The nose takes pride of place in the middle of our faces, dominating the appearance from front and side views. It lies directly between our eyes and is often the focus of attention as our eyes flit from one side of a person’s face to the other during conversation. A coarse or prominent nose may overshadow a naturally attractive face and draw the focus of our gaze away from beautiful eyes or an otherwise harmonious face. The nose enjoys a disproportionate degree of influence on our appearance and, whether we like it or not, we all subconsciously compare differing proportions of the nose to other facial reference points when deciding on the attractiveness of a person. Nasal surgery is most often requested for nasal refinement or reduction and only rarely for nasal augmentation. Reduction rhinoplasty is always performed under general anaesthetic and can be performed through a variety of techniques. Mr McDiarmid uses the open approach (with internal nostril scars and a small scar across the columella) almost every time as he feels that the degree of predictability of outcome is far greater. He also feels that the excellent exposure of the anatomy that this approach offers, combined with the ability to add subtle cartilage grafts and cartilage shaping manoeuvres, can provide a dramatic improvement in nasal tip definition and fine tune the ultimate result.

The patient is first ‘set-up’ for the surgery by infiltrating local anaesthetic and adrenaline into the soft tissues, positioning the operating table with a head-up tilt and hypotensive anaesthesia. The tip cartilages are first dissected from the overlying skin exposing their shape and configuration. Next the nasal dorsum is exposed and inspected. The hump is then removed and the nasal bones mobilized by osteotomy. The septum is exposed if necessary and straightened if deviated. Usually non-structural (non load bearing) septal cartilage is harvested and used as grafts (spreaders grafts, columellar strut and lateral crural strut grafts). These grafts are then delicately sutured in place with precise tolerance and the skin closed once the optimal cartilage configuration has been attained. Occasionally it is necessary to reduce the size of the nostrils and nostril reduction is performed through a small incision in the crease around the ala of the nose, which usually leaves an imperceptible incision. A vaseline-gauze pack is placed loosely in each nostril and a plaster of Paris splint is placed over the nasal bones to keep them in place.

Augmentation Rhinoplasty,
 or building up of a flat, depressed nose, is a particularly challenging undertaking. Mr McDiarmid performs this procedure under general anaesthesia and prefers to use a combination of morsellised auricular cartilage and temporal fascia. In some cases, cantilevered iliac crest (hip) bone graft can be the ideal material of choice for this purpose. Nasal implants are occasionally useful for subtle improvements. Rhinoplasty is first performed to move the remaining nasal structures into a better position, then the tissue chosen for augmentation is harvested from its donor site and inserted into the nose in the ideal measure.

The nose does not live in isolation from the face and occasionally the main reference points by which we judge the size and shape of a nose may also need to be adjusted to achieve a harmonious appearance. These key subconscious reference points are the chin, the premaxilla (and anterior nasal spine) and the brow.