I have always felt strongly that there is no substitute for experience in surgery as experience and judgment are inextricably linked. Judgment guides decision-making and instills confidence while infusing humility into surgical practice.
Sadly, governmental bureaucracy, changing medical economics, liability concerns and evolving educational paradigms have left modern-day surgical trainees behind my generation of plastic surgeons.
Having trained arduously in general surgery, vascular surgery, trauma surgery, cancer surgery, cardiothoracic surgery and several surgical subspecialties prior to training in plastic/reconstructive surgery and then signing on for additional microsurgical training not only bent my experience curve significantly, but accelerated my surgical judgment in such a way as to give me a unique perspective on my rhinoplasty practice.
My fifteen years of performing rhinoplasty can be broken out into three distinct five-year periods. Like all young enthusiastic surgeons beginning their practices, I was eager for the opportunity to utilize the skills that I garnered from eight years of surgical training and thrilled to help people with surgical problems.
Reconstructive Surgery and Rhinoplasty
My mindset and practice patterns are molded from a strong background in reconstructive surgery and my interest in rhinoplasty quickly grew out of my desire to perfect my knowledge of and facility with anatomy. I made a conscious practice of taking on mostly straightforward cases while my experience was limited and nearly all of my rhinoplasties were performed via the ‘closed’ technique whereby the operation is done exclusively through incisions on the inside of the nose.
During this 5-year period, I would estimate that there were approximately 10-15% of my patients whom I would have done something slightly differently in their rhinoplasty operations if I had them do it over again. This even though those patients were perfectly happy with their results.
A Better Understanding of Anatomy
Years 5-10 of my rhinoplasty practice were marked by an even better understanding of anatomy and an appreciation for precision in achieving consistent results. During this time, I began using an ‘open’ approach almost exclusively except for the simplest cases. In the ‘open’ approach, a small incision is made in the columella at the bottom of the nose and joined to internal incisions in order to provide unparalleled exposure to the nasal anatomy during surgery.
This conversion to the open rhinoplasty technique allowed me to focus more precisely on the changes I was making to my patients’ noses in a much more reproducible and sustainable way. At this time, I became more thoughtful about the things I would need to do to become ‘expert’ in rhinoplasty.
I had already become keenly interested in rhinoplasty surgery and a student of anatomy and various technical maneuvers. This translated into focusing a significant portion of my practice toward rhinoplasty. My conviction was that in order to be truly expert in rhinoplasty, I couldn’t be a casual or part-time rhinoplasty surgeon.
During this time, I was more satisfied with my surgical results and likely would have altered my surgical approach in only 5-10% of cases notwithstanding patients being pleased with their results.
A Refined Understanding of Perfection in Rhinoplasty
In the most recent 5-year period of rhinoplasty my practice, I have developed a more refined understanding of what it means to strive toward perfection in rhinoplasty. The biggest technical change in my practice has been the use of structural cartilage grafting as a matter of routine rather than reserving it for difficult cases.
As I have worked toward becoming a ‘rhinoplasty expert,’ I have devoted even more of my practice toward nasal surgery. This has come to include a significant percentage of redo surgery, cases from other practices and complex reconstructive cases.
While taking on increasingly challenging cases, I have come to know the joy of helping to repair patients’ broken spirits even when ‘perfection’ no longer matters. I have also come to know the anguish and humility brought on by occasional complications. At this point in my rhinoplasty journey, I look at fewer than 5% of post-op results feeling as if I could improve on the result significantly.