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Chapter Preoperative Concepts for Rhinoplasty 65
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expand the medical history. Careful review of previous nasal surgery provides
invaluable information to assess the patient’s candidacy for rhinoplasty.
Attention should be paid to the number of previous rhinoplasties, whether an
open or closed approach was used, and the dates when these procedures were
performed. It should also be noted whether or not the procedure was successful,
along with reasons for failure if that is the case, and any perioperative complications that may have occurred. Previous nasal traumas or nasal operations can
alert the surgeon to potential structural abnormalities, such as septal fracture or
depletion or exhaustion of local or distant gra material, so that these potential
problems can be factored into the planning process.
Nasal obstruction is frequently caused by abnormalities of the nasal septum, nasal valves, or inferior turbinates, which normally regulate nasal airow.
All nasal and upper respiratory symptoms or complaints should be thoroughly
investigated; these problems are usually related to some anatomic structure or
associated deformity. In patients who complain of frequent nasal obstruction, the
cause is usually signicant septal deviations, dysfunction of the internal and/or
external valves, and/or hypertrophied inferior turbinates. e latter, which are
oen associated with a long history of allergic rhinitis, produce symptoms that
are worse at night when the inferior turbinates become engorged. ese patients
generally use antihistamines, local decongestants, and/or short courses of corticosteroids once or twice a year. Such patients must be told that their symptoms
of allergic rhinitis may persist for a long time and may even be exacerbated during the postoperative period.
Patients with a history of nasal surgery may have obstructions as a result of synechiae or scar contracture involving the internal structures of the nose.
Scar contracture at right internal valve
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Dysfunction of the nasal airway is frequently seen in secondary rhinoplasty patients and should be carefully investigated.
Patients should also be questioned about other factors that could complicate
the operative procedure, such as sinusitis, asthma, bronchitis, tobacco and alcohol consumption, and illicit and prescription drug use. For example, medicines
containing acetylsalicylic acid tend to increase the bruising and bleeding associated with surgery, whereas certain antidepressants may lead to perioperative
hypertension. Smoking may increase the risk of postoperative wound healing
complications and may prolong postoperative nasal obstruction, with persistent
irritation of the respiratory tract.
PHYSICAL EXAMINATION
e physical examination identies correctable nasal deformities and is used to
determine whether the patient’s goals and expectations are realistic. e surface
anatomy of the nose directly reects the underlying framework. A systematic,
detailed examination provides the surgeon with a list of problems from which to
formulate the operative plan. Examination should begin with a full facial analysis
to assess facial balance and the potential benet of adjunctive procedures. Next,
the nasal structures are observed. Skin thickness and texture, nasal deviation,
shape and width, alar rim morphology, tip denition, projection and rotation,
nasal base width, and nostril shape should be thoroughly analyzed and documented (see Chapters and ).
Chapter Preoperative Concepts for Rhinoplasty 67
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e internal nasal examination includes speculum examination and dynamic
maneuvers. Adequate lighting and instrumentation are requisite. In some instances, it may be necessary to perform this before and aer vasoconstriction of
the nasal mucosa. It is essential for assessing and documenting the preoperative
status of the functional airway and for discussing the potential strategies for altering nasal appearance and the potential benecial eects these changes may
have on improving nasal airow (for example, spreader gras and dorsal width;
alar contour gras and alar rim appearance).
Nasal obstruction at the internal valve may be evident by analysis of the external
nose. Some patients may note improvement of nasal airow by pulling laterally
on the cheek, mimicking the Cottle test.
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e Cottle test is performed by applying lateral traction on the medial cheek at
the level of the internal valve. Subjective improvement of nasal airow on the
side tested may indicate nasal obstruction at the internal valve. Alternatively, a
cotton-tipped applicator can be used to open the internal or external valve to
evaluate for nasal obstruction at these sites.
With normal respiration, external valve collapse may not be present, but dynamic
external valve collapse can be elicited by having the patient inspire forcefully.
Normal inspiration
Forced inspiration
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Nasal strip test Cottle test
Gruber et al described the use of nasal strips to evaluate inspiratory function at
the internal and/or external nasal valve. e nasal strip is applied to the middle
third or lower third of the nose, and the patient reports whether this improves,
worsens, or has no eect on nasal airow. is test can help predict whether surgical correction of nasal valvular dysfunction will improve airow.
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Septal
perforation
Identication of preexisting synechiae, septal deformities, or perforations should
be reported to the patient preoperatively to avoid mistaken blame later. Abnormalities of the septum or turbinates are presented to the patient to allow discussion of surgical correction. (For a detailed description of the complete physical
examination, see Chapter .)
Nasal obstruction is common among patients presenting for rhinoplasty. However, many patients are unaware that they have this problem and may become
more aware of symptoms postoperatively if these are le untreated.
