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"  On a bitter night in February 1992, Hope, a 19-year-old aspiring actor, and her boyfriend, an early Internet entrepreneur, headed out for some sinus-clearing chili dishes and tangy margaritas at a Mexican restaurant on Manhattan&amp;#039;s Upper West Side. It should have been a celebratory occasion: Six weeks earlier, Hope\u2014whose pillowy lips, high, rounded cheekbones, big, bright smile, and wild auburn mane drew comparisons to Julia Roberts in Pretty Woman\u2014had undergone rhinoplasty, commonly known as a nose job. She had long viewed her olfactory organ as oversize, practically begging for reduction and refinement so as to harmonize with, rather than from, her otherwise comely features.  A month and a half post-op, Hope&amp;#039;s nasal anatomy was still in a highly delicate state, but the black-and-blue bruising around her eyes had faded, and the nose itself was finally pain-free. However, as she entered the restaurant on that dim winter evening, Hope smashed her schnoz smack into a plate-glass door that she failed to see. Blood spattered everywhere; she lost consciousness for a time and ended up in the emergency room. She had shattered her septum, twisting her nose to the right, narrowing and raising her right nostril in Picasso-esque fashion, and leaving her with a permanent asymmetry in the middle of her face. The truth is, Hope already hated her nose job and even wished she had her old honker back. &amp;quot;He gave me a too-thin nose with a pinched tip,&amp;quot; she said bitterly about her plastic surgeon. &amp;quot;I looked like I&amp;#039;d had a nose job. It was the Diamond Nose.&amp;quot; The term, once uttered worshipfully but now muttered in denigration, refers to the handiwork of Howard Diamond, MD, a Manhattan plastic surgeon wildly popular in the &amp;#039;60s and &amp;#039;70s who, irrespective of patients&amp;#039; individual features, churned out cookie-cutter conks instantly recognizable by their uniformly scooped-out bridges and turned-up ends.  Beholding her new reflection served only as a cringing reminder to Hope of her adolescent self-loathing and desperate approval-seeking. &amp;quot;It was an impulsive decision,&amp;quot; she says. &amp;quot;My mother encouraged it. A lot of my friends had their noses done. I wanted to fit in. At the end of the day, I didn&amp;#039;t like me, and that&amp;#039;s why I had the surgery. Now, when I look at pictures taken before, I ask, `Why did I do this?&amp;#039; There was nothing wrong with me.&amp;quot; Hope learned a classic plastic-surgery lesson the hard way: Cosmetic procedures, especially rhinoplasty, are not to be indulged in lightly. The operation, surgeons say, may be the most challenging and difficult of all cosmetic surgeries, and yet, according to the most recent statistics from the American Society for Aesthetic Plastic Surgery, we now undergo some 150,000 rhinoplasties per year, and the American Academy of Facial Plastic and Reconstructive Surgery estimates there are around 40,000 do-overs annually. &amp;quot;A certain percentage require revisions, including small tweaking as well as big operations,&amp;quot; says Jack Gunter, MD, professor of plastic surgery at University of Texas Southwestern Medical Center in Dallas. &amp;quot;The statistic that&amp;#039;s reported is 10 to 15 percent overall.&amp;quot;  The nose is a diminutive structure, bely its internal complexity, which includes a valve and several bony structures that control the dynamics and temperature of airflow and 5 million scent receptors that detect odors and transmit the smells to the olfactory bulbs in the brain. And rhinoplasty is notorious for its vagaries. Nasal tissues can be wayward, the cartilage refusing to bend to the surgeon&amp;#039;s will or the skin too thick to drape smoothly and evenly over the underlying structure. Furthermore, an alteration such as the removal of a hump from the bridge can change the shape and position of adjacent parts of the nose, prompting a cosmetic domino effect.  But the &amp;quot;real wild card,&amp;quot; Upper East Side plastic surgeon David Hidalgo, MD, says, &amp;quot;is how a patient heals. It is not unusual for a result that looks great on the table to be less stellar when healing is complete. This can be due to scar-tissue formation that masks subtle aesthetic nuances in shape or to soft-tissue contraction during healing, which can collapse cartilage that has been weakened as a side effect of improving shape.&amp;quot; Given the fickleness of the nose and the protean nature of the procedure, many plastic surgeons think rhinoplasty is best left to the relatively few who specialize in it. &amp;quot;There are perhaps only a dozen surgeons who do more than 250 rhinoplasties annually,&amp;quot; says Rollin Daniel, MD, a nose-job-only surgeon in Newport Beach, California, and cofounder of the Rhinoplasty Society, an elite professional group. &amp;quot;And secondaries,&amp;quot; Gunter says, &amp;quot;are the most difficult in cosmetic surgery. With primaries, we have to reshape the nose. With secondaries, there&amp;#039;s very little normal anatomy. The cartilage is distorted or missing. You have to rebuild the nose. There&amp;#039;s scar tissue, making the dissection more difficult. The skin is harder to drape properly.