Rhinoplasty requires great attention to detail. It is best, however, not to postpone the surgery indefinitely. The overlying soft tissue on the bridge of the nose is not sufficient to conceal even the slightest irregularity. With aging, the skin loses elasticity and may not adapt to the new shape. Development of scar tissue beneath the skin may alter the result desired by both patient and surgeon.

The concept of an attractive nose is very individual - what one person likes, another does not. A nose may protrude too much or not enough. It may be hooked or depressed. The tip may be bulbous or pinched; it may turn up or turn down. The septum may deviate, or it may be markedly crooked. The nose is rarely symmetrical; even the beauty queens of Hollywood constantly request that the cameraman take their "best" side.

It is necessary for the surgeon to understand exactly what the patient is looking for. The patient's desires and the surgeon's abilities can be clarified by the study of black-and-white photographs. The desired changes can be drawn on the photos until both surgeon and patient are satisfied.

Rhinoplasty can be done under local or general anesthesia. Young people often prefer to be asleep during the operation. If general anesthesia is used, endotracheal intubation is performed: a breathing tube is inserted through the mouth into the trachea (windpipe) to prevent blood from getting into the lungs while the patient is unconscious. When general anesthesia is used, most surgeons also inject local anesthesia containing epinephrine into the tissues to limit bleeding that may obscure the operative field. The anesthesiologist must be able to prevent excessive bleeding, which is not only dangerous for the patient but difficult for the surgeon.

The surgery itself is performed through incisions within the nostrils unless the nostrils themselves are to be decreased in size or otherwise shaped. Through these incisions, the soft tissues are separated from the underlying bone and cartilage. The cartilage of the tip is modified and the undesirable bone hump is removed by saw or chisel and filed for smoothness. The lateral nasal bones are fractured inward to recreate the pyramidal form of the upper part of the nose.

If, on the other hand, the dorsum (ridge) of the nose needs to be augmented, cartilage or bone can be inserted into the pocket between the bone and skin. Nasal septal cartilage is often used. Large defects can be filled with some type of synthetic material.

When crookedness of the nose is caused by deviation of the septum (the cartilage on the inside of the nose that separates the two nostrils), a modification or resection of the septum is indicated.

Endoscopy is a surgical technique used for many years to perform knee operations and gall bladder operations. It has only recently been applied to rhinoplasty. In this innovative procedure, tiny incisions are made in the skin through which are inserted small straw-sized tubes containing a viewing scope and microsurgical instruments. The viewing scope, which functions like a camera, is connected to a video monitor onto which it projects a greatly magnified image, enabling the surgeon to operate by viewing the surgical site on the screen.