The nose job. Such an inoffensive, even cheerful, euphemism. An unwanted bump is “straightened” or the long nose sweetly “bobbed”.
The nose is simply “fixed”. Matter-of-factly, we tell friends and family: “I don’t like my nose, so I’m having it done.” Once the province of celebrities and the affluent, the nose job has become one of the most popular and accessible procedures. There’s something almost coy about the term, playing hide and seek as it does with its stern medical counterpart “rhinoplasty”, the word the plastic surgeon will use during the consultation.
While rhinoplasty remains a popular cosmetic surgery in both the US and the UK, plastic surgeons admit that it has low patient satisfaction rates compared to other aesthetic procedures. Many surgeons blame “poor patient selection” – by which they mean patients with unrealistic expectations. Others acknowledge that rhinoplasty is one of the most technically challenging cosmetic surgeries and thus prone to more botched results.
As a teenager, I had a nose job that went badly awry and required revision, a journey that was emotionally and financially draining. For Jewish Americans like me in the 1970s, nose jobs were fairly common, especially on the two coasts. My parents encouraged me to narrow the wide tip and, although initially hesitant, I was open to what seemed at the time like a minor intervention. But my surgical result was anything but. I was left with a lump on one side of what had been a straight bridge and a flat columnella (the piece between the nostrils). In chiselling the tip, the surgeon had removed too much of the lower nose, which left me feeling as though part of my face was missing. As time went on, the tip started to droop due to lack of support. After two revision surgeries, I resigned myself to the fact that there were mistakes that could not be reversed, even by a very talented surgeon.
Still, most patients are very pleased with their outcomes. If you go online to discussion boards that focus on rhinoplasty, you will find abundant accounts by delighted patients extolling their surgeries as life-changing. Some acknowledge that the new nose isn’t identical to the perfect nose they anticipated, but are pleased nonetheless.
Patients considering a nose job necessarily have a range of concerns, and it’s indisputable that surgery will cause physical discomfort. With rhinoplasty, the most unpleasant part tends to be during the initial aftermath. Patients are bruised and swollen and their noses are packed with gauze, but it looks much worse than it feels. Once the initial post-op edema subsides (relatively quickly), some swelling may persist for many months. The degree of pain and post-op swelling and bruising depend on the individual’s own threshold for pain as well as the extensiveness of the surgery (rhinoplasties vary from minor to major interventions. Typically, when individuals seek plastic surgery, they are so invested in the transformation that the relatively short period of discomfort seems worth it. When I was first considering surgery, I was apprehensive about both the pain and the recovery period (how long before I could re-enter the world looking normal?), yet I found both easily manageable.
What can be truly distressing, however, is the discrepancy between expectation and outcome. Most patients eagerly await the resolution of the swelling as a kind of final unveiling of their beautiful new nose; but sometimes they are stunned, as I was, by the revelation of all that went wrong. What was indiscernible in the swollen tip is now exposed as lopsided or dented. The broad bridge of the swollen nose resolves into a twist, the opposite of the smooth straight line the patient was after. Post-operatively, the patient may not breathe as well as they once did.
Other changes can manifest themselves decades after the original surgery. Thinning skin can expose hitherto concealed cartilage grafts, while contracting scars might compromise the nasal structure.
Even though plastic surgeons concede that the operation is complex, much of the popular literature enthusiastically suggests the inevitability of a positive result and minimises, omits or misrepresents the risks. While minor primary surgeries to the nose (say, shaving off a bump) mainly have successful outcomes, more extensive interventions require commensurately more surgical skill.
Surgeons I’ve interviewed explain that for young and less experienced surgeons, rhinoplasty has an unusually steep learning curve due to the lag time between the surgery and its final result a year later; only then can surgeons assess what they should do differently. A recent issue of Annals of Plastic Surgery, published this month, is entirely devoted to rhinoplasty, and it’s sobering reading. Most articles make clear what the general public doesn’t know about the procedure – that the technique (as well as outcome) of the nose job remains heavily disputed among surgeons. And there are many things that affect the outcome, from the inherent structure of the individual’s nose to the surgeon’s experience, planning and skill.
Patients who experience poor outcomes often have to resort to expensive revision surgeries. One’s “fixed” nose, the nose that was intended to increase one’s confidence, instead leaves one feeling damaged.
For a long time after the initial surgery, my nose was all I saw when I looked in the mirror. The very idea of cosmetic surgery stirs up fantasies of miraculous transformation. Most of us like to believe we are realistic about what surgery can accomplish, but cosmetic surgery comes with implicit promises of greater physical perfection that can be psychically distorting. When the result is not only less than the patient expected but also worse than the original, it can feel devastating.
Nevertheless, because the healing process is protracted, one tells oneself that what looks bad in the short term is wholly attributable to swelling (at least, that’s what my surgeon assured me). Don’t obsess, in other words – everything will turn out right in the end. So many little girls have been raised on fairytales about ugly ducklings becoming swans that we are pre-programmed to be patient in anticipation of beauty. Every day, we look in the mirror, waiting.
Surgical error isn’t the only problem. Patient dissatisfaction also ensues from significant disconnects between the surgeon’s aesthetic goal and the patient’s. Surgeons might be thoroughly pleased with results that leave patients anguished. The nose seems strangely short, for example, or the altered tip the surgeon deemed too narrow, the patient now sees as bulbous. The dorsal hump the patient hated before surgery is still in plain view. In these cases, there was a bad match between surgeon and patient.
