Nosing around for perfection

Daniel Becker, the resident nose job expert at HUP, performs around 100 rhinoplasties a year. Daniel Becker has probably seen every nose shape and size there is. A professor in the Ear, Nose and Throat Department at the Hospital of the University of Pennsylvania, Becker is HUP's resident expert rhinoplasty -- the technical name for a nose job. The nose guy, as he calls himself. Since Becker arrived at Penn 3 1/2 years ago, his practice has grown to the point where he now performs the majority of the rhinoplasty operations in his department-- about 100 a year on patients ranging in age from 16 to 78. And much of his practice -- about 40 percent of the rhinoplasties he performs -- is fixing nose jobs that did not heal properly. "My specialty is taking care of the nose inside and out," he explained. It used to be that surgeons would remove tissue and bone when performing rhinoplasties. But that technique often results in problems later on, such as obstructed breathing or a skeletonized shape, which is what Becker often finds himself correcting. "The nose has a structural support like a bridge," Becker said. "If you take away too much, then it doesn't have the support it needs and it doesn't work." Otorhinolaryngologists now resect swaths of cartilage from the ear or septum -- the wall that divides the nose into left and right halves -- and insert them into the nose through incisions made either in the inner nose -- a technique known as endo nasal rhinoplasty -- or on the columella, the bridge that separates the nostrils, known as open rhinoplasty. Many of the revisions that Becker does are on patients who had rhinoplasties 10 or 15 years ago. But he also sees patients who had more recent surgeries, which he views -- to some degree -- as a sign of incompetence on the part of the surgeon who did the original operation. "Clearly, there is not enough understanding about rhinoplasties out there," he noted. "Some things are done improperly." But not all of the revisions he sees are necessarily the result of a poor nose job, Becker points out. About 2 to 8 percent of any surgeon's rhinoplasties will need touch-up operations. But Becker says he strives for perfection with every rhinoplasty. "There is an expression that the best outcome is a happy patient and a happy surgeon," he said. "The worst outcome is a happy surgeon and an unhappy patient. The most common should be a happy patient and an unhappy surgeon." Striving for perfection is important because, for many people, a changed nose can mean a changed self-image. "It can make a wonderful improvement in people in the way they view themselves," he said. "If you ruin someone's nose, then it can be devastating." And Becker wants to dispel the image of nose jobs patients as rich people who are never satisfied with themselves. He points out that a good number of the rhinoplasties he performs are on students. Students, according to Becker, have the same reasons as anyone else for having their noses done: function, aesthetics or both. But students tend to wait until graduation before they have their noses done. "When people begin a new life, they want a new appearance," Becker said. "That's a good time for them to make that change." Whatever the reason for the operation -- Becker has even operated on men whose noses were crushed in fights -- the goal is always the same. "You don't want someone to look like they just had an operation," Becker said. "You just want them to look good." Modern surgical tools and techniques have been so refined that patients experience little or no scarring or bruising. Even the incision wounds are barely visible when they heal. And the pain is minimal. About the only post-operative symptom is fatigue. Otorhinolaryngologists like Becker now use powered instruments for tissue shaving and specially made osteotomes, which are used to reshape bone. "He utilizes traditional techniques combined with new approaches and instrumentation," said Andrew Goldberg, a fellow HUP otorhinolaryngologist. A typical rhinoplasty can last anywhere from one to three hours plus recovery time and costs a few thousand dollars. But for most patients, the outcome is well worth the price. "I've never seen a smile on a face as big as the smile on the face of a rhinoplasty patient after you take the cast off," Becker said.