Dan Childs talks with Singapore cosmetic surgeon Dr. Woffles Wu about the evolution of rhinoplasty - and the latest procedures for beautiful noses
In the facial neighbourhood, no feature commands a more prime piece of real estate than the nose. So it shouldn't come as a surprise that as the centrepiece of the face, the nose has huge implications for attractiveness. Just ask Cyrano de Bergerac.
It is because of this fact that when many a prospective patient tries to decide where to start with cosmetic surgery, the answer is often right in the middle of his or her face. In fact, rhinoplasty - commonly referred to as a "nose job" - was one of the first modern cosmetic surgery procedures, first hitting the surgery scene in the 1880s.
In recent decades, rhinoplasty has become the defining procedure in plastic and cosmetic surgery. It is consistently one of the most commonly requested cosmetic operations by patients in the United States. According to statistics compiled by the American Society of Plastic Surgeons, 389,015 rhinoplasties were done in that country in 2000, including 150,185 on men. The trend is reflected around the world, and today rhinoplasty is consistently among the top five procedures performed in Asia and beyond.
But why are so many people looking for a new nose?
"The reason why rhinoplasty is so popular is that very few people have very nice noses," answers Singapore cosmetic surgeon Dr. Woffles Wu. He adds, though, that Asians seek a completely different result than their Caucasian counterparts when it comes to rhinoplasty.
"Most Caucasians have noses that are too big for their faces," he says. "They may have a large nose, a hump on the nose or nostrils that are too wide. So for Caucasians, we generally find that they want their noses smaller.
"Asian noses, on the other hand, tend to have a flattish bridge, a bulbous tip, and wide, flared nostrils," Dr. Wu continues. "So the ideal for Asians would be a nose you would see on many of these Korean movie stars - high and thin, with a sharply projecting tip and petite nostrils."
To achieve these different ideals, Dr. Wu draws upon a range of various procedures. These procedures, when taken together, comprise a "toolbox" of nose reshaping techniques that today's cosmetic surgeons have at their disposal. Combined with a wealth of fillers, implant designs and other materials, Dr. Wu says today's surgeon can use these various procedures to offer a completely individualised approach to each and every nose.
Reduction vs. Augmentation
Dr. Wu says that in the past 10 or 15 years, two different basic types of rhinoplasty have dominated the rhinoplasty scene. The first, known as the Caucasian reduction rhinoplasty, is popular among Westerners who hope to give their noses a smaller size and better overall shape.
"In the Caucasian reduction rhinoplasty, we would remove the hump of the nose, trim down the cartilage of the tip, sag it down a bit and do work on the septum," Dr. Wu says. "That's the classical kind of rhinoplasty in Caucasians."
Dr. Wu adds that Asians, on the other hand, generally opt for rhinoplasty in order to increase the height and sharpness of their noses.
"Traditionally, Asian augmentation rhinoplasty was usually a question of a 15 to 20 minute job in which you would make a slit in the nostril and push a pre-cut implant into the nose," he says.
But why would Asians desire a higher, sharper nose? Some critics of Asian augmentation rhinoplasty point to the procedure as one that diminishes the character of the Asian face, contributing to a "westernised" look. However, Dr. Wu disagrees, noting that the procedure often brings the faces of his Asian patients closer to the Eastern ideal.
"Now, one common misconception is that Asians have augmentation rhinoplasty performed in order to westernise their appearance," he says. "This is not true, as augmentation rhinoplasty does not necessarily mean the creation of a Caucasian nose.
"Most if not all of my clients do not want a western nose. On the contrary, they are in favour of making their nose higher, sharper and more defined in order to approach the ideal of the Asian nose. Who ever said that Asians want to look like Caucasians?"
An inside job: the nasal implant
Dr. Wu says that while he performs both reduction and augmentation procedures, the Asian portion of his clientele normally benefits most from the insertion of a nasal implant.
"When it comes to a simple implant, I choose to go through the mouth," he notes. "I make a slit on the inside of the mouth between the upper lip and the gum. So what I'm doing is making a tunnel in the upper sulcus of the mouth. Then I insert the implant through that route."
One advantage to this method, he says, is that the operation leaves no visible scars - all of the incisions are made on the inside of the mouth. He adds that the mouth is also a natural pick for an incision since it tends to heal perfectly well in most every case.
"I'm a kind of guy who likes to leave as few scars as possible," Dr. Wu says. "I like to refine these scar-free techniques so we end up doing better for our patients."
The other advantage he notes is that the creation of this "tunnel" between the mouth and the nasal area allows him to guide the implant straight into place - without the worry of a crooked result.
"Often when you put an implant in, what it does is push the existing cartilage to the side," Dr. Wu notes. "So paradoxically, this can make the tip of the nose seem even bigger, when what you want to do is to make it sharper and more delicate.
"By going through the mouth you leave the nose virgin, and the implant almost never goes crooked through that technique. This is a huge plus, because sometimes an implant can become twisted as a result of scar pull, or you will end up seeing a visible scar near the nostril."
