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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_4366_Библиотеки_им_академика_М_И_Перельмана
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Chapter Preoperative Concepts for Rhinoplasty 75
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e surgeon may also use photographs to demonstrate qualities that the patient
cannot appreciate such as asymmetries and disproportions seen in the lateral,
basal, and bird’s-eye views. Photographs from other patients may be used to demonstrate the limitations and potential complications associated with the proce
dure. Facial disproportions should be pointed out to the patient to demonstrate
that some asymmetries may not be corrected by the surgery or that additional
procedures (for example, orthognathic surgery/genioplasty) may be necessary
to accomplish the patient’s goals.
Photographs obtained using standardized techniques include frontal, lateral,
oblique, basal, and overhead views. ese are essential for detailed aesthetic
analysis and accurate preoperative planning.
COMPUTER IMAGING
-
Patients and surgeons alike want to have a visual reference for the surgical outcome. is can be provided to the patient via acetate tracings or computer imaging. ese techniques allow the surgeon to simulate the proposed nasal changes
and enable the patient to view and analyze them before surgery. is may alleviate anxiety and allow the patient to participate in the planning process. Imaging
or other predictive tools can demonstrate the limitations of the procedure and
help to establish realistic expectations.
Computer imaging is useful for showing the patient what changes may be possible with rhinoplasty.
It is important to review the purpose of these media with the patient to prevent
any misinterpretation or implied guarantee. It is useful to have patients sign a
disclaimer to clarify their understanding of the purpose of the imaging process.
(For an in-depth discussion of computer imaging, see Chapter .)
All images that are viewed are only a representation of the result that could be
achieved through the proposed surgery. Imaging is used as an educational tool
to benet the patient and does not guarantee any result.
Part One Basic Perioperative Concepts76
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Computer imaging has been an essential part of our practice for more than
years. It provides an important visual tool that greatly enhances patient/surgeon
communication. Many commercial soware systems are available for this purpose; we use an adaptation of Adobe Photoshop. Preoperative photographs are
manipulated to demonstrate changes in nasal shape and are presented in a format
that is easy for the patient to review.
Next, the dierent anatomic relationships are manipulated to mimic the changes
expected from rhinoplasty. e imaging process begins with previously obtained
digital images of the patient, which are duplicated side by side, with one image
representing the “preoperative view” and the other the potential “postoperative
view.” When the desired changes are achieved, a printout is generated with the
precise measurements and alterations that are to be made, and the duplicate images are saved for consultation and viewing with the patient.
ese computer-generated images must be carefully assessed to ascertain that the
proposed changes can realistically be achieved. is must be done before reviewing the images with the patient during a second consultation. e surgeon should
not be overly optimistic about the potential results to avoid patient dissatisfaction
postoperatively. e computer images are generally not given to the patient except in isolated circumstances. Computer imaging can be misconstrued by some
patients to be an implied contract for postoperative appearance. Careful disclosure has prevented this from occurring in our practice. It is extremely important
to specify that imaging represents the surgical goals, not the nal result. Even
with a successful operation, patient satisfaction frequently depends on what the
patient has been promised. is disclaimer should be provided orally and as part
of the written consent process to document the objective of predictive imaging.
Computer-generated images must be carefully assessed to ascertain that the proposed changes can realistically be achieved before reviewing the images with the
patient during a second consultation.
AESTHETIC ANALYSIS
Balanced or harmonious facial proportions are consistent with an aesthetically
pleasing overall facial form. Complete facial proportions and their relationship
to the nose must always be considered because the nose occupies a central position in the overall facial aesthetics. Aesthetic facial and nasal analysis in the
rhinoplasty patient should be performed in a systematic manner. (For further
discussion of facial analysis, see Chapter .)
Chapter Preoperative Concepts for Rhinoplasty 77
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Pt. Name:______________________________________________
Address:_______________________________________________
______________________________________________________
City State Zip
MRN: ________________________________________________
Authorization for Audio Recordings,
Photography, or Other Images
for Non-Treatment Purposes
DOB: _________________________Sex: ___________________
DOS: _________________________________________________
I hereby authorize the ____________________________________________________________________________________at
(insert name of department)
UT Southwestern Medical Center to make audio recordings or to take photographs, videotape, or digital images of me (“Images”).
I understand that UT Southwestern may use and release my images for the following purposes:
(1) educational lectures and presentations for health care professionals; (2) scientific publications such as journals or books;
(3) patient education materials; (4) broadcast, print or internet media.
I understand that, after release of my images, they may be subject to re-disclosure.
derstand that this authorization is voluntary and I may refuse to sign. UT Southwestern may not condition my health care
I un
services on the completion of this authorization.
Unless otherwise revoked, I understand that this authorization will expire 50 years from the date of signature. I understand that
I may revoke this authorization at any time, except to the extent that UT Southwestern has relied on this authorization, by sending
a written statement of revocation that specially refers to this authorization. The written statement of revocation should be
d to:
forwarde
UT Southwestern Medical Center
Attention: Department of ________________________________
5323 Harry Hines Blvd.
Dallas, Texas 75390- _____________
I hereby release UT Southwestern Medical Center, The University of Texas and its Regents, officers, agents and employees from
any and all liability connected with the capture, use, or release of my images.
