Despite utmost diligence, I have not managed to get rid of performing recurrent rhinoplasty. During a certain period in my life, it caused me great distress. It was only dozen years ago when I understood that there is nothing shameful in recurrent rhinoplasty and it allows taking finishing the result to greater than usual lengths. I understood that achieving facial harmony by rhinoplasty alone is as complicated as building a multi-storey house of cards, where hitting the bullseye at first attempt is more of a lucky chance than a rule. We can even build high rises with playing cards, if we use glue and wait for it to dry. In case of major aesthetic defects, American plastic surgeons Gary C. Burget and Frederick J. Menick managed to get beautiful results only after developing a method consisting of 3-4 recurrent surgeries. In its essence, this method is very similar to building a skyscraper of playing cards, with at least a month of healing period following the completion of each storey! I was consoled by the fact that even the greatest experts need several repetitions to achieve perfect results. It took six coats of paint and four coats of lacquer to achieve the required quality of the bodywork of Rolls Royce! This equals to ten recurrent surgeries! Despite using microscope and fine instruments, I still think of rhinoplasty as a hatchet job to certain extent. Manageability of the process is similar to baking pastries, where the result depends on air pressure and mood of yeast. In a way, a nose job reminds me of fixing up car bodywork in Soviet times: details were not replaced, dents were hammered out, plastered and painted. It was fine to drive such a car in the streets during daytime, but after the nightfall and when streetlights were lit, an observant viewer instantly noticed that the car had been “caught between two trams”. I almost always find the signs of surgery in nose jobs performed by me or my colleagues. So, it is probably safe to show off the result until other people do not notice it.

Most people are “nose-blind”; they do not attribute any importance to even considerable aesthetic defects or notice the signs of a nose job. An entirely different group is composed of patients undergone the surgery, plastic surgeons, photographers, and cartoonists, who have an eye for detail, imperfections and harmony. Third group consists of oversensitive people who spend hours in front of the mirror and grieve over selfies, made with mobile phone and thus with wide-angle distortion, observing, measuring, comparing and criticising. They emphasize even such “defects” that remain unnoticed for everyone else. The selfies with wide-angle distortion, caused by tablet and phone cameras dominate focuses on nose and all blemishes are displayed in a grotesque way. Widespread use of smart device photography increases the demand for correcting minor defects, especially among aesthetically oversensitive people. The results of plastic surgery are once again scrutinised by using the same distorted photos. On the one hand, it is technically difficult to achieve small changes close to the accuracy of a surgery, and on the other hand, wide-angle photo turns the tiniest postoperative imperfections into “problems”. This opens the door to a chain of surgeries. I decide on performing the surgery only after making sure that rhinoplasty can increase the amount of joy in the patient’s life. The extent of such joy must sufficient to persist even after all the unpleasantries and costs related to the surgery. Sometimes, this may require more than one surgery! Therefore, I am always open to recurrent surgery, as long as changes are technically feasible, aesthetically justified and requested by the patient. During my practice, I have had cases that could be described as “road to hell of recurrent surgeries”. These are cases, where I had to perform 4-5 recurrent surgeries over the period of ten years, moving “one step forward, one step backward”. The process resembles pencil drawing, using repeated lines to nail the perfect contour. Repetition ends only after the patient is happy and content, desired change is smaller than the accuracy level of surgical technique or further changes would not be aesthetically justified, or patient gets tired and gives up aspiring to the ideal due to lack of motivation or money. I am not stopped by boredom or tiredness!! Perhaps recurrent surgeries are not a highway to hell, but a stairway to heaven, climbing the “beauty ladder” step-by-step?!? Great Russian author Lev Tolstoy re-wrote his texts by hand, dozens of times, without “copy-paste”, until he was satisfied with the result. Our entire world is a world of repetitions. We cannot count the number of generations necessary for “remodelling” our species to reach its current relatively mediocre result. In his interview with singer Tarmo Pihlap, TV host Urmas Ott said that he felt sorry for his colleagues who had stopped working, some of them deceased, without never really becoming aware of how difficult their jobs were. In the same interview he admitted that interviewing is like playing tennis. It is impossible to “learn it by heart”. The situation is always unique and new.

I would like to say the same applies to rhinoplasty. For me, rhinoplasty is like a game of chess. I cannot state as if I were absolute expert in this field. No, there’s nothing unnatural in recurrent surgeries. There is nothing unnatural in giving up the yearning for perfection and coming to terms with mediocrity. I will leave that decision to my patients. If you wish, we shall climb the “beauty ladder”, if not, then we will not. The most important thing is to find joy and contentedness or reaching the point, where going on would cause more pain and worry.

The world is suffering from greed and selfishness. Everyone is trying to sell something. Including plastic surgeons – perhaps they in particular want to embellish their activity? The tendency to highlight advantages and conceal disadvantages is very common. We all have excellent results to show to the world. If not, then we can use photo-technical dissembling. For example: preoperative photo on the internet site is larger, sadder, taken by using wide-angle distortion and lighting that brings out the aesthetical defect. Sometimes we can notice a hint of a little “photoshop help”. The results, on the other hand, are displayed in a joyful, gracious and embellished mode and the percentage of recurrent surgeries is kept below ten. Many colleagues try to sound like gods, stating that they score a goal with rhinoplasty at the first try in 95% of the cases. Even ten-metre penalties in football are not realised at such certainty rate! It is either a lie, or ignorance towards patients who would like to improve the result towards perfection. Such practice spreads and if one wishes to go with the general flow, one has to “blow smoke” to a smaller or greater extent. Unpleasant, is it not?! When meeting a “internet-smart” patient in my surgery, it usually takes me a lot of time to explain, how “aesthetic ideal can be attainable with unlimited number of recurrent surgeries”. Naturally, they are not keen on believing me.

Michael Jackson is frequently used as an example of the powerlessness of recurrent surgeries! But things are not quite as they seem! A colleague of mine introduced his story at one of the rhinoplasty congresses. It turns out that his result improved after five recurrent surgeries, but then occurred sudden radical change, which led to the appearance of Michael Jackson, as we remember. An Italian colleague said that we should give patient what they wish!” Michael Jackson wished, demanded, paid, and eventually bought a result like that! There are always those, who cross boundaries in the name of happiness, stupidity or money. I consider recurrent surgeries that test the limits of capabilities and expertise justified, if they promise to increase the joy in the life of a person chosen me as their surgeon.

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