Rhinoplasty: The Most Difficult Operation in Plastic Surgery

"Nose-jobs" have evolved over the years, but are still a big operation.

Which do you think is the most technically difficult operation in plastic surgery? Limb replants? Face transplants? Maybe bodylifts? In fact, most plastic surgeons will tell you that rhinoplasties are the most difficult operation. Rhino—what? No, that’s not an operation on that one-horned African animal. But the root of the word—“rhino” means “nose” in both the rhinoceros and rhinoplasty. 


Rhinoplasties are operations that change the shape of the nose. They’ve been performed in one form or another for hundreds of years, but they only became popular in the 1960s. Back then, rhinoplasties were dubbed “nose-jobs”, and were really pretty radical, unsophisticated procedures. Surgeons made incisions inside the nose and performed the operation upside down and inside out. To an observer, that operation would have looked like the doc simply jiggling a series of instruments inside the nose. And, truth be told, only the surgeon knew just what he did in that nose. Even the scrub nurse couldn’t tell. Nowadays, there’s about 134,000 nose altering operations each year. Not quite as popular as liposuctions and breast implants, but still a healthy number.

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Those 1960s nose jobs were really pretty brutal procedures. Bone and cartilage was chomped away, without a good understanding of the long-term consequences of the procedure. Plastic surgeons developed their own techniques, often performing the same procedure on everyone.  It was sort of like they placed their signature on the faces of their patients, and those schnozzolas became known as “signature noses”. You could tell which surgeon did which nose by identifying that characteristic swoop or shortened tip. Those noses often looked pretty good back in the 60s, but the surgeons didn’t count on the tissue thinning that occurred over years, and in fact, decades. So those cute noses in 1965 often looked twisted and tiny by 1985. And by the 80s, with a few decades of experience behind the cosmetic surgery profession, the operation changed.

By the mid 1980s, rhinoplasties were done more conservatively. Incisions were made between the nostrils, allowing the skin to be lifted off the nose like the hood is lifted off of a car. This allowed the operation to be performed “outside in”, not “inside out”, and this added great precision to the procedure. The focus no longer was simply on making the nose smaller. It was realized that correct proportions and proper angles were as important, or even more important, than size. Surgeons began to individualize the operation, respecting ethnicity and patient desires.

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