A 47-year-old patient’s nose tip was lifted and sculpted with a combination of cartilage reduction, cartilage stitching, and tip grafting to support and strengthen his tip. Additionally, due to his thick skin, skin defatting was also performed to further achieve tip definition..

There was an era when people sought a rhinoplasty surgeon to create a more attractive nose by removing cartilage and shaving down bumps and imperfections, thereby erasing the original characteristics of the nose. However, times have changed dramatically, and now more people look for surgical techniques that can produce a natural-looking rhinoplasty result that preserves the individual’s unique features.

Techniques have improved considerably in recent years, and we can now deliver subtler and customized results from rhinoplasty surgery that are unique to each patient. My patients do not want to have the same nose as someone else; they want to look like themselves, only better. Our goal with rhinoplasty surgery is to produce the smallest changes for maximum effects. In rhinoplasty procedures, less is more. Even a few millimeters of cartilage, skin, or bone can have a major impact on the outcome.

By using a high-definition telescope system for visualization of the dorsal nasal bridge and bump, I have been able to perform a more precise endonasal rhinoplasty. I could see the bridge in high magnification and on a high-definition screen and, therefore, better judge the amount of cartilage and bone that need to be removed, avoiding the fake “scooped” look.

There is no one “ideal” shape and structure for the nose anymore. Educated patients today do not want the rhinoplasty results that their parents may have had 25 years ago. Patients will no longer accept looking like they have had a rhinoplasty procedure. This procedure has evolved considerably since the days of the pinched, upturned noses of the 1970s and 1980s. Several factors have contributed to this trend, including a better understanding of the long-term effects of the surgery, improved communication between patients and surgeons, and a desire on the part of patients to have less dramatic and visible changes.

As was commonplace in the 1970s and ’80s, rhinoplasty results often took on a “ski slope” appearance to the bridge with over-resected nostrils. Reduction rhinoplasty operations were standard, aggressive removal of cartilage was the norm, and there was little concern for nasal breathing. More cartilage and bone tissue were removed, and the end result was usually a much smaller nose.

Today, it is just as common to add cartilage or other graft materials to create an improved contour, rather than taking tissues away that may need to be replaced in the future. Rhinoplasty was still considered a relatively new discipline, and there was only a short list of surgeons who were famous for doing noses. Surgeons were exceedingly arrogant and paid little attention to what the patient asked for.


In my practice, I have a very open dialogue with all my patients. They express their desires and expectations, and I offer recommendations. You cannot really do an adequate rhinoplasty consultation in less than a full hour, and often more time is needed to answer all the patient’s questions. Typically, I insist that the patient return for a second preoperative visit to review everything discussed.

Extreme care is taken so that each nasal alteration I undertake will be appropriate for the patient’s facial features and skin thickness, gender, and ethnic background. No two noses should be approached in the same manner. In fact, I can honestly say that I never perform the same nasal operation twice.

Modern methods have shown us to use more conservative, cartilage-sparing techniques as opposed to the aggressive cartilage-removal techniques used in the past. The more tissues removed, the more difficult to reverse or correct the effects of the surgery. I have learned through experience that it is best to preserve any positive aspects of the nose, especially in the tip region.

Whenever possible, I prefer an endonasal approach. I try to avoid overly complex and invasive procedures to minimize operative time and postoperative healing for my patients. In the case of some secondary or corrective nasal surgery, complex deformities from trauma or previous surgical attempts may necessitate a more invasive or open approach to achieve the best outcome.

Many patients today do not even realize that a prior nasal surgery can be improved significantly with another operation. Revision nose surgery can bring balance and harmony to the face and correct asymmetries, irregular areas of cartilage and bone, as well as functional defects.

Revision rhinoplasty often presents a challenge to the surgeon to overcome the trepidation of the patient. My main goal with secondary nasal procedures is to restore support and structure to the nose for a long-lasting and aesthetically pleasing result.


Rhinoplasty methods have advanced so that educated patients have high expectations for beautiful and natural-looking results. Patients want a rhinoplasty surgeon who can avoid some of the most common pitfalls of nasal surgery, including a scooped-out bridge, pinched tip, polybeak, and saddle nose deformity. These kinds of problems can be avoided with careful attention to detail and flawless surgical technique.

A natural-looking nose should have character, and there should be no distortion of the tip, nostrils, or internal structures. A well-done rhinoplasty should look good and function optimally, to allow the patient to breathe well.

Another typical complaint of rhinoplasty patients is not being able to breathe properly after the surgery. To develop a healthy respect for the nasal airway, expert rhinoplasty surgeons may spend years in training operating exclusively on functional issues inside the nose before proceeding to reshaping the external nose. By improving their understanding of nasal function and respecting the integrity of the structure of the nose, advanced rhinoplasty surgeons can achieve beautiful results without compromising the patient’s breathing.

This less aggressive, cartilage-sparing approach to cosmetic nasal surgery has contributed to minimizing some of the unwelcome side effects of previous generations of rhinoplasties.

Well-informed patients expect to be an integral part of the decision-making process when it comes to the changes that shall be made to their noses. I always ask patients considering a rhinoplasty what they want to change about their nose, and what they like and would leave alone. This discussion offers clues to what the patient really wants and allows me to formulate a surgical plan to meet their expectations. This manner of open communication between patients and surgeons can only lead to more predictable and satisfying outcomes.

Computer imaging is a valuable consultation tool, especially for teens and younger patients who are comfortable with technology. However, I caution my patients that the images shown on the screen are intended to merely give the patient a general idea of what can be achieved with surgery. Although I endeavor to get their results as close as possible to the computer-generated image, I am always careful to present realistic and achievable outcomes to avoid potential misunderstandings from arising.

Reviewing photographs of other patients who have similar bone structures and issues to be addressed is another essential component of the consultation process. Visualization enhances the patient’s understanding, expectations, and overall experience leading up to their rhinoplasty procedure, and cements a healthy bond between patient and surgeon.

Sam Rizk, MD, FACS, is a board-certified facial plastic surgeon in New York City and director of Manhattan Facial Plastic Surgery. He can be reached at www.drsamrizk.com or (212) 452-3362.