Though the procedure for inserting an implant is often the same from operation to operation, the end result must always be tailored to the individual patient.
"Not all of these procedures are the same, since there's always a bit of individuality to every nose that I work on," Dr. Wu notes. "There are about 40 different styles of implants to choose from. With this variety, it's generally easy to find one that is ideal for a particular patient. I have also designed five models of implants that are suited directly for Asian faces."
However, the insertion of a nasal implant alone can sometimes lead to an unbalanced look. This is where a chin implant comes in. The chin implant can also be inserted through an incision within the mouth for a scar-free result, and the extra volume it adds at the bottom of the face is often the perfect complement to the higher, sharper nose achieved through augmentation rhinoplasty.
"(Nasal implants and chin implants) go hand in hand most of the time," Dr. Wu says. "This is because, invariably, you'll find that Asians tend to have a small chin. If you augment the nose but not the chin, it has the effect of making the face look like a bird's."
Dr. Wu says that around 20 per cent of his patients have a chin augmentation at the same time as their augmentation rhinoplasty. "In most cases, I would say that it really looks much better when you also perform the chin augmentation," he adds.
Synthetic meets natural - the composite rhinoplasty
Whenever an implant is placed beneath the skin at any point in the body, it will exert pressure on the skin above it. Perhaps this is most apparent when it comes to the nose. Since a nasal implant is particularly pointed in shape, the skin above the implant will be subject to a significant increase in pressure from below. In the worst cases, this additional pressure from the synthetic material of the implant can result in a condition known as extrusion - essentially the eruption of the implant through the tip of the nose.
"Extrusion is scary," Dr. Wu says. "I had one patient recently in which I thought the skin at the tip of his nose was thick enough to use an implant alone. Six months later, the skin at the tip of the nose began to look shiny and taut, suggesting that the implant might extrude. So what I had to do was redo the procedure using the composite rhinoplasty technique."
The composite rhinoplasty, Dr. Wu says, is a more sophisticated and refined way of performing Asian augmentation rhinoplasty. The technique, which he has presented at various scientific meetings, gives an added degree of freedom when dealing with implants by incorporating a small amount of the patient's own cartilage. In a way, he says, it represents the harmonious combination of Caucasian rhinoplasty's use of natural materials and the augmentative properties of the implant used in Asian rhinoplasty.
"What I've done is to blend both operations together in order to draw from the strengths of both techniques for the purpose of augmenting the Asian nose," Dr. Wu says. "Not every patient can do with just the implant alone. In some cases you want a raising of the bridge, a narrowing of the nose and a straightening of the tip. That's when I combine augmentation with cartilage work."
Specifically, Dr. Wu adds a thin cartilage "veneer" to the tip of the nasal implant. This small piece of cartilage acts as a buffer between the synthetic material of the implant and the skin of the nose. Since the skin "recognises" this cartilage tip as part of the patient's own body, the chances of extrusion are far less likely.
"I call this an interpositional graft," he says. "What it is, basically, is a cushion, which means I can exert a little more pressure with the implant, which gives a greater tip projection. And this is what most Asian patients want. They want nose height, especially between the eyes."
So in essence, the surgeon performing the composite rhinoplasty uses the patient's own cartilage to recreate the tip of the nose, thus making it as sharp as possible. Dr. Wu adds that other materials in the patient's nose can also be rearranged to further enhance the results on the procedure. "I also redistribute fat in the tip of the nose," he says. "With regard to this fat, I actually used to just throw it away. Now I clump it up into a ball and put it on top of the reconstituted cartilage of the nose.
"So what we're doing then is avoiding the main problem area of the traditional implant, which is extrusion of the tip. Because what we're doing is using a mixture of natural materials, called autogenous materials, and synthetic materials like silicone. This is why I refer to it as the composite rhinoplasty."
Aside from extrusion, the use of the patient's own cartilage at the tip of the implant also limits the normal reaction that the body has to a synthetic substance, a reaction surgeons call a foreign body reaction.
"As with any foreign material, the body develops a fibrous reaction that envelops the implant, kind of like an internal scar," Dr. Wu says. "That internal scar has bulk, however slight, even if it is very thin. If you have an increase in bulk of one millimetre, the net effect when you account for the implant folding across the tip of the nose is a two-millimetre increase in width.
"It is inevitable that this fibrous reaction develops around the synthetic implant. But when you use the patient's own cartilage, you do not elicit a reaction. Therefore the tip can be very delicate when you use this method."
In fact, the technique can be performed without the use of a synthetic implant at all. In this variation, a small piece of cartilage is harvested from another cartilage-containing area of the body, such as the ear or the rib. The cartilage is carved into shape and inserted much in the same fashion as a silicone implant would be used. However, Dr. Wu says the harvesting of this cartilage means an additional incision somewhere else in the body.
"So instead of creating this extra wound, I generally use a silicone implant to create height between the eyes," he says.
