5.1 Taking Stock: The Goals of Revision Surgery

The first impression is always an outward one. We perceive the proportions of a face, the skin type, and especially the overall facial appearance and attractiveness. Fine, symmetrical facial features are perceived as more aesthetically appealing than coarse features. But the more time we spend with a person, the more other qualities start to matter: personal charm, voice, and character. These qualities are also important in evaluating candidates for facial revision surgery. Taken as a whole, they may “trump” the external facial features or they may not. A perfect face is not beautiful if it masks an arrogant or narcissistic personality. Inner beauty, then, is ultimately superior to outer beauty while also serving to enhance it.

The question of whether aesthetic surgery can make people happy is disputed. An exhibition titled Glück welches Glück (“Happiness What Happiness”) opened at the German Hygiene Museum in Dresden in 2008 and dealt with this question ( Fig. 5.1 ). ¹ It included an exhibit on cosmetic surgery featuring surgical instruments from various periods of history so that visitors could experience the practical side of cosmetic surgery. The instruments designed by Jacques Joseph were of particular interest. Joseph repeatedly cited the great psychological importance of reconstructive and cosmetic surgery in his writings. Going against the mainstream of contemporary professional thought, he was the first to define cosmetic surgery as an aesthetic endeavor. ²

Everyone has their own definition of happiness. Most candidates for revision rhinoplasty and most of our own patients come to us because they hope to be happier by becoming more attractive. Some are struggling with a sense of being disfigured due to an accident or tumor resection. The hopes of becoming both happier and more attractive are in fact justified, because patients tend to be more self-confident and content following a successful operation. In this sense, a positive result of revision surgery can make people happier.

The present book runs the gamut from major and minor functional–aesthetic corrections to breathtaking reconstructive revision surgery. This is in keeping with the philosophy of Joseph, who wrote:

The principal motive is not vanity but a sense of being disfigured, or an antipathy toward disfigurement and its psychological effects. The goal of rhinoplasty, then, is to cure mental depression by creating a normally shaped nose. It has an unquestionable social impact and represents a significant branch of surgical psychotherapy. ²

Figs. 5.2 and 5.3 show two examples of the innovative work of Jacques Joseph illustrating two sides of the same coin: functional–aesthetic surgery and nasal reconstruction.

5.2 The “Sender” and the “Receiver” in Facial Surgery

While in the planning stage of a revision rhinoplasty, the surgeon should address or readdress the crucial question of in what way and to what extent the revision candidate will actually benefit from another operation. ³ The goal of rhinoplasty is less to create individual “parts” with a pleasing anatomic shape than to contribute to an overall improvement in facial appearance. ⁴ Simply stated, the nose is the sender and the face is the receiver. Standard formulas, lines, and angles are available for orientation purposes ( Fig. 5.4a ), but the rhinosurgeon must also make intuitive choices based on an appreciation of facial aesthetics ( Fig. 5.4b, c ).

The oldest theorems in geometry presumably originated from Pythagoras (ca. 599 BC), who was quoted as saying “numbers are crucial in nature and in art.” ⁵ The Venetian monk Fra Paciolo di Borgo made a detailed study of proportions and aesthetics during the Renaissance. He published his book in 1509, reporting the discovery of the “golden section.” We credit his contemporary, Leonardo da Vinci (1452–1519), with dividing the face into three equal sections by horizontal lines. Albrecht Dürer (1471–1582) was the most important German painter, printmaker, and draftsman of his time. He studied the theory of proportions and what constitutes beauty, which was considered the goal of art. ⁶ Dürer believed that beauty could be constructed with a “compass and straightedge.” The vertical subdivision of the face into five equal portions dates back to Powell and Humphries. ⁷

The nose is a central, solitary structure that functions as a bridge joining the upper third of the face to the lower third. It forms the geometric ordinate by which facial symmetry or asymmetry is assessed. Every rhinoplasty will ultimately influence facial anatomy and appearance. Despite its central role, the nose ranks low in the aesthetic hierarchy of facial features. It should showcase the dominant expressiveness of the eyes and brows as well as the lips with their delicately curved Cupid bow, without drawing attention to itself. Nevertheless, the nose should have an individual shape, it should fit the face, and preferably it should contribute to an elegant profile line by harmonizing with the trichion and pogonion. A “standard” type of nose cannot meet these criteria for all individuals.