&amp;quot; Mallets and chisels aside, cosmetic surgeons also agree that, emotionally and psychologically, repeat rhinoplasty patients are often emotionally fraught (and justifiably so!), ratcheting up the pressure of an already demanding procedure. Hope certainly fit the profile of a secondary rhinoplasty candidate. Not only was she unhappy about her nose, but its malfunctioning physiology caused a round-the-clock deluge of mucus that led to countless indignities, from chronic sinus infections to boyfriends&amp;#039; complaints about her snoring. Yet putting up with such unpleasantries still seemed preferable to another agonizing round of surgery\u2014until 1996, when Hope bumped into a high school classmate she hadn&amp;#039;t seen in many years. The woman stared at her for several unforgiving seconds before blurting, &amp;quot;What happened to you?!&amp;quot;  That was it. The lash of those words provoked Hope to throw down the gauntlet, or, in her case, the Breathe Right strips. No longer a self-pitying, scalpel-shy victim, she became a disgruntled cosmetic-surgery consumer entitled to the Rolls-Royce of reconstructive nose jobs. Jetting between New York and Los Angeles to meet with a who&amp;#039;s who of surgeons\u201415 or so in all\u2014she racked up thousands of frequent-flier miles and shelled out sky-high consultation fees.  Her timing was propitious, coinciding with a revolution in rhinoplasty that transformed and refined the procedure, enabling surgeons to achieve more exacting results. Its leading practitioners rejected the homogenizing reduction of noses and innovated a radically new technique. In the old-school closed method, all incisions were made inside the nose, which limited the possibility of making dramatic changes or correcting extreme anomalies. In the new open method, a single, minimally scarring incision is made across the columella, the strip of skin separating the nostrils, which, like popping the hood of a car, releases the nose&amp;#039;s outer covering of skin. Peeling it back, the surgeon exposes the entire inner hub of nasal organs and can repair, rearrange, and reconstruct any damaged, off-kilter, or missing pieces with precise cartilage grafts.  &amp;quot;An open rhinoplasty is like opening your closet door wide to see everything hanging on the rod together,&amp;quot; Hidalgo analogizes. &amp;quot;This allows you to select, edit, and rearrange freely. Closed rhinoplasty only opens the door a crack, so you have to reach in and pull items out one at a time. It&amp;#039;s dark in there, and you never see everything at once. Open rhinoplasty is especially useful in secondary operations, where often all the clothes have been pulled off the hangers and lie in a crumpled heap inside.&amp;quot;  Although this evolution of the procedure should have made it a snap for Hope to land a specialist, remarkably, she found herself out of options in 2002. &amp;quot;No doctor would agree to operate,&amp;quot; she says. &amp;quot;They didn&amp;#039;t think they could improve on my nose. They&amp;#039;d say, `You&amp;#039;ll never be happy. You&amp;#039;re a pretty girl. Leave well enough alone.&amp;#039;&amp;quot; But in 2008, long after Hope had forsaken her quest, the possibility of a reprieve presented itself when she came across an article on using injectable fillers to camouflage nasal deformities and finesse flawed rhinoplasty. Coincidentally, her best friend had just recommended a registered-nurse-cum-aesthetician named Robin Hillary who, working from an examining room at an Upper East Side plastic surgeon&amp;#039;s office, could do wonders with such needlework.  Hope quickly became a devotee of Hillary&amp;#039;s no-knife nose job, which entailed endless injections of Juv\u00E9derm, a hyaluronic-acid-gel formulation that was squirted into Hope&amp;#039;s ragged nasal bridge to smooth its surface irregularities. Though impermanent, the effect was a clear improvement. However, when Hillary tried to inflate Hope&amp;#039;s collapsed right nostril with filler, the treatment backfired. It further compressed the already squashed nasal opening, almost sealing it shut. After about six months of giving Hope&amp;#039;s nose her best shots, Hillary, recognizing that her syringes had their limitations, suggested that Hope meet with the plastic surgeon working away in the very next room. Other than the $250 consultation fee, what did Hope have to lose? So in December 2008, Hope met with plastic surgeon Craig Foster, MD. &amp;quot;You&amp;#039;ve got the stigmata of a rhinoplasty. The tip is pinched,&amp;quot; Foster noted, ticking off a litany of problems and speculating about their causes and possible solutions. &amp;quot;The goal is to make your nose look less operated-on, straighten it, and open up your airway,&amp;quot; he said.  On January 13, 2009, Hope returned to undergo secondary rhinoplasty surgery, a $10,000 operation ($1,000 more than a primary) in Foster&amp;#039;s state-of-the-art facility. (Many top surgeons outfit their private offices with customized operating rooms.)  In preparation, Hope changed into a burgundy medical gown and matching booties and took a seat in a private waiting area, where I kept her company. &amp;quot;For almost 20 years, I&amp;#039;ve lived with a crooked nose,&amp;quot; she said, her voice cracking and her eyes welling. &amp;quot;All I&amp;#039;ve done is look at other people&amp;#039;s noses. I think my twisted nose is the first thing people see, and they think something really bad happened, like I had a coke problem. Now I&amp;#039;m nervous, but I&amp;#039;m excited. I can&amp;#039;t believe I&amp;#039;m finally going to do this. But it was fate.