This chapter is an attempt to explain and define the difficult nose. Many readers may find it an excrutiating numbers-oriented attempt while others will hopefully learn to analyze a nose and devise an effective operative plan. Most of the photographic analysis involves angles and ratios, which can be done easily in five minutes on a computer screen or on a lateral photograph with a transparent overlay. The goal is to stimulate the surgeon s thought process not offer a fixed solution. I have found the minor to moderate to major progression extremely effective in helping me to devise the definitive operative plan. The more accurate the analysis the more refined and correct the operative plan, which results in simpler surgery and superior results. Without question, time spent on analysis is saved intraoperatively. Also, it is better to use an eraser on a photograph than try to undo a surgical misadventure.
One final caveat: do not attempt difficult cases early in ones practice; classic surgical sayings are indeed true and probably evolved from rhinoplasty. First, surgical judgment comes from surgical experience, which is often acquired from mistakes. Second, every good result brings you three cases, every bad result loses you nine cases. Why attempt the difficult when you have little to gain and lots to lose? Third, the preop course is finite, the postop course is infinite. Everyone enjoys the operating room, but happiness with your practice will be determined in the exam room. If you dread hearing the patients complain about their results, then don’t take on the problem to begin with; no one is forcing you to do a case. Remember, the requisite skills for rhinoplasty are best acquired in a progressive sequence where one learns the basics in easier cases before attempting the more difficult.
KeywordsLateral Cartilage Alar Cartilage Spreader Graft Skin Envelope Columella Strut
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