My first revision surgery was just such a bad match. Because the surgeon agreed that my first surgery was disastrous, I didn’t look any further. Before I went under, I heard him tell a nurse: “Look what some joker did to this poor girl’s nose.” He harvested cartilage from behind my ear in order to replace those bits excised during the original surgery. The surgery on my ear was more painful than my nose and took considerably longer to resolve. Some patients are advised that so much cartilage is required for grafts that the surgeon will need to invade the ribs for a bountiful supply. There are associated risks; although rare, pneumothorax (collapsed lung) is one, and surgeons describe in chilling detail how to assess its severity and remedy it on the operating table. Pain (possibly prolonged) always results from such intercostal harvesting.
This second nose was very small and didn’t suit my face or my idea of what “real” noses should look like. Put differently, it was a great nose on someone else’s face. If I had been paying more attention, if I had even momentarily put aside my driving fantasy about being “fixed”, I should have recognised that every woman in his office, from nurses to receptionists, was branded by his signature style – the tiny up-tilted nose.
For my third, and final, surgery I went to a surgeon whose practice was largely devoted to revising other surgeons’ bad rhinoplasties. He not only improved function (the second surgery had partially blocked my airway with bone), he expanded the bridge and supplemented the supporting structure of the lower third of my nose. This last surgery took place 20 years after the initial operation.
Whatever picture they may bring to the surgeon, patients should be aware that surgeons remake noses in line with their own aesthetic vision. And like any fashion trend, aesthetics in noses vary over time. Indeed, they can go out of style. The history of the nose job in the United States is deeply linked to the pursuit of ethnic assimilation to an ostensibly generic “American” appearance. The paradigm of the “perfect nose”, unmoored from any particular face, is what resulted in the proliferation of “cookie cutter” 1960s and 70s nose jobs among certain affluent populations in the United States. The ski-slope nose coveted by so many Americans whose ethnic appearance diverged from the prevailing white Anglo-Saxon Protestant aesthetic, was often sought with little regard to facial context. These surgical noses tended to exaggerate aspects of the Wasp ideal – too small, too turned-up, pinched and over-sculpted nasal tips. Patients who were initially pleased with their results became less so as fashions in beauty shifted. By the 1980s, surgeons began to identify the various “deformities” (such as “alar retraction”, by which they mean flared nostrils), associated with what for years had been the quintessential fixed nose.
Some surgeons specialised in revising noses that were now deemed “overdone”. In the 1990s, there was widespread criticism of the “operated on” nose and, in its place, surgeons claimed to build a “natural-looking” nose tailored to enhance the individual face. Since that time, there has been a growing body of surgical literature urging surgeons to attend to racial and ethnic differences, both anatomically and in the service of culturally sensitive aesthetic outcomes. Still, many plastic surgeons persist in aesthetic homogeneity and rely on what they consider the ideal (white) proportions for their surgical templates. Just last year, for example, a study claimed to have confirmed the most attractive measurements for nasal tip projection and rotation among young white women. Despite increased consciousness among surgeons of aesthetic relativism, there is no avoiding the obduracy of each surgeon’s perspective. The plastic surgeon isn’t simply a technician; rather, she or he is an individual guided by personal taste. Yet, in a mass culture dominated by celebrity images of beauty, we can feel as though beauty is entirely objective and its standards universally shared. The presumption of a shared aesthetic can mislead both patients and surgeons.
This is not intended to dissuade people from having surgery. Rather, I am urging prospective patients to be as informed as possible – about how experienced their surgeon is, about the varying approaches (eg “closed” rhinoplasty, where the surgeon works within a limited visual field, v “open”, where the surgeon unmoors the nose from the face) as well as the real physical limitations of the body itself.
As members of a culture deeply invested in physical appearances, we are all at some risk when we visit plastic surgeons, those self-styled architects of beauty. We may be overly vulnerable to their assessment of our flaws because, after all, they are the experts, aren’t they? There are surgeons who will sweet-talk you. My first surgeon reeled me in with a photo of a model he had operated on, all the while promising an enormous (and frankly impossible) improvement to my appearance.
Make sure you schedule consultations with several surgeons. Ironically, although we commonsensically tend to seek multiple bids on a new roof for our house, when it comes to our own bodies we can be easily swayed by the first “magical” surgeon we visit. If the surgery begins to sound extensive (if it involves grafts, for instance), you should be doubly cautious because more can go amiss.
If you are looking for an outcome congruent with your race and ethnicity, go to a surgeon who is both surgically experienced with and aesthetically sensitive to a diverse patient population. Different surgeons may present different operative plans and objectives to you, and you will need to decide among them. One determining factor is whose work you like best – insist on seeing a lot of before and after photos. Of course, photographs can mislead through carefully staged angles and lighting, but at least you will know if you and the surgeon are on the same page regarding appearance.
Imaging software – both 2D and 3D – used to simulate what the change will look like on your own face, is a marketing tool that can be simultaneously informative, seductive, and beside the point. Real flesh and bone will not yield to the scalpel like a two-dimensional image.
The psychic risk posed by such technology comes with the implicit temptation to imagine ourselves as infinitely mutable; this morphed version of our face beckons us into a future of potentially unsatisfying surgeries that don’t measure up to the screen image.
Failed nose jobs can become lifelong obsessions, as patients wander from one expensive surgeon to another. It is not simply the search for the perfect nose that compels us. Many of us yearn for our pre-operated, intact nose – so we can go back to the beginning, before the physical and emotional damage to our appearance from which we cannot recover. The real risk of rhinoplasty is not necessarily physical at all. It is about becoming more preoccupied with one’s appearance after the surgery than before.
