The More the Better: Does Complexity in Rhinoplasty Come Naturally?

Abstract

Facial Plastic Surgery & Aesthetic MedicineVol. 24, No. 3 ViewpointFree AccessThe More the Better: Does Complexity in Rhinoplasty Come Naturally?Abel-Jan TasmanAbel-Jan Tasman*Address correspondence to: PD Dr. Abel-Jan Tasman, ENT Department, Cantonal Hospital St. Gallen, Rorschacherstr. 95, St. Gallen 9007, Switzerland, E-mail Address: abel-jan.tasman@kssg.chhttps://orcid.org/0000-0001-5052-5444ENT Department, Cantonal Hospital St. Gallen, St. Gallen, Switzerland.Search for more papers by this authorPublished Online:15 Jun 2022https://doi.org/10.1089/fpsam.2021.0287AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail In 1988, when the first laparoscopic cholecystectomy was performed in the United States, it was predicted that the conventional endonasal rhinoplasty approach would become an anachronism within a decade.1 Although visceral surgery evolved toward less invasive techniques, a growing number of maneuvers and more dissection indeed became part of a typical rhinoplasty. Currently, the complexity of rhinoplasty as it is taught at courses is intimidating to many young surgeons. Masters in the field who have followed the evolution of rhinoplasty for decades doubt if they would be able to learn rhinoplasty as a novice today (M. B. Constantian, pers. comm.). Have different maneuvers and a variety of grafts been added to a technically challenging operation only because they improve outcome?Fascinating recent research on problem-solving investigated whether people are as likely to consider changes that subtract components from an object, idea, or situation, as they are to consider changes that add new components.2 A toddler had made a bridge of building blocks symmetrical by taking one block away. His father, who was then still looking for a block to add to the opposite side for symmetry, decided to study the preference of additive versus subtractive solutions in problem-solving. Eight experiments have shown that people systematically default to searching for additive transformations, and consequently overlook subtractive transformations. Participants were less likely to choose advantageous subtractive changes when the task did not cue them to consider subtraction. Defaulting to searches for additive changes, the authors concluded, may be one reason that people struggle to mitigate overburdened schedules, institutional red tape and damaging effects on the planet. One interpretation of these studies was that people might expect to receive more credit for additive solutions than for subtractive ones.3 The tendency to subtract increased, according to one of the studies, if subjects were unfamiliar with components they could add or leave out.2As surgeons, could we too expect that adding complexity to our procedures will be good for our reputation? If so, are we more likely to incorporate surgical maneuvers that we have seen demonstrated in a most convincing and didactic manner by opinion leaders?4 If we are indeed hardwired to overlook or undervalue subtraction in problem-solving, we must be less likely to critically reflect cues to simplify rhinoplasty.In a rhinoplasty forum I was recently stamped “a minimalist” after I suggested leaving a nasal tip untouched in a patient whose preoperative photographs were discussed. Most elaborated on how they would reshape and reposition the tip that looked fine to me. Having simplicity in one's approach acknowledged certainly is a compliment in many art forms, but maybe not so in facial plastic surgery. The complexity of contouring the nasal tip has been abundantly described and the multitude of techniques that are available make it inevitable for the surgeon to execute good judgment in determining how their skill level matches the progressively more complex techniques.5 The research on problem-solving suggests that we may also try to keep our good judgment when it comes to simplifying an operation.One way to do so, for me, is to simulate the desired outcome of surgery with the patient, beginning with small changes that address the main complaint. Further modifications are then added until a consensus is reached. As surgeons we may find details such as less fullness in the supra-alar groove and supratip, a defined arch between tip lobule and alar lobule, and an appropriate nasal tip position desirable.4 Patients in contrast may be less sensitive to these improvements. In addition, rhinoplasty should be not only ethnically congruent requiring ethnically sensitive nasal analysis.6 It should be individually congruent too, and I am often surprised by what a patient is willing to accept as an individual trait, often related to a familial or ethnic background.I agree that rhinoplasty should be “tip intensive” in the majority of patients and “as the tip goes so goes the result.”5 Some tips will still look good after dorsal modification and may either be left untouched or may require small modifications that can be achieved through an endonasal approach. Opting for less dissection through an endonasal approach should not be considered an anachronism today. We have a natural tendency to prefer complex solutions. This fact should cue us to consider simplicity in rhinoplasty surgery too.Author Disclosure StatementNo competing financial interests exist.