The quick fix - injection rhinoplasty
Dr. Wu says that another interesting development for rhinoplasty procedures involves the use of semi-permanent fillers for augmentation - in short, nose job by injection.
"Essentially, what we have here is a five-minute rhinoplasty," he says. "For example, if a patient comes in and says, ‘I want to have my nose bridge raised,' I will often use a semi-permanent filler. I will inject it between the eyes, over the bridge of the nose. So what we're doing is using a filler as an implant to raise the bridge of the nose. It's essentially an injectable implant."
Dr. Wu says that, like any other variation of a cosmetic procedure, the injection rhinoplasty has its particular advantages. One big mark in the plus column, he notes, is the fact that the procedure takes so little time to perform.
"One of the reasons this method is so popular is because some patients really don't have the time to take a week off to recover from traditional rhinoplasty," he says. "Also, this method has virtually no bleeding or downtime. So you can see how this is one of the nicest things that has come out in terms of modern rhinoplasty. And it's only possible because of the improved filler materials that we have at our disposal."
The trade-off, he says, is permanence. As Dr. Wu prefers to use semi-permanent fillers when performing augmentation rhinoplasty, he says the results are relatively short-lived when compared to the lifelong results achieved when using an implant.
"Of course, you're using a semi-permanent filler, so it doesn't result in a permanent augmentation," he says. "But it will be six to 10 months before the patient needs another top-up. This is generally enough time for the patient to see if he or she likes the results and wants to have it done again."
He adds that injection rhinoplasty using a semi-permanent filler gives the patient the option to safely "test-drive" an augmented nose before opting for a permanent augmentation. This option, combined with the short operation time and nearly non-existent downtime, makes injection rhinoplasty a hit with many patients.
"They really like it," Dr. Wu says. "Doing rhinoplasty through injection, that is a real significant advance. It's more of a look-see technique with a view to long-term results."
Experts note that rhinoplasty is arguably one of the most complex procedures in modern cosmetic surgery - perhaps in the realm of all surgeries. Special attention must be paid to the individual structure of each patient's nose in order to ensure a result that is visually pleasing.
"I believe that without knowing intimately the anatomy of the nose it will be very difficult to get rhinoplasty right," says Dr. Wu. He adds that his study of the anatomical basis of nasal surgery, for which he won the Young Surgeon's Award in 1990, gave him a good background in dealing with the special problems encountered when augmenting the nose.
"You need to know how to handle the tissues of the nose, as well as when you can put on additional pressure to the skin of the nose during augmentation."
Aside from extrusion, improperly performed rhinoplasty operations can result in other complications, such as obstruction of the nasal passages. The nose is also very highly vascularised, meaning that it contains a wealth of blood vessels. Surgeons must be particularly careful when working around these blood vessels in order to ensure that excessive bleeding does not occur.
And as with all surgical operations, infection is a big consideration. Risk of infection can be limited by ensuring a sterile environment and proper bandaging following the operation. Dr. Wu adds that the chances of infection when using a synthetic implant can be minimised by leaving the surface of the implant intact.
"I try never to modify implants," he says. "At most I will just make minor adjustments. If you start carving silicone, you're turning a regular surface into an irregular one. This predisposes the patient to infection."
Due to its less invasive nature, the list of possible complications associated with injection rhinoplasty is considerably shorter. However, it is still important that patients seek out a trained hand when shopping around for this procedure. After all, the attractiveness of your face depends on whom you trust to work on it.
The bottom line
Compare modern rhinoplasty to what it was 20 or 30 years ago, and you'll see that the unflatteringly termed nose job has truly evolved into an art in its own right - one that requires an eye for intricacy and attention to detail. In the years to come, Dr. Wu says that it is likely that the existing methods of rhinoplasty will continue to be polished by surgeons.
"I think what the future holds for us will be a constant refinement of existing techniques," he says. "The improvements we will see will probably be the result of a greater understanding by plastic surgeons of the anatomical principles of the nose."
The ballpark cost for a traditional open rhinoplasty in Malaysia ranges between RM 3,000 and RM 5,000. However, costs vary from surgeon to surgeon, as well as what technique is used. An injection rhinoplasty, for example, generally costs significantly less than the insertion of an implant.
Dr. Wu says that he normally charges between * S$1,600 and S$1,800 (RM 3,650 - RM 4,100) for an injection rhinoplasty that lasts between six and 10 months. Insertion of an implant costs about * S$5,300 (RM 12,100), and the cost of composite rhinoplasty hovers between * S$7,500 and S$9,500 (RM 17,100 - RM 21,700).
With all of these options at their disposal, today's cosmetic surgeons enjoy a deep toolbox when it comes to giving their patients the noses of their dreams.
"So now we have a range of different rhinoplasty procedures we can offer patients," Dr. Wu says. "Of these, however, I actually find the composite rhinoplasty to be the most useful, as it combines the strengths of two broad styles of rhinoplasty."