Like a mountain range that rises between beautiful valleys, the nose can determine whether the face paints a pretty picture. Chan Li Jin sniffs out some nose issues.
Since time immemorial, the nose has been known to be among the key features that determine the appealing factors of one’s facial appearance. Along with language development, which has countless innuendoes using the word ‘nose’ (examples include "turned the nose up", "to poke one’s nose into a situation", and "to have a nose for news"), the shape of the nose has also been used to indicate personal characteristics or predispositions.
In the West, witches and cold-blooded criminals are almost always portrayed with wicked-looking, hooked noses; in Japan, having a long nose symbolises Tengu, the reincarnation of a disgraced samurai. And who can forget the story of Pinocchio, whose nose would grow longer every time he told a lie?
In The Face, which won the 1992-93 Los Angeles Times Book Prize for Science and Technology, author Daniel McNeill describes the nose as the most variable part of the face: "It can be snub, ski-slope, bulbous, bent like a boomerang. It can be aquiline (‘curved like an eagle’s beak’), straight, Roman (‘having a prominent, slightly aquiline bridge’). The classic ‘English’ nose, like Henry VIII’s, is straight with a delicate camber. The nose can be flat and wide, or splayed out and close to the skin. It can be long, high, and narrow, like a blade."
According to McNeill, scientists have found that most men prefer women with small noses. Apparently, the late Hollywood star and sex symbol, Marilyn Monroe, used to hold her lower lip down when she smiled so that her nose seemed smaller. Maybe she was on to something!
One thing’s for sure – you can’t miss the nose on one’s face. But this little organ plays a more important function in our lives than just to sit in the middle of our face and determine how we look.
"Our survival depends on the olfactory nerves (relating to sense of smell) which are housed in the interiors of the nose. Being able to smell food that has gone bad or avoiding the stench associated with bacteria-infested surroundings are some of the ways Man has kept alive on this planet," says Professor Dato’ Dr. Balwant Singh Gendeh, the Head of the Nose & Sinus Unit, University Kebangsaan Malaysia Medical Centre (HUKM).
Apparently, having a straight, well-shaped nose isn’t all about beauty, either. Having a straight nose ensures that we are breathing in a balanced amount of air. "When either side of the nose faces blockage due to a misshapen septum (bridge), allergies, or a growth or trauma, a patient will not be able to breathe well. This leads to poor sleep and breathlessness, which eventually results in irritability, personality disorders and effects self-esteem and personal development," explains Professor Gendeh.
Most Ear, Nose & Throat (ENT) specialists are able to correct functional problems such as deviated septums, blocked noses due to allergies or growths, and broken noses due to accidents or assault. However, the results may not be aesthetically pleasing, and this is where cosmetic rhinoplasty comes into the picture.
Professor Gendeh elaborates, "Basically, rhinoplasty is divided into two categories – trauma or non-trauma. Under trauma, the patient could have sustained a saddled, crooked or twisted nose. Non-trauma cases can be due to congenital causes or due to chronic rhinitis (irritation and inflammation of some internal areas of the nose) or sinusitis associated with an obvious deviated septum that is not responding to optimal medical therapy.
"Yet, cosmetic rhinoplasty is still slow to catch on, mainly because of the lack of trained experts," says Professor Gendeh. The major challenge for a rhinoplasty surgeon is to have an in-depth knowledge of the anatomy of the nose.
The nose consists of four main sections – the dividi septum or bridge, the tip, the alar or the flared sides, and the cartilage and nasal dorsum, which cover the sloping areas on both sides of the nose. Underneath the nasal pyramid lies a complex mish-mash of cartilages, fibrous attachments and nerves that make up the interior parts of the nose.
The most challenging rhinoplasty cases are the ones involving congenital deformities such as a cleft lip and palate, which affect the shape and function of the nose – the "tense nose", also known as the "Bishop’s Nose" (a completely flat nose). In these cases, extensive reconstruction would be needed in order to improve both function and appearance, thus requiring long hours of surgery.
Rhinoplasty is not recommended for anyone below the age of 18, as their dividi septum is still growing. For patients over 50, there is higher risk of complications due to skin laxity and slower rate of recovery.
What To Expect
Before surgery, a systemic analysis would be conducted, which includes evaluating the lateral nasal profile, frontal, top and basal views. Photographs are usually taken for a clearer picture of how the nose looks from these angles, which are later shown to the patient in order to facilitate doctor-patient communication.
Other factors that the surgeon will take into consideration before the surgery are: the kind of anaesthesia required, the patient’s gender, background and expectations, skin type, age, facial features, general health and any medication they might be on.
Patients would need to stay off aspirin-based and blood-thinning agents such as health supplements of garlic, ginger, ginseng and ginkgo biloba pills, as well as contraceptives, two weeks prior to a rhinoplasty.
