For the most part, the patient decides, but her desires are tempered by the plastic surgeon showing what is possible and what is not possible. Here's how I do it: the patient tells me what she notices about her nose, what she doesn't like, and what she would like to have changed. I then tell the patient what I think can be accomplished, and to what extent. We discuss any other changes that I recommend, and we bat it back and forth until we come up with a plan for surgery. Sometimes a patient brings photographs of other noses that she likes to the consultation. That's not particularly helpful, because we can't put someone else's nose on the patient's face; rather, we can only make certain changes to the nose that she already has. Still, it can be interesting to see the features that the patient finds attractive on other peoples' noses. Plastic surgeons still exist who will not accept input from the patient; they just say that the doctor is in charge and that his judgment will determine how the nose will look. You should never ever have surgery by a doctor who works that way. Your plastic surgeon should carefully listen to, and address, every one of your concerns about the appearance of your nose. Another important point to remember: just because a plastic surgeon appears to understand what you want in a nose does not mean that he can accomplish those changes in the operating room. You must see before and after photographs of his other patients, preferably patients with noses similar to yours, before hiring him to perform your operation. Go here for more information on finding a competent plastic surgeon.