During the second half of the 20th Century, rhinoplasty or nasal surgery became one of the most common operations performed by facial plastic surgeons. Women and men were eager to take advantage of new cosmetic skills for personal and professional reasons. The idea that one could look more attractive or handsome with a “nose job” spread rapidly. Women were entering the business world after taking over men’s jobs in WWII. They wanted to look their best and nasal surgery became popular quickly.
The emphasis in those years was to improve the form and appearance of the nose. Was there a bump below the bridge from a previous break? Did it end in a bulbous tip? Or did the nose appear too long or large for facial proportions? Were the nostrils too wide or flat? Depending on the age of the patient, what were the skin conditions? Surgeons had different reduction and modeling techniques to follow in order to satisfy the desires of their patients and meet medical standards. Some surgeons became known for their signature “nose job”; this could be a plus or a minus depending on the satisfaction of the patient. Not everyone saw it as a status symbol.
It is now 2015 and we live in a healthcare environment where the emphasis is on both form and function of all body parts including the nose. Rhinoplasty today has moved into an important new stage where the form and function of the nose are equally important to the individual as well as to the surgeon. The essential difference is the emphasis upon the patient’s breathing. The facial plastic surgeons are aiming to improve breathing in a cosmetically positive way. Their central goal is to improve Quality of Life (QOF) for their patients.
Have you seen the TV ads of a man or woman lying in bed with a strip across the nose? They are people with sleep problems who have trouble breathing during the night. The strips pull the nose into a position that clears the passages to allow air to flow in and out. It is a sign of the times that these ads highlight the large number of people with nasal obstructions , blocking their breathing and affecting their general health. They also may be breathing through their mouth during the day as well or having other symptoms related to breathing problems. Walking steps or physical exertion during exercise will increase their mouth breathing.
During the last ten years, certain facial plastic surgeons have developed methods that aim at improvement of breathing and quality of life (QOL). Their aim during surgery has been to use new structural techniques that improve the internal function of breathing as well as the external form of the nose. At Penn Medicine in Philadelphia, Doctor Oren Friedman has been at the forefront of this approach to rhinoplasty. He is Director of Facial Plastic Surgery there and I was fortunate to be able to interview him for this article. He shared valuable information about research and questionnaires that are used to measure a patient’s QOL after rhinoplasty .
There are two that have been developed in the field: Nasal Obstruction Symptoms Evaluation (NOSE) which scores nasal function before surgery , and the Rhinoplasty Outcome Evaluation (ROE) which scores nasal shape after surgery. At Penn Medicine, they have used both NOSE and ROE scales for patients to determine QOL results after surgery that aimed at improvement in both form and breathing functions. The NOSE instrument asks five questions about function. The patient circles numbers on a scale from 0 Not a problem, 1 Very mild problem, 2 Moderate problem, 3 Fairly bad problem , 4 Severe problem. Here are the five items: l. Nasal congestion or stuffiness. 2. Nasal blockage or obstruction. 3. Trouble breathing through your nose. 4. Trouble sleeping. 5. Unable to get enough air through your nose during exercise or exertion.
The ROE instrument asks about aesthetic changes primarily. The numbers to circle are: 0 Not at all. 1. Somewhat. 2 Moderately. 3 Very much. 4 Completely. The questions: 1. How well do you like the appearance of your nose? 2, How well are you able to breathe through your nose? 3. How much do you feel your friends and loved ones like your nose? 4. Do you think your current nsasal appearance limits your social or professional activities? 5. How confident are you that your nasal appearance is the best that it can be? 6. Would you like to surgically alter the appearance or function of your nose?
Dr. Friedman summed up, “The primary goals of rhinoplasty are to improve form and function of the nose for the long term. We believe it is appropriate to measure these same outcomes retrospectively. If a patient feels improved and happy with the surgical outcomes three years postoperatively (our average follow-up time), we believe this measure accurately reflects their ultimate quality of life change. He also said, “One recent patient , a woman in her early 50’s who had endured years of blocked nasal breathing, described her successful rhinoplasty with great joy and enthusiasm as ‘A life changing experience! I can breathe!’”