Identity Loss Syndrome after rhinoplasty

One of the possible unexpected  psychological effects patients may experience after having rhinoplasty can be a sense of loss of identity. This occurs when one experiences a disconnect with their new physical appearance which they either can't accept or takes a long transition period to get accustomed to.One who undergoes a multitude of  initial cosmetic procedures at once or within a short period of time, are more  prone to suffer from this syndrome, versus someone who has a single or few minor cosmetic changes. However the nose is a prominent feature of the face, and therefore a very large proboscis that is dramatically reduced or reshaped after initial rhinoplasty can have dramatic psychological effect creating a self identity crisis. For example pre-rhinoplasty I had a very large hooked crooked nose. After my initial rhinoplasty i ended up with a over shaved bridge, which created a ski sloped nose with a over projected tip. The look (which was very contrasting with my original nose) never fitted in with  my round face, and looked unnaturally long resulting in a Cyranno type appearance. Others who may likely experience this syndrome are those belonging to certain ethnicity, race or have a family physical trait. A middle eastern person or a descendant of, may want to keep a more rounded profile or lowered tip then a 'perfectly' straight septum, or a Colored or Asian individual may want a wider nose then the Caucasian standard ideal nose. Another group who would be susceptible to this identity loss syndrome (I.L.S.) would be those who feel a reduction in their gender defined degree of physical characteristics. A male may feel emasculated if he always had a more rugged 'Roman like' shaped nose , and then after rhinoplasty ended up with more feminine looking nose (more obtuse nasolabial or nasofrontal angle). Same could hold true for women who have petite features and end up with a more masculine nose, due to more acute tip angle, or increase in size/shape of their new nose due to cartilage replacement grafts. Another subgroup are those who feel a disharmony between their physical appearance and their personality type. This  can occur where one ends up with a  nose shape that makes them look rugged/ more aggressive looking or weaker/softer looking  which is in disharmony with their  type of personality.  A person may also associate and develop a strong negative feeling  with their new look not based on gender issue's but because their new look simply resembles a character type they view negatively or very foreign. One other group who may experience  I.L S. are people who have become very accustomed to their facial imperfection (i.e.slight deviated septum, or asymmetric nose), which had become subconsciously a personal identity marker. This is why it is critical for the surgeon and patient to be on the same page, as to what result the patient is seeking. However a patient seeking primary rhinoplasty may not know what they really want.  It may be wise for the surgeon to have a questionnaire that can address these questions, and issue's, just before consult, so the surgeon can further explore these possible issue's that even the patient may not of been cognizant of prior to making the appointment. A follow up appointment may be needed to give time to the patient to be more specific about what cosmetic change their seeking, and to figure out what they like and don't like about their nose. The use of a picture or computer imaging is very useful to experiment with different looks at different angle views to give the patient an idea of how they may appear post rhinoplasty. Young patients may need to realize and be counseled that their favorite celebrities nose(s) may look totally wrong with their facial features.

http://www.dailymail.co.uk/femail/article-2127322/Can-plastic-surgery-change-personality-Excessive-cosmetic-procedures-lead-identity-crisis-warn-psychologists.html

Anatomic reconstruction of the alar cartilages in secondary or revision rhinoplasty

In my October 22, 2012 post i discussed if there is a surgical decision point such as a  50% rule relating to  missing cartilage where some surgeons decide to  rebuild the alar cartilages or other nasal cartilage in general instead of using an assortment of different individual grafts and fillers. While still not knowing the precise answer to that question, the following article which i discovered after writing that article sheds some light on the issue, and it seems a bit more complicated then that. It emphasizes the advantage of anatomic reconstruction of the nasal tip cartilages instead of using nonanatomic cartilage tip grafts.

ANATOMIC RECONSTRUCTION OF THE NASAL TIP CARTILAGES IN SECONDARY AND RECONSTRUCTIVE RHINOPLASTY    Author: Dr. Frederick J. Menick

   Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain but frequently the alar cartilages are missing- unilaterally, bilaterally, completely or incompletely- with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columella retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance or malposition have been noted.

   Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear and rib cartilage, fixed to the residual medial crura &/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule, and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair.

   Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to surgeon's advantage. A rigidly supported framework with a nasal shape, can mold a covering forehead flap ro the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal.

   Anatomic alar cartilage reconstructions were used in 8 reconstructive and 8 secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized. (Plast, Reconstr. Surg. 104: 2187, 1999.)

http://www.drmenick.com/wp-content/uploads/2012/06/PDF%20Anatomic%20Reconstruction%20of%20the%20Nasal%20Tip%20Cartilages%20in%20SecondaryReconstructive%20Rhinoplasty.pdf

My shrinking nostrils: Nasal tip collapse as a result of rhinoplasty

By now  those of you who have been following this site, will be aware of the terms external and internal nasal valve collapse. When thinking of those terms we automatically think of lateral collapsing of the nasal wall towards the septum particularly with inspiration. But when a significant amount of your tip cartilage (the middle and medial crura) are excised during rhinoplasty you will likely notice, as is in my case, that your nostrils are now significantly less projected then they were before your primary nose surgery. In fact the short projection of my nostrils were pointed out to me by a revision rhinoplasty surgeon a few months back. At closer inspection of the base view of my nostrils, I would guesstimate (since i don't have nostril pictures of my original adult pre-operated nose) that my nostrils are close to  half the length of what my  nostril projection was prior to my primary surgery. I have had my tip reduced in all of my three revision rhinoplastys, as well as reduced and reshaped in my primary. My nasal spine was also reduced in one of my revisions. The problem of an overly large  nasal tip was a result of my primary nose surgeon being overly aggressive with my bridge (I had a very large hooked shaped nose), so by overcompensating for that, the surgeon ended up giving me a ski sloped nose with a very long protruding tip... the Cyrano effect  A big cosmetic assessment mistake that was made by my last surgeon was not understanding how to safely bring into balance the longer tip with my scooped out bridge. The safe, smarter but more complex procedure which should have been performed, was to add grafts to my bridge building it up to line up better with  my tip. Another possibility which could of been performed alone or in tandem with the former was to reshape the tip cartilages using sutures and rotate it downward, since I already had some excision to my tip cartilages previously. Unfortunately the surgeon wasn't that experienced or skilled so he decided to opt for quick & easy 'fix'  and aggressively excise the tip cartilages further down, not taking into account all the previous excisions i had. So in essence he was able to achieve the cosmetic goal of reducing the length of my tip, but unfortunately not without major consequences. I don't believe I have tip ptosis at least not a very distinguishable form of it because my tip was already positioned fairly high after my first revision surgery. However it's very likely that the major and minor supporting tip structures have been negatively impacted on, as well as the vascularity of my skin and soft tissue envelope. I would assume that in order to correct my flattened "shrunk" nostrils i would probably require tip projection as well as correcting the lateral collapse I have, to achieve a normal and relatively proportional sized nostrils ( proper ratio's) for the base of my nose. It's also important to recognize that anything which decreases the nasal valve cross sectional area can negatively impact the nasal airway, creating further feeling of nasal obstruction. Even though there's a significant amount of information about reducing flared out nostrils for cosmetic reasons, not much exists for increasing or restoring the size of one's flattened out nostrils due to prior nose surgery's. At least not that I have found online. As far as nasal tip ptosis is concerned I will discuss that in greater detail on another post.

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