By Abel-Jan Tasman
John Orlando Roe entered history as the father of aesthetic rhinoplasty after having reported a “simple operation” in 1887 describing the correction of a “pug nose” through an endonasal approach. Four years later Roe performed endonasal hump reductions. It was seven years later that Jacques Joseph published similar techniques, presumably without knowledge of Roe’s reports. Joseph is generally accepted as the founder of functional rhinoplasty. In 1982 Weir described the technique of “nasal infraction”, augmented saddle noses with implants made of duck-sternum and described the rotation of the drooping tip by a wedge excision from the caudal septum. The latter technique is today still named after him. The first transplantation of costal cartilage was published by Mangoldt in1900. Many new instruments were introduced between the 1960’s and 1980’s. At the time, various modifications of osteotomes replaced the hand-held saw for the lateral osteotomy. Reports on the use of a drill in 1981 were long forgotten when the development of shavers and endo-nasal drill systems 20 years later brought up the discussion of powered instrumentation for rhinoplasty again, indicating the unresolved issues regarding ideal instrumentation. Reliable data on growing interest in facial plastic surgery in Europe are not available. In the US the number of facial plastic surgical procedures increased by 34% between 2000 and 2004. This increase was mainly attributable to the popularity of non-surgical procedures such as botulinum toxin and fillers, whereas the most popular aesthetic procedures were blepharoplasty followed by rhinoplasty. The impression shared by many facial plastic surgeons is that there is a growing interest in rhinoplasty in Europe as well and this trend is expected to become stronger. Every experienced rhinosurgeon has operated a number of patients in whom the unfavourable postoperative course clearly indicated that the indication was a mistake. Unfortunately, patients frequently manifest themselves as bad candidates after surgery and one of the major unresolved problems is how to recognise the high risk patient early in the consultation. As reliable criteria have not been defined, the surgeon has to rely on his instinct. Long lists of attributes such as obsessive, perfectionist, compulsive, impolite, flattering etc., have been proposed to help the surgeon. The acronym SIMON (single, immature, male, over-expectant, narcissistic) was coined for the male high-risk patient whereas SYLVIA (secure, young, listens, verbal, intelligent, attractive) can be considered to be a good candidate. These criteria are clearly of little help in face of the individual patient and the first sign of alarm for the surgeon is frequently an intuitive spontaneous feeling of disliking the patient. A psychiatrist condensed the role of instinct into the phrase “if you cannot elicit a smile from your patient, don’t operate”.