As Published in TGForum and Trans Gender Community News
The nose, as the central feature of the face, exhibits great variation in size and form, but in its most fashionable form today is thin, sloping ever so gently with a well defined tip. In its best form it "fits" the face, is perfectly symmetrical and is unobtrusive nor obviously "fixed". To achieve this harmony, rhinoplasty or nasal reconstruction is undoubtably among the most difficult plastic surgery with tolerances of error at 1mm. So who needs rhinoplasty. Certainly people with a deviated septum and breathing difficulties will benefit, but these are a minority of those who seek this surgery. Now everybody thinks their nose is too large when they are looking at Vogue. But if you have a nasal deformity such as a hump, asymmetry, traumatic break or over projection of the tip, then you may consider rhinoplasty as an improvement to your appearance. In most cases there is a strong psychological component to how you see yourself and wish to be seen.
When the physical deformities are obvious, the solutions are easily
obtainable. When psychological perceptions are extensive and the
physical deformities minimal then the results may not be achievable.
Many a Plastic Surgeon has met the patient who arrives with a picture
of Rene Russo or Michelle Pfieffer and who forgets all the other facial
features upon which that nose happens to perch. Unrealistic
expectations produce a dissatisfied patient. So it is necessary to come
to an understanding with your surgeon as to what is achievable and what
is not. This is usually accomplished with pictures taken from all
angles in his office and then shown to you with a computer or projector
so that the doctor can demonstrate what can be accomplished. We in the
Transgender Community have a more difficult request as we wish to
feminize our features and we may have expectations beyond the reality
of the surgery. This may lead to a "plastaholic" and is best discussed
with your mental health advisor before undergoing the surgery. But
let’s say everything is emotionally stable and your request can be
satisfied by your Plastic Surgeon. Just what is he going to do.
First
there is the office visit where he pokes and probes your nose to
demonstrate patency of the air passages, the spring of the nasal tip
and obtains a complete medical history. It is probably best if you
return to discuss the pictures and preoperative instructions at which
time other facial asymmetries may be pointed out to you which you did
not appreciate initially.
An understanding of the nasal anatomy is best appreciated when
the nose is divided into thirds. The bony upper third is a projection
of paired nasal bones from the skull and upper cheek bone. This area
may be reduced by filing the convex hump or cutting the side portion to
thin the nose. The middle third is formed by cartilage attached to bone
which is usually the point at which a nose is broken by trauma. 
This angle must be maintained because if there is aggressive removal of
a large cartilaginous hump the air passage or internal valve may
collapse making nasal breathing impossible. These cartilages can be
trimmed more easily on the sides thus thinning the middle nose. The
lower third or tip is where the artistry occurs. Here a set of lower
cartilages can be molded, shortened or lengthened to effect a perfect
triangular tip. The base of the nose where the skin hangs is the
columella and should be no more that 3-5 mm deep. The texture and
thickness of the skin are important to the outcome as they must drape
easily over the new tip.
There are numerous approaches to modifying the tip and a surgeon who can produce only one configuration is not for you. Do you recognize Dr. X’s nose wherever you go? And shaping the lower cartilages must be done with care so as not to collapse the external breathing passage. Tip support must be emphasized so that your nose does not droop postoperatively.
The
traditional approach is to make incisions inside each nostril at the
level of the upper and middle cartilages or lower inside the tip
nostrils. These incisions can then be joined across the midline septum
and continued to a dissection of the bony cartilaginous portion.
Occasionally an external incision is made across the basal columella if
necessary to allow elevation of the tip. Almost all procedures can be
performed through the first closed approach and more recently an
endoscopic procedure has been described with an incision under the
upper lip.
These procedures are performed as outpatient surgery in a hospital or doctor’s office surgery suite with an anesthesiologist present. Uniformly there is swelling and bleeding under the skin resulting in lower "black and blue" eyelids which resolves within a week or two. Postoperatively serious taping of your nose is undertaken and a set of instructions with limitations on physical activities is presented. Serious post operative nose bleeds can rarely occur but usually there is a paucity of post-op complications.
Be sure to look at the noses your surgeon has done to assess his results and his ability to tailor his rhinoplasty to your face.
Best Wishes in Your New Future,
Cerise Richards, M.D.