CHAPTER 18 Male Rhinoplasty: Expert Technique

10.1055/b-0040-178158

CHAPTER 18 Male Rhinoplasty: Expert Technique

Summary

Male rhinoplasty is a highly specialized subset of an already complex operation, both in its execution and in managing patients’ expectations. This chapter aims to list the salient points any rhinoplasty surgeon would be required to understand and implement in improving their male rhinoplasty outcomes. Much of the old “SIMON” (see chapter 17) concept does not apply today, as all patients live in this social media, “selfie-centric” state, and may be overly concerned about physical attributes. Male patients require even more careful scrutiny in screening from the first point of contact with the surgeon’s office to the last postoperative visit. Attention to the nuances in the desired profile height and curvature versus straightness, tip shaping, overall size, and tip–nostril relationship is essential. Nasal airway complaints are common and require expert care with addition of spreader grafts in most cases as well as proper external valve reinforcement. A detailed review of surgical techniques and sequences will be provided along with discussion on optimizing pre- and postoperative communication.

Introduction

Rhinoplasty continues to be a complex surgical undertaking for both novice and seasoned surgeons. The dynamic interactions that occur intraoperatively and postoperatively between the cartilage or bone frame and overlying soft tissue or skin create a level of unpredictability that is inherent to the operation. Rhinoplasty on males may possess a slight decrease in these inherent challenges. By and large, men do not require or request as much alteration of the nasal tip and overall cosmetic appearance of the nose compared to women. There are exceptions to this, however, as more people, male and female, are looking at social media along with the applications, which can alter the facial contours and appearance within seconds. Digital filters that narrow and downsize the nose and face are popular and used by men also. Communicating accurately and intelligently with male rhinoplasty patients preoperatively is perhaps the most important step in reducing unsatisfactory outcomes. With realistic expectations, men can experience great satisfaction in the functional and aesthetic nasal changes they seek.

The old “SIMON” acronym for single, immature, male, obsessive, and narcissistic still holds some weight and should be considered when taking on male patients. ¹ ^, ² Today, one must also take into account the overall expectations and requests of each male patient. Some will bring in morphed images of their noses for evaluation, while others may state, “you are the expert so you know best.” Both scenarios require care and caution to plan and deliver the optimal outcomes. In addition, male sexual orientation can sway male aesthetic preferences toward or away from more refined and narrower contour end points that are more similar to females in the morphological spectrum.

Obsessive and self-centered “traits” are more pervasive as a whole in our society today, as indicated by selfies and countless images shared by so many on social media. Males may simply be engaging in what has become a normative behavior without being any more obsessive or narcissistic (i.e., SIMON) than the female equivalent. Furthermore, many male patients that I have actually come across are very intelligent and not immature and are also quite appreciative of their rhinoplasty results. Selection of the proper patient who will handle the healing ups and downs as well as one who has appropriate expectations is something that comes with clinical intuition as a plastic surgeon and becomes more acute with experience gained. While some patients may slip through the cracks, astute judgment calls will limit those patients who may never be satisfied or “happy,” whether male or female.

The most commonly requested goals listed by males seeking rhinoplasty are as follows:

Dorsal reduction.
Dorsal narrowing or straightening.
Nasal breathing improvement.
Tip elevation.
“Subtle” tip refinement.

The list may seem similar to many females, but the degree of magnitude in individually altering these parameters is less when performing male rhinoplasty. 3–7 For example, tip rotation must not be excessive, whereas slight overrotation will be appropriate in a female patient. The box below has a list of general guidelines. Below, the different anatomical regions will be delineated.

Skin/soft tissue.
Dorsum.
Nasal tip.
Nostrils, airway.

Male Rhinoplasty Goals

Avoid general feminization.
Conservative dorsal narrowing.
Maintaining straighter dorsal contour lines.
Nasolabial angle of 90° to 95° (varies with ethnicity and alar rim position).
Avoid a supratip break.*
Maximize nasal airway.
Liberal use of spreader grafts.
Maintain relative tip width during refinement.
Nose-chin-lip relationship is significant for overall balance.

*Some males may request a slight supratip break. Precise preoperative communication and goal setting are critical in planning nuances and preferences such as this.

Male Rhinoplasty Considerations by Anatomical Regions

Skin/Soft Tissue

The male nasal skin envelope is generally thicker, more sebaceous, and less elastic than female skin. This holds true as a generality across all ethnicities. However, when skin is thinner, it is critical to be particularly careful to avoid long-term visibility of grafts that are placed. The nasal tip in a male that shows any visible graft edges can be unsightly and be a telltale sign of surgery, which is often a male patient’s greatest fear.

The limitations in skin retraction along with the implications on nasal size reduction should be discussed with patients. However, techniques can be employed to exert a visual footprint on the overlying skin by using softer grafting techniques and limited soft-tissue debulking. Judging skin elasticity and thickness is the key. The tip complex and its often heavier soft-tissue demand support with a columellar strut graft, which is also important in maintaining tip position and shape long term ( Fig. 18.1 ). In addition, mucosal lining excision can reinforce final tip position long term (see below). ⁸

Dorsum

Dorsal height is important in respects that are very different than female aesthetic rhinoplasty goals. First off, the end point in dorsal profile height is higher than female height. Male forehead and brow ridge prominence often require radix augmentation to maintain a more masculine nasofacial balance ( Fig. 18.2 ). However, the nasal root and forehead must not be in the same plane, and an appropriate nasofrontal angle should be established. Overall dorsum and tip projection can be slightly overprojected, but malar prominence and other facial dimensions should be taken into account, particularly in the context of aging or future aging. Males want to look young, and as facial deflation sets in, the nose cannot look disproportionately large.

In the anteroposterior view, dorsal contour lines generally are maintained in a straighter fashion than the curvilinear lines of females ( Fig. 18.3 ). The dorsal width can be wider in males and use of spreader grafts should be more liberal than females. More cartilage frame support is needed in males in which nasal bones or cartilage and any dimensional nasal reduction can create airway compromise.