My Personal Approach and Philosophy

Daniel G. Becker

My personal philosophy of rhinoplasty focuses on one essential goal – to achieve a result that makes the patient happy. With this essential goal in mind, I take a conservative approach to rhinoplasty and seek a natural, unoperated look. I avoid over-aggressive resection maneuvers. I focus on maintaining structural support, and seek a natural “unoperated” appearance. I have provided before and after surgical photos in my websites that I hope reflect my approach. Ultimately, success in rhinoplasty is based on well-developed judgment, wisdom, and accumulated knowledge and experience. Like most surgeries, rhinoplasty is both a science and an art. Skill comes from experience and wisdom, combined with a measure of talent. The surgeon must have a detailed understanding of the multiple anatomic variants encountered. The surgeon must also have accumulated the appropriate surgical techniques and experience.

In an effort to minimize risks and complications, I have studied them intensively throughout my career. I have also had the opportunity, due to my surgical practice in revision rhinoplasty, to see the kinds of complications that occur all over the world. I have also developed a significant surgical experience in correcting many of the problems that occur. I have also written extensively about complications of rhinoplasty and their correction. In My focus on this subject has culminated in a recent textbook. With these introductory thoughts in mind, and with the permission of my publishers (Thieme Publishers, New York City, New York), I have reproduced in its entirety a chapter from this medical textbook, in which I discuss my personal philosophy and approach to revision rhinoplasty. Instead of a theoretical discussion, this chapter provides a “brass tacks” description of my approach to patients and my practical thoughts on the subject of the practice of revision rhinoplasty. It is my hope that this information will be useful to the reader.

Revision rhinoplasty is a term that encompasses a wide spectrum of problems, from straightforward to complex. In an established revision practice, patients seeking consultation include many who have all but lost hope. Commonly, the experienced revision surgeon will find that significant improvement is possible (Fig. 18-1). However, to achieve success, it is important that the patient and surgeon come to a realistic understanding of what can and cannot be accomplished. Verbal communication supplemented by computer imaging helps the surgeon and patient arrive at a shared surgical goal.

The revision rhinoplasty patient needs an environment in which he or she will be able to develop and maintain trust. This environment is best created by dedicating oneself to revision surgery, by placing a strong emphasis on patient education, by taking the time necessary to answer the patient’s questions and concerns, and by being honest and plainspoken. The patient must feel that the surgeon has a passion for the operation and that the surgeon has dedicated him- or herself to the pursuit of excellence in nasal surgery, specifically revision surgery.

The revision patient is acutely aware that surgery is not an exact science and that complications can occur. The revision patient understands that complications also can occur in revision surgery; with this in mind, it is critically important that the surgeon show a special attention to risk management.

For many revision patients, life begins to revolve around their nose. It is important that patients be prepared for a shift in focus. They should be prepared to shift focus toward getting on with their lives after the important changes to their noses have been made.

The revision surgeon’s job does not end after surgery. If the result of a revision achieves the shared surgical goals, the surgeon should caution the patient to avoid the impulse to make additional small changes. The result should not become a “moving target.”

When there are problems that may benefit from additional work, naturally, the revision surgeon addresses them forthrightly. Conversely, it is important that the patient give thoughtful consideration to the recommendation by the experienced revision surgeon that no further surgery should be contemplated. In this setting (as in all aspects of patient care) it is important that the surgeon and patient have established a trusting relationship. Still, each patient ultimately bears a certain amount of responsibility for his or her own actions and decisions.

With the psychological, emotional, and technical factors in mind, it is important that the revision surgeon approach the nose with an emphasis on risk management. Surgery is not an exact science, and the results are not always predictable. The surgical plan is designed to achieve the shared surgical goals with as little trauma as possible. The patient is reminded that complications can still occur and that not all complications are correctable.

Ultimately, success in revision rhinoplasty is based on well-developed judgment, wisdom, and accumulated knowledge and experience. Like most surgeries, revision rhinoplasty is both a science and an art. Skill comes from experience and wisdom, combined with a measure of talent. The revision surgeon must have a detailed understanding of the multiple anatomic variants encountered. The surgeon must also have accumulated the appropriate surgical techniques and experience. Specifically, the revision surgeon must acquire knowledge of the surgical alterations that occur and how to achieve an improvement or correction when the result is undesirable. This second skill set is acquired by careful follow-up of operated patients over time.

My personal philosophy of revision rhinoplasty focuses on achieving two essential goals. The first is to make the patient happy. Hand in hand is the second goal: for this to be their last nasal surgery. With these goals and these introductory thoughts in mind, in this chapter I will discuss my personal philosophy and approach to revision rhinoplasty in terms of the psychological, nontechnical aspects, as well as the technical, surgical aspects. I will provide my general thoughts and a “run-through” of my current approach. Instead of a “theoretical” discussion, this chapter provides a “brass tacks” description of my approach to patients and my practical thoughts on the subject of the practice of revision rhinoplasty. It is my hope that this information will be useful to the reader.

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