Rhinoplasty (nose job) is probably the oldest plastic surgery procedure known. Centuries before the Renaissance, enlightened Indian surgeons figured out a way to reconstruct a rudimentary nose after the original one had been cut off. This was a common punishment for a variety of evildoers, including adulterers and thieves. The operation, referred to in the early plastic surgery literature as the Indian Flap, created a semblance of a soft tissue projection where the nose ought to be, using a flap of skin from the upper arm. The procedure was fraught with dangers, including death from blood loss or massive infection. But it is a vivid testimony to how important a nose is to anyone lacking one, even the most reprehensible miscreants, that they would risk their lives and go through weeks of painful surgery to end up with something that probably looked like a small penis between their eyes and mouth…if they were lucky.
The modern rhinoplasty was invented by a German Jewish plastic surgeon named Jacques Joseph about 100 years ago. He became the toast of prewar Europe by operating on his predominantly Jewish clientele to make them appear more Northern European, perhaps even Aryan. In that era, among his patients, looking non-Jewish could mean the difference between financial, social, or political success or failure. A few years later, it could make the difference between life or death in Hitler’s extermination camps.
A similar operation is often performed today on the same ethnic type as Joseph’s patients, although not necessarily only on members of the Jewish faith. Anyone from the Middle East, from the Mediterranean region, including, Italy, Greece, Macedonia, Armenia, etc. or individuals anywhere in the world who carry the genetic code for a large nose with a hump on it may choose to have a rhinoplasty, for much the same reasons that existed during Joseph’s era. That pre-war racism has fortunately gone sub rosa, but the desire still exists for a nose that conforms more closely to what most of the Western world considers pleasing.
Not all those wanting a nose job want to have that Nordic or Western appearance. Racial differences exist, and nowadays the natural beauty of many different types, especially Asian and African, are widely recognized…just look at the covers of Vogue and other fashion magazines. These patients tend to have flatter, wider noses. If they wish to look more Nordic, or Western, procedures exist which actually may build up the bridge of the nose, and narrow the nostrils.
But since most of current American plastic surgery practice exists of reduction rhinoplasty rather than augmentation rhinoplasty (yes, the same terms used with breast procedures) I’ll just be addressing that type of surgery in this article. And a lot has changed in that arena since Joseph’s time.
Until recently, rhinoplasty was performed through incisions inside the nostrils, with no external scar. For most patients, this was the answer…the hump was reduced and the ridge of the nose was straightened, and the tip was sculpted a bit to make more of a point rather than a box or ball, and then the bones were narrowed. If needed, the septum was straightened at the same time (septoplasty), which helped to improve a patient’s breathing. Sometimes septoplasty was performed in patients who didn’t really require it, in hopes of ill-gotten insurance payments. But the important thing at this time was that the nose was made smaller and more defined.
In the late 70’s and early 80’s it became apparent that many reduction rhinoplasties needed to have the tip made more defined than could be achieved by simply removing cartilage. In fact, adding cartilage in the form of cartilage grafts became quite common, to create a more sharply defined, more protruding tip. In this situation, cartilage was taken, most commonly from the nasal septum, but also from the ear, or even the rib, shaped and inserted under the skin of the nasal tip. When it worked well, it was a superb result. But it was a bit unpredictable, and didn’t necessarily translate all that well from the hands of the masters who described the procedure to the plastic surgeons in the community.
In the 90’s, the open rhinoplasty became the procedure of choice for reconstructing a poorly defined, boxy, or very wide tip. In this case, a small incision is made right across the base of the nose and connected to the incisions inside the nose. This enabled the surgeon to elevate the skin of the tip off the cartilage, and give him (or her) free rein to manipulate the tip cartilages under direct vision. Narrowing the dome, adding a graft for more projection, and shortening (or lengthening) the tip became much easier and more reliable.
The open technique became so popular that the closed technique was all but abandoned by residency training programs. The end result is that plastic surgeons under the age of 50 have absolutely no experience with the closed technique, and look upon an older surgeon that performs that procedure with wonderment. In fact, savvy patients (and we see a lot of them in Beverly Hills) may guess the age of a plastic surgeon by which technique he prefers.