&amp;quot; Those were Hope&amp;#039;s parting words as a nurse appeared, escorting her to the operating room as I trailed along.  Climbing on the operating table, Hope lay back, offering up her delicate wrist for the anesthesiologist&amp;#039;s fentanyl-laced IV drip and immediately conking out. Foster daintily sliced across her columella with a small blade and retracted the outer layer of skin, keeping it in place with surgical hooks, his access to the subcutaneous nasal skeleton of bone and cartilage now unfettered.  Foster&amp;#039;s first order of business was Hope&amp;#039;s septum. Though crooked, it was surprisingly &amp;quot;unmolested,&amp;quot; as he put it, and thus was an excellent donor site for grafting. (In some cases when a nose has already been operated on, there may be no excess septal cartilage to spare for grafting, in which case an ear or a rib provides the source.) Foster pared and shaped translucent cuttings from it for implanting in the defective areas. To counter the depression in the cartilage on the left side of Hope&amp;#039;s nose, he sewed a &amp;quot;spreader&amp;quot; graft to her septum, straightening out its contour and widening the middle of her bridge to ease her breathing and stop her unremitting spigot of mucus. &amp;quot;Everybody&amp;#039;s nose runs all the time,&amp;quot; Foster said while doing so. &amp;quot;The usual problem in an operated nose is that scars inside get in the way of the flow. It pools and runs out of the nose instead of going back down the throat.&amp;quot; To &amp;quot;remarry the tip and the bridge&amp;quot; of Hope&amp;#039;s nose, as Foster put it, he added a strut to stabilize its pinched end and pre-empt drooping. And to flesh it out and make it broader and rounder\u2014at Hope&amp;#039;s request\u2014he sutured to each side a lateral graft. Finally, to fix her flattened right nostril, he sliced an opening along its outer edge, into which he inserted a rim graft, much as you might cut open a tiny pita-bread pocket and fill it with your stuffing of choice.  It had been an hour since Foster began. He had already re-draped the skin, stitching it to the columella. But then, without looking at his hands but rather keeping his eyes straight ahead, he started running his fingers up and down the length of it, as if playing the piano, relying on touch to determine the symmetry and linearity of forms. He must have hit a wrong note, because his fingertips hesitated, sensing a deficiency on the left side, which meant he wasn&amp;#039;t done yet. Although he had already stitched the columella closed, Foster cut the suture and lifted the skin once again, adding another small graft to the tip.  &amp;quot;Let me just noodle this a bit,&amp;quot; he said, focusing on Hope&amp;#039;s nostrils before finishing up. &amp;quot;Her rims are in a better position\u2014not perfect. Five to 7 percent of my rhinoplasties aren&amp;#039;t perfect. I have to futz around with them six to nine months later.&amp;quot;  But Hope was immediately over the moon with her new nose. Right away, despite her post-op condition\u2014which she described as like &amp;quot;being hit by a Mack truck,&amp;quot; her nose so blocked that it felt as if she&amp;#039;d snorted &amp;quot;a brick,&amp;quot; the dried blood caked onto the sutures tugging at her tender columella, not to mention her inability to sleep upright as dictated by the aftercare instructions\u2014she was able to pierce through an addling haze of Vicodin to behold, in the blimp of swollen tissue throbbing in the center of her face, an inchoate vision of nasal pulchritude. All the wrongs that had been plaguing Hope for years had finally been made right. Not only was her ski-jump bridge gone, but so were the pinched tip and the broken septal bone poking out on her right side. And\u2014finally!\u2014she had two open and functional nostrils. As Foster had counseled Hope to be prepared for extended swelling\u2014nine to 12 months for a secondary rhinoplasty (as compared to six to nine months for a primary)\u2014she took it in stride, her spirits buoyed at every milestone in the healing process. Among the most memorable was Day 34, the first time she sneezed, the blast shooting out any remaining temporary stitches. &amp;quot;Oh, my God, it felt so good!,&amp;quot; she recounted. &amp;quot;It was better than an orgasm!&amp;quot;  As the months passed, her days of snoring and sinus infections became distant memories, and her new nose brought unexpected positive changes, like a newly vibrant sense of smell, as well as livelier taste buds. And because Hope could now breathe out of both nostrils, her oxygen intake was bolstered and her skin more radiant, eliciting compliments over its healthy glow. In April, at a follow-up appointment with Foster, Hope reported the reactions that she had been receiving about her nose. &amp;quot;People are saying, `You look great.&amp;#039; But they can&amp;#039;t figure out what it is.&amp;quot;  &amp;quot;A good sign of surgery is when you can&amp;#039;t pinpoint where the change comes from,&amp;quot; the surgeon replied. &amp;quot;I love my new nose,&amp;quot; she said, breaking into her Julia Roberts grin. &amp;quot;It&amp;#039;s still swollen, but I know it&amp;#039;s just right\u2014not too small, not too big, not too wide, and not too skinny. This is the nose I wish I&amp;#039;d gotten from the get-go. It&amp;#039;s a botched job gone good.&amp;quot; "^^<http://www.w3.org/2001/XMLSchema#string>
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