Potential cartilage donor sites (especially in secondary rhinoplasty patients) are
evaluated when necessary to allow preoperative discussion and justication of
distant gra sites. In patients presenting for secondary rhinoplasty or who have
undergone a previous septoplasty, it is important to assess for the presence of
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septal cartilage. If septal surgery has been performed previously, a cotton-tipped
applicator can be used to palpate the septum to assess for rigidity if septal cartilage is still present or accidity if it has been harvested. Where septal cartilage has
been harvested, it is important to estimate the width of the anterior septum or
L-strut. is can be performed by using a cotton-tipped applicator in the dominant hand to sweep across the septum in a posterior to anterior direction toward
the dorsum. e distance between the dorsal edge of the septum and where the
posterior edge of the L-strut is encountered can be estimated.
Physical examination should focus on the skin envelope, the osteocartilaginous
framework, internal nasal structures, and identication of potential cartilage
donor sites. Evaluation of nasal airway function is included in the physical examination.
PATIENT SELECTION
Aer a detailed history is obtained and physical examination is completed, the
surgeon should be better able to render judgment as to whether the patient is a
good candidate based on the patient’s goals and expectations, in conjunction with
the deformities noted during physical examination. Emotional factors elicited
in the history are also considered at this time. Patients presenting for aesthetic
surgery during periods of signicant upheaval or emotional strain should not
undergo surgery, even if they possess correctable anatomic deformities. Surgery
should be delayed until the other aspects of their lives are stabilized.
Congruency between the patient’s and surgeon’s goals and expectations is critical
to successful and satisfying outcomes from aesthetic surgery.
Ideal patients are secure, emotionally stable, well informed, and understanding
of the limitations of rhinoplasty, and realistic in their expectations. e acronym SYLVIA describes the appropriate female rhinoplasty patient who is secure,
young, listens, and is verbal, intelligent, and attractive.
,
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Red Flags When Assessing Patients Suitability for Rhinoplasty
1. Minimum disgurement
2. Delusional distortion of the body image
3. An identity problem or sexual ambivalence
4. Confused or vague motives for wanting the surgery
5. Unrealistic expectations of change in life situations as a result of the surgery
6. A history of poorly established social and emotional relationships
7. Unresolved grief or a crisis situation
8. Present misfortunes blamed on physical appearance
9. Older neurotic man overly concerned about aging
10. A sudden anatomic dislike, especially in older men
11. A hostile, blaming attitude toward authority
12. A history of seeing physicians and being dissatised with them
13. e indication of paranoid thoughts
Conversely, patients who have unrealistic expectations, insecurities, and/or excessive concerns about minimal deformities will most likely be disappointed regardless of the postoperative aesthetic improvement. Listed above are some red ags
that may indicate that a patient has underlying psychological issues. Examples
of these patients are categorized by the acronym SIMON, which refers to an individual who is single, immature, male, overly expectant, with narcissistic traits.
,
An emotionally unstable patient adversely inuences the relationship between
the surgeon and the patient and constitutes the general basis of poor results.
Secondary rhinoplasty patients who express anger toward their previous surgeon
or are actively involved in litigation, those desiring a result that is beyond the
realm of the aesthetic norm (for example, wanting a dorsal hump created), and
those with a controlling or confrontational personality should be approached
with extreme caution and should not be operated on in most cases. e decision
to proceed with or end the doctor-patient relationship should be made at the
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completion of the assessment. Patients who are not good candidates should be
told early in the process. Proceeding with imaging or further appointments will
only make the process of ending the relationship more dicult and problematic.
Patients who express anger toward previous surgeons or who have personalities
that are confrontational or controlling should not be operated on.
DIGITAL PHOTOGRAPHIC ANALYSIS
Standardized photography should be obtained for all patients preoperatively (see
Chapter ). Photographic analysis is a key component of the secondary examination. Subtle asymmetries and deformities are more easily identied on quality photographs and with simultaneous evaluation of the deformity in multiple
views. Photographs also serve as useful visual aids in the communication process between patient and surgeon. Multiple-view photographs allow patients a
chance to more accurately demonstrate their concerns, improving the surgeon’s
comprehension of the patient’s goals and expectations.
Photographs also provide a signicant contribution to the medical record by documenting the preoperative and postoperative status of the patient. Good-quality
photographs depend on proper positioning, cameras, lenses, and ashes. Every
eort should be made to standardize techniques for the purpose of comparison
between visits. Digital photography has made obtaining photographs of the patient relatively easy, ecient, and cost eective. Additionally, it allows for easy
storage and retrieval. We use a digital single-lens reex system with a minimum
resolution of 3 pixels at dpi, a mm lens, and dual lighting with
a blue background. e images are then stored in a database to allow high-quality
printing, image manipulation, and retrieval.
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e following standardized views are obtained and analyzed in all patients:
1. Anterior (frontal)
2. True lateral (right and le)
3. Oblique (right and le)
4. Basal (high and low)
Anterior Right lateral Left lateral
Right oblique Left oblique
High basal Low basal Overhead
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