After the surgery, the nose will be swollen, stuffy and painful for about two weeks during which patients are advised to stay away from dust, contact sports, iced or cold food and beverages, and to avoid sleeping on their side. Full recovery is usually achieved after a year.
Most rhinoplasties are done from the inside of the nose, so there will hardly be any noticeable scarring. A rhinoplasty can cost anywhere between RM6000 to RM10,000, depending on the extent of functional and cosmetic correction involved. Some cases may require surgical revisions at a later time, for best results.
For all procedures, minor corrections may be anticipated post-surgery (about 10 to 15 percent). Any unevenness can be corrected by surgical revision using autologous (patient’s own) grafts or implant materials like Gore-Tex®.
After their procedure, patients will need weekly follow-ups for the first two weeks; visits then become monthly, then every three months, and finally, annually.
Hospital stay usually ranges from two to four days, depending on the extent of surgery performed. Incision site and nasal swelling may take a few weeks to heal depending on the patient’s skin thickness.
Scientists have found that most men prefer women with small noses. Apparently, the late Hollywood star and sex symbol, Marilyn Monroe, used to hold her lower lip down when she smiled so that her nose seemed smaller. Maybe she was on to something!
What Can Be Done
Nasal Tip Reshaping
In rhinoplasty, tip surgery is either the primary objective or a major factor that plays a decisive role in determining the overall aesthetic success or failure of the surgery.
Traditionally, tip surgery has been the domain of Caucasians, but its importance has been generally underestimated among Orientals, especially the Malays and Chinese, as they feel their nose type is unsuitable for tip surgery. However, careful observation has revealed a surprising diversity in how their nasal tip is shaped.
In the past, the most recommended aspect of nasal surgery for Orientals was to alter the tip using a silicone implant, because of their thick skin and underdeveloped nasal tip.
However, various tip surgery techniques once thought to be applicable only to Caucasians are also largely applicable to Orientals. The best material currently being used in dorsal augmentation is harvested autologous cartilage and bone. The limitation of using an autologous graft is that it is difficult to acquire in sufficient quantity and is absorbable to a certain extent.
Successful tip surgery is possible only when accurate diagnosis, adequate analysis, and precise execution of surgical techniques are in harmony. It is essential to have a thorough understanding of the anatomical characteristics of the lower lateral cartilage consisting of the nasal tip, structures supporting the tip, and their mutual dynamics.
Nasal Hump Reshaping
For Oriental noses, a mild nasal hump may need dorsal augmentation and also tip surgery.
Nasal Alar-Columella Reshaping
Only when the collumella (the central position of the nostril that is composed of soft tissue overlying cartilage structures) appears proportional from the lateral view, can the nose be described as good-looking.
The extent and shape of the columella is not only affected by its own appearance, but also greatly influenced by the structure and shape of the alar. The shape of the nasal base created by the relationship between the columella and the alar is described as the alar-columella relationship. From a frontal photograph view, the cosmetically desirable alar-columella relationship is one that takes on a wing-like shape of a gull.
The best implant material currently being used in alar-columella reshaping is harvested autologous cartilage and bone.
Dorsal Hump Reduction
Involves surgery on the nasal dorsum to reduce the size of the nasal hump. It is especially popular among Indian and Caucasian women, whose prominent nasal humps are considered aggressive and unfeminine.
Nasal Width Reduction
Involves the construction of a cosmetically balanced nasal bridge and reduction of the width of the nose (also known as an alar base surgery, base reduction, alar base resection and alar wedge resection).
Usually, an autologous (patient’s own) cartilage or bone would be used in the construction of a cosmetically balanced nasal bridge.
A broken or fractured nose can result in a crooked or twisted nose, the axis of which is not located at the very centre of the face. Causes of a deviated nose include congenital deformity, injury during childhood, indistinctive repetitive trauma, obvious external trauma to the nose, complication of surgery, infection and so on.
The most important cause is external nasal trauma. Nasal trauma incurred during the infant to juvenile period may stay hidden while nasal and facial development is in progress, only to manifest itself as an obvious nasal deformity during the adolescent period. Breaking the nasal bones (nasal osteotomies) and nasal dorsum augmentation may be necessary.
The best material currently being used in broken nose repair is the harvested autologous cartilage and bone where necessary.
The septum (structure that serves as a partition between the two sides of the nose) is made up of the septal cartilage and the bony part. The asymmetric alignment and deformity of the septal cartilage with the various surrounding structures can result in deformity of the external nose. Septoplasty involves the surgical straightening of the deviated nasal septum.
A simple septal surgery needs no autologous grafts or implants unless it is combined with rhinoplasty procedures. There is a low incidence of septal perforations associated with revision septal surgery, which can be corrected with further surgery.