So You Don’t Like The Way You Look?
Well, would you change your face if all it took was the price of a good stereo, a few days’ living in bandages, and some tiny scars even if your closest friends wouldn’t notice—that is, if that was all it took?
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The board-certified plastic surgeons and the converts have formed competing factions. The American Society of Plastic and Reconstructive Surgeons represents the board-certified doctors, and the American Academy of Facial Plastic and Reconstructive Surgery is largely drawn from the ranks of maverick otolaryngologists, with representatives from other specialties. Along with the converts has come the tendency of plastic surgeons to specialize in certain regions of the body or even certain features. Gilmore specializes in the head and neck, and he feels that his background in otolaryngology has given him more familiarity with the anatomy of those areas than a plastic surgeon would ordinarily acquire in his training. On the other hand, he also feels that he could learn something from even more narrowly focused specialists. He thinks, for example, that ophthalmologists should be able to do the best—and safest—eyelid surgery. “I welcome the chance to learn from these people,” he says. “And I think that the competition is driving the quality up.”
Today Jim Gilmore lists himself as both plastic surgeon and otolaryngologist in the Yellow Pages, but his practice is almost entirely limited to cosmetic facial surgery.
“We Need to Get Away From the New York Nose”
The operating room in Gilmore’s offices has $50,000 worth of the latest surgical equipment, including a complete emergency unit with a cardiac defibrillator. In the middle of the room is a padded, contoured recliner that can be stretched out full length or adjusted to various angles and heights in order to bring the upper body and head into the right position. Gilmore prefers to operate in his office with a local anesthetic because the work goes faster and the patients don’t bleed as much as they would under a general anesthetic; both are factors that lessen swelling and speed recovery. And a rapid recovery was definitely important to this morning’s patient.
She was a fashion model, and although she was still an ingenue—her picture had just come out in Seventeen magazine—she was savvy enough to know that her nose just wasn’t right. It was a smidgen too long, and instead of plunging straight to the tip, or perhaps even displaying a hint of graceful concavity, the profile was marred by a slight hump. “People tell me that I have such pretty skin I should do face modeling,” she explained. “But I can’t do it with my nose.” What she needed was a few subtle alterations, and then she needed to get back to work. “Maybe I’ll go to New York and become famous,” she said as she waited for the knife.
The nose job, or rhinoplasty, as it is known to surgeons, is the speediest and most economical of all cosmetic surgical procedures from the patient’s point of view. The average surgeon’s fee is $1500 to $2000. When done in a doctor’s office, the operation is no more expensive than a ski trip or five days in Cancún. It takes about 45 minutes to an hour; it requires a small, superficial protective cast that comes off in a week; and although it is usually about a year before what is referred to as the final result is visible to the expert eye, from a layman’s point of view all of the swelling and bruising vanishes within about two weeks. But for the surgeon, rhinoplasty is an invitation to disaster.
Cosmetic surgeons rarely reach unanimity on a technical issue, but one thing they invariably agree upon is that rhinoplasty is by far the most difficult procedure to perform and, they will admit, the easiest to botch. “Noses,” says Gilmore, “are unforgiving. This is where we separate the men from the boys.” This is also where he feels he does his best work. Because he thinks it is a challenge equal to his skills, the perfect nose job is Jim Gilmore’s obsession.
The model was already in the twilight zone induced by Valium and intravenous Sublimaze—rhinoplasty patients are generally taken deeper than face lift patients because of the sensitive nerves in the nose—when Gilmore stuffed her nostrils with cotton soaked in a cocaine solution. Then he took a large syringe full of Xylocaine—the local anesthetic—and began injecting up, down, and inside the nose. Wearing a blue fiber-optic light on his head, Gilmore pulled the right nostril open with a small retractor and with the scalpel in his other hand made a quarter-inch long, curving incision on the inside of the nostril. The model’s feet twitched and a single tear ran down her cheek, but she remained calm. Then Gilmore inserted a small pair of scissors into the incision and created a narrow tunnel along the length of her nose between the skin and the underlying bone and cartilage. At this point the model mentioned that Eileen Ford of New York’s Ford agency was going to be in town and she wondered if she might be able to see her today. And at this point all that stood between her and the perfect nose were a few millimeters of bone and cartilage, a surgeon’s judgment, and any one of a number of things that could go wrong.
For a structure that is primarily an air conditioning, humidifying, and filtration duct for the air that enters the body (smelling is really a secondary function), the nose is fairly complicated. At the top the nasal bones give the nose its definition by coming together above the septum (the cartilage that partitions the nostrils) to form a sort of tent shape. The lower two thirds of the nose is shaped by a set of cartilages that allow the nose a convenient flexibility and resistance to impact. In addition to the septum, there are the paired upper lateral cartilages, which slightly overlap the nasal bones, and the paired lower lateral or alar cartilages, which slightly overlap the upper lateral cartilages. The alar cartilages have a graceful U-shape, and they extend from the outer rim of the nostrils, next to the face, to the tip of the nose and then loop around under the septum to give firmness to the columella, the bridge of flesh that divides the nostrils at the very bottom of the nose. The alar cartilages are where the surgeon has to start worrying.
When Jim Gilmore sees nose jobs by other surgeons he is frequently critical. “We need to get away from the ‘New York nose,’ the mass production nose,” he says. “We need to strive for the aesthetic nose.” Gilmore believes that the nose and the rest of the face are a sort of ecological system and that any changes have to be in harmony with the whole. You can’t put the same perfect nose on everybody’s face. So what Jim had done with the model, as he does with every patient, was to study her face very carefully. He watched her as she talked and moved around. He studied her pictures on slides and Polaroid prints taken from the slides. He studied the pictures in her modeling portfolio. And then he decided how to sculpture her nose so that it would be the perfect nose for her face, and for what she wanted to do with that face. And that would all begin with the alar cartilages.
Inserting a pair of scissors into the incision, Gilmore snipped through the skin enveloping the right alar cartilage. He probed the incision with tweezers and found the upper edge of the alar cartilage (where it abuts the upper lateral cartilage), then pulled the cartilage over and out of the incision so that it was exposed and inverted. Then he repeated the procedure in the left nostril. Through experience he had learned to think of the alar cartilages as a sort of tripod, with the two wings under the columella forming one leg and the two wings running to the face on each side of the nose forming the other two legs. If he shortened the two side legs by clipping off a section from the surgically exposed top of each cartilage, then the tip of the nose would shorten and move up toward the upper lateral cartilages just like a camera tripod with sections of two of its legs suddenly collapsed. The only problems were figuring out just how much to shorten those two legs and making sure to shorten each exactly the same amount.
Cosmetic surgery texts are full of gruesome pictures of nose jobs that have been bungled by “inexpert” handling of the alar cartilages; secondary repair, the undoing of botched nose jobs, is a common enough procedure to have entered the medical vernacular. In severe cases the nose can crinkle up like a piece of aluminum foil, a condition that is substantially irreparable. More commonly, the tip can end up uneven, with unsightly bumps caused by scar tissue, or simply too upturned— the “bobbed nose” of lore and legend. Gilmore, however, was confident that he could avoid disaster; the only thought that nagged him was whether this would be the best he was capable of, the best of all possible noses for this patient. The decisive moment upon him, he took his small surgical scissors and snipped off a triangular portion of each cartilage—about seven or eight millimeters on a side—then let them spring back into the incisions. Allowing for the tendency of the columella to swell under local anesthetic, he judged the angle and height of the tip to be correct. Now he had to make sure that everything that followed would harmonize with what he had done to the tip. And from here on out he would be working almost entirely by touch.
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