technique (which I do not perform), designed to give the surgeon better visibility. Some say the operation is hard because the anatomy is so intricate.

Others say that rhinoplasty is difficult because patients’ cosmetic expectations are so high; and some surgeons believe that rhinoplasty is difficult because the nose, unlike other body areas, has “a mind of its own,” so that the surgeon has relatively little control over the final outcome.

I disagree with all of these theories, and over the span of my teaching career I have tried to convince rhinoplasty surgeons of a different explanation. Rhinoplasty is hard, I believe, because we (patients and surgeons alike) have been thinking about it in the wrong way.

Rhinoplasty may be the most difficult operation that plastic surgeons perform, but perhaps that is what makes it so rewarding.  Unlike other operations that can be preplanned and premarked ahead of time, rhinoplasty is like a game of chess.  The surgeon performs one step, and must observe how the nose reacts in order to make the proper judgments during surgery. It is an interactive operation.  This unique feature is what prompted me in 1984 to devise software that acted like a flight simulator, permitting surgeons to perform 200 different rhinoplasties on a personal computer. At that time, the flight simulator needed a staggering 12 megabytes of storage capacity!

By using this “flight simulator,” surgeons could experiment with different kinds of procedures and observe how the nose would react, and what the ultimate healed appearance would be.  Before there was such a thing as “virtual reality,” there was a Rhinoplasty Simulator.  It was rhinoplasty’s special challenge that fascinated me when I first began my practice in 1978, and that continues to this very day.

Why Fixing Your Deviated Septum Will Not Be Enough to Fix Your Breathing

Remember that the septum is only one side of the airway: the nasal sidewall, containing the two valves, is the other side.  Unless valvular function is optimal before surgery or can be made optimal, septal surgery by itself will not do very much.  That is the reason that many patients who have undergone septoplasty (90% of my secondary rhinoplasty patients) are disappointed in the amount of improvement.

Every patient undergoing airway surgery for a deviated septum, with or without a rhinoplasty, should be evaluated for valvular function so that abnormal function can be corrected at the same time.


Consultation fee: $250.00

Surgical fee: $6,800.00 to $10,500.00

Hospital and anesthesia fees (for cosmetic/self-pay patients): Approximately $3,100.00

Because Dr. Constantian operates in a hospital setting, the hospital and anesthesia fees are not within his control and may change from time to time. If you would like more information, please call our New Hampshire office.

Contact Our Practice

If you are considering undergoing primary rhinoplasty, contact our practice, located between Boston and Manchester, to schedule a consultation.

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