Everyone has seen a bad nose job. But, what makes a patient who has had a rhinoplasty look like theyve had a rhinoplasty? Should patients still expect these unnatural looking results or has this procedure evolved since the days of the pinched, upturned noses of the 60s, 70s and 80s? The short answer is that although rhinoplasty is still one of the most popular cosmetic procedures year after year, fewer patients look as if theyve had their noses done. There are several factors that have contributed to this trend including a better understanding of the long term effects of the surgery, more communication between patients and their surgeons and a desire on the part of a majority of patients to have less drastic and noticeable changes There was a time, not too long ago, when every nose job performed by a particular surgeon looked identical, regardless of the differences in the patient he or she was performing it on. Aggressive removal of cartilage was the norm and there was little concern for nasal breathing. This was partly due to ignorance(rhinoplasty surgery was a relatively new discipline and no one was aware of the long term effects of these destructive practices) and arrogance(the surgeon, not the patient dictated what was aesthetically desirable or pleasing). But all that is changing. In our practice there is a very balanced dialogue between the patients desires and expectations and the advice and counsel of the surgeon. Each nose must be appropriate for the patients facial type, body size, gender and ethnic background and no two noses should be approached in the same manner In addition, long term observation of patients who have undergone rhinoplasty has taught us to use more conservative, cartilage sparing techniques as opposed to the often difficult to reverse cartilage removal techniques of the past. Another complaint of rhinoplasty patients, besides looking too done, was not being able to breathe properly after the surgery. With proper training and a healthy respect for the nasal airway this too is changing. Many rhinoplasty surgeons now spend years in training operating exclusively on functional issues inside the nose before proceeding to learning how to reshape the outside of the nose. By improving their understanding of nasal function and respecting the integrity of the structure of the nose modern day rhinoplasty surgeons can achieve beautiful results without compromising a persons breathing. This less aggressive, cartilage sparing approach to cosmetic nasal surgery has helped minimize many of the unwelcome sequelae of previous generations of rhinoplasties. Knowledgable, informed and educated patients are demanding more natural results and are expecting to be part of the decision making process when it comes to deciding what changes to make to their noses. The first thing we ask a patient who is considering rhinoplasty is what they would do if they were the surgeon. What would they change, and what would they leave alone. Only then do we begin to formulate a surgical plan. Open communication between patients and their surgeons, which includes the use of computer imaging, can only lead to more predictable and satisfying outcomes.