Of course, even older surgeons, such as myself, must adapt to new techniques. Otherwise we just become older instead of wiser. I still do about 75% of my rhinoplasty procedures via the closed technique…most patients don’t need the added intricacy of the open technique, nor the external scar, in order to get a perfectly satisfactory result. But the scar is very minimal, so if a patient comes to me with what I would refer to as a difficult tip, meaning a poorly defined flat or boxy tip, I don’t hesitate to open it up to get the best result.
It’s good to have options. Jacques Joseph wasn’t so lucky.
The modern rhinoplasty was invented by a German Jewish plastic surgeon named Jacques Joseph about 100 years ago. He became the toast of prewar Europe by operating on his predominantly Jewish clientele to make them appear more Northern European, perhaps even Aryan. In that era, among his patients, looking non-Jewish could mean the difference between financial, social, or political success or failure. A few years later, it could make the difference between life or death in Hitler’s extermination camps.
A similar operation is often performed today on the same ethnic type as Joseph’s patients, although not necessarily only on members of the Jewish faith. Anyone from the Middle East, from the Mediterranean region, including, Italy, Greece, Macedonia, Armenia, etc. or individuals anywhere in the world who carry the genetic code for a large nose with a hump on it may choose to have a rhinoplasty, for much the same reasons that existed during Joseph’s era. That pre-war racism has fortunately gone sub rosa, but the desire still exists for a nose that conforms more closely to what most of the Western world considers pleasing.
Not all those wanting a nose job want to have that Nordic or Western appearance. Racial differences exist, and nowadays the natural beauty of many different types, especially Asian and African, are widely recognized…just look at the covers of Vogue and other fashion magazines. These patients tend to have flatter, wider noses. If they wish to look more Nordic, or Western, procedures exist which actually may build up the bridge of the nose, and narrow the nostrils.
But since most of current American plastic surgery practice exists of reduction rhinoplasty rather than augmentation rhinoplasty (yes, the same terms used with breast procedures) I’ll just be addressing that type of surgery in this article. And a lot has changed in that arena since Joseph’s time.
Until recently, rhinoplasty was performed through incisions inside the nostrils, with no external scar. For most patients, this was the answer…the hump was reduced and the ridge of the nose was straightened, and the tip was sculpted a bit to make more of a point rather than a box or ball, and then the bones were narrowed. If needed, the septum was straightened at the same time (septoplasty), which helped to improve a patient’s breathing. Sometimes septoplasty was performed in patients who didn’t really require it, in hopes of ill-gotten insurance payments. But the important thing at this time was that the nose was made smaller and more defined.
In the late 70’s and early 80’s it became apparent that many reduction rhinoplasties needed to have the tip made more defined than could be achieved by simply removing cartilage. In fact, adding cartilage in the form of cartilage grafts became quite common, to create a more sharply defined, more protruding tip. In this situation, cartilage was taken, most commonly from the nasal septum, but also from the ear, or even the rib, shaped and inserted under the skin of the nasal tip. When it worked well, it was a superb result. But it was a bit unpredictable, and didn’t necessarily translate all that well from the hands of the masters who described the procedure to the plastic surgeons in the community.
In the 90’s, the open rhinoplasty became the procedure of choice for reconstructing a poorly defined, boxy, or very wide tip. In this case, a small incision is made right across the base of the nose and connected to the incisions inside the nose. This enabled the surgeon to elevate the skin of the tip off the cartilage, and give him (or her) free rein to manipulate the tip cartilages under direct vision. Narrowing the dome, adding a graft for more projection, and shortening (or lengthening) the tip became much easier and more reliable.
The open technique became so popular that the closed technique was all but abandoned by residency training programs. The end result is that plastic surgeons under the age of 50 have absolutely no experience with the closed technique, and look upon an older surgeon that performs that procedure with wonderment. In fact, savvy patients (and we see a lot of them in Beverly Hills) may guess the age of a plastic surgeon by which technique he prefers.
Of course, even older surgeons, such as myself, must adapt to new techniques. Otherwise we just become older instead of wiser. I still do about 75% of my rhinoplasty procedures via the closed technique…most patients don’t need the added intricacy of the open technique, nor the external scar, in order to get a perfectly satisfactory result. But the scar is very minimal, so if a patient comes to me with what I would refer to as a difficult tip, meaning a poorly defined flat or boxy tip, I don’t hesitate to open it up to get the best result.
It’s good to have options. Jacques Joseph wasn’t so lucky.
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