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Russell W. H. Kridel, MD, and Ali Rezaee, MD

When approaching rhinoplasty in men, the surgeon must quickly differentiate between the patient whose main motivation is for reconstructive surgery and the patient with no traumatic deformity or significant breathing problem whose concern is only cosmetic. There is no question that nasal injuries secondary to sports, altercations, or other mechanisms frequently involve men, and it is reasonable for these patients to wish to have the nose returned to a preinjury state without other modification. The most common presentation to the facial plastic surgeon or otolaryngologist is the man who truly presents for evaluation for nasal obstruction who has a history of previous trauma and who also notices that his nose is crooked or irregular since his injury. When the patient learns that he has an obstructing septum, the typical male patient often then asks, “Gee, Doc, if you have to operate on my septum, can you make the outside of my nose a little more straight or smooth at the same time?” (Fig. 1).

	Fig. 1. A and B, Eighteen-year-old man sustained nasal trauma at age 15 and underwent unsuccessful nasal surgery. His motivations were to improve breathing and have his nose restored to its preinjury state. Surgery required osteotomies as well as multiple cartilage grafts to recreate symmetry.

This patient is much different from the male patient who has been bothered by the natural inherited shape of his nose. The first patient has presented for medical relief and has a society-sanctioned reason for a rhinoplasty; the latter is there to assuage his own internal mental discomfort with his appearance—a narcissistic concern that society still believes is more acceptable for women to harbor. Goin and Goin⁸ therefore feel that such male concerns with the nose may need to be “more powerful and perhaps more pathological than the female’s.” Indeed, many studies do point to psychological instability in male rhinoplasty patients and a greater number and a greater severity of postoperative psychological disturbances. Jacobson et al¹³ felt that the nose is consciously identified as the paternal feature and that nasal surgery is an attempt to disassociate oneself from the father’s undesirable traits or weaknesses. The problem occurs because while trying to separate himself from his father, the male patient still does not want to lose his symbol of masculine identity. Others have warned us even more strongly that there is a definite psychological interrelationship between a man's nose and his penis, both being prominent midline appendages. Schilder²¹ believed in the fear of the loss of a body part more when it is an appendage than when it is concretely attached to the rest of the body. Goldwyn¹⁰ points out that the “nose may be the focus of sexual inadequacy” and educates us on marked similarities:

The nose contains erectile tissue similar to that of the genitalia, and in both males and females it responds to sexual excitement. In many cultures and at different times in history, the size of the nose was equated with the size of the penis, hence virility. A common punishment for adultery in India 3,000 years ago and in Germany in the Middle Ages was amputation of the nose—another displacement, cultural rather than personal.

Goldwyn¹⁰ further observes that the male rhinoplasty patient is more inclined to be dissatisfied with his surgical results (Fig. 2). Wright²⁵ adds that the degree of deformity in the man cannot be equated with postoperative satisfaction, which makes it difficult for the most talented surgeon to succeed. What makes it worse, Wright²⁵ continues, is that the surgeon often becomes the recipient of the patient’s anger and repressed hostility. The danger to the operating surgeon cannot be understated: in most cases where physicians have been murdered by their postoperative patients, the assailants have been men, the majority of whom had undergone rhinoplasty ^{6, 7,10,13, 24}

	Fig. 2. A and C, A 31-year-old man who sought rhinoplasty predominantly for cosmetic purposes although he did note some crookedness to his nose. He disliked the convexity of his dorsum and thought that his tip was extremely broad. Computer imaging was performed and reviewed with the patient to reach a surgical goal. B and D, Postoperative figures show the results, which closely mirrored the computerimaged goals. Despite the fact that the results that the patient wanted preoperatively were obtained, he was unhappy with his outcome postoperatively. It took 2 years for the patient to accept his new nose and report that he was finally very happy with the result. To achieve his result, the open rhinoplasty approach was used to debulk the supratip skin, perform cephalic trim of the lower lateral cartilages, place double-dome sutures, insert a columellar strut, and place a tip graft.

Certainly not all male patients are to be shunned because of the risk that some pose to the surgeon. Careful selection of the patient helps to weed out the most potentially troublesome. In fact, Goin and Goin⁸ ask

Is the rhinoplasty surgeon stumbling through his daily routine like a shell-shocked, disoriented infantryman alone at night in an unmarked minefield? No, we don’t think so. If the military metaphor is to be continued, he is more like the combat-wise veteran patrolling a jungle path where he knows that there is a small, but real, chance of ambush. He has led many patrols down similar paths and knows where ambushes are likely to occur and half-knows, half-senses the warning signs that precede them.