By signing this authorization, I acknowledge that I have read and understand the statements contained herein. I understand
UT Southwestern will provide me with a copy of this signed authorization form.
Patient:
Print Name: ____________________________________________ Signature: ______________________________________
Date: _______________________________
If Patient Has a Legal Representative, Complete the Following:*
Name of Legal Representative: _____________________________ Signature: ______________________________________
Date: _______________________________ Relationship to Patient: ____________________________
)edoc liam(
)tnemtraped fo eman tresni(
By signing this authorization, I certify that I have the legal authority to serve as the above named patient’s legal representative.
*Note--Proof of legal authority may be required for legal representatives.
Form # FMA/AARPOINTP-001 / 10.11
A standard model release form is used, as shown.
Original – Health Information Management Department Copy – Patient
Part One Basic Perioperative Concepts78
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Systematic Nasal Analysis
View Characteristics
Frontal
Facial proportions
Skin type and quality Fitzpatrick type; thin or thick; sebaceous
Symmetry and nasal deviation Midline; C-; reverse C-; S- or S-shaped deviation
Bony vault Narrow or wide; asymmetrical; short or long nasal
bones
Midvault Narrow or wide; collapsed; inverted-V deformity
Dorsal aesthetic lines Straight; symmetrical or asymmetrical; well- or ill-
dened; narrow or wide
Nasal tip Ideal, bulbous, boxy, pinched; supratip; tip-dening
points; infratip lobule
Alar rims Gull-wing−shaped facets; notching; retraction
Alar base Width
Upper lip Long or short; dynamic depressor septi muscles; upper
lip crease
Lateral
Nasofrontal angle Acute or obtuse; high or low radix
Nasal length Long or short
Dorsum Smooth; hump; scooped out
Supratip Break; fullness; pollybeak
Tip projection Overprojected or underprojected
Tip rotation Overrotated or underrotated
Alar-columellar relationship Hanging or retracted alae; hanging or retracted
columella
Periapical hypoplasia Maxillary or so-tissue deciency
Lip-chin relationship Normal; decient
Basal
Nasal projection Overprojected or underprojected; columella-to-lobule
ratio
Nostril Symmetrical or asymmetrical; long or short
Columella Septal tilt; aring of medial crura
Alar base Width
Alar aring
Aer determining the operative goals for the patient, an operative plan is developed, and a graphic worksheet is completed and added to the patient’s record.
e worksheet shown details the intended operative approach and sequence, the
source of autologous gras, and the planned osteotomies.
Chapter Preoperative Concepts for Rhinoplasty 79
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OPERATIVE PLAN
Type
☐
Primary
☐
Secondary
☐
Partial
☐
Deviated
☐
Cleft lip-nose
☐
Ethnic
☐
Other
Approach
☐
Cartilage splitting
☐
Cartilage delivery
☐
Endonasal (closed)
☐
External (open)
☐
Other
Tip/Lateral Crura
☐
Complete rim strip
☐
Alar contour
☐
Lateral crural strut
☐
Attenuated
☐
Morselized
☐
Transected/Resected
☐
Anterior
☐
Posterior
☐
Other
Tip/Medial Crura
☐
Sutured domes
☐
Sutured to strut
☐
Resected
☐
Caudal margin
☐
Vertical segment
☐
Other
Tip/Miscellaneous
☐
Columellar strut
☐
Tip graft
☐
Alar spreader graft
☐
Unusual suturing
☐
Resected caudal septum
☐
Caudal septal repositioning
☐
Alar base resection
☐
Other
Effect on Tip
☐
Increased tip projection
☐
Decreased tip projection
☐
Increased tip rotation
☐
Lengthened nose
☐
Altered columellar-alar
relationship
☐
Altered columellar-labial angle
☐
Other
Dorsum
☐
Reduction
☐
Augmentation
☐
Altered N-F angle
☐
Widened
☐
Spreader grafts
☐
Autospreader flaps
☐
Other
Nasal Bones
☐
Medial osteotomies
☐
Lateral osteotomies
☐
Complete
☐
Greenstick
☐
Multiple
☐
Other
Grafts (autologous)
☐
Septal
☐
Auricular
☐
Rib
☐
Temporal fascia
☐
Implants
☐
Homologous cartilage
☐
Other
Miscellaneous
☐
Nasal septum resection
☐
Resection of turbinates
☐
Mentoplasty
☐
Augmentation
☐
Reduction
☐
Frenuloplasty
☐
Malar augmentation
☐
Repair of septal perforation
☐
Banked cartilage
☐
Other
Degree of Difficulty
1 6
2
7
8
3
4
9
5
10
Part One Basic Perioperative Concepts80
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PREOPERATIVE PATIENT PREPARATION
At the conclusion of the initial consultation, the patient is interviewed by a
patient coordinator who provides a comprehensive preoperative information
packet. is packet includes relevant informed consent forms, names and phone
numbers of the appropriate sta members, nancial/billing requirements, directions to local surgical facilities, preoperative and postoperative instructions, a list
of medications to avoid, and the expected postoperative convalescence.
During this interview the patient coordinator further discusses the patient’s expectations, the anticipated length of the surgery, and the inpatient/outpatient
admission status. Potential complications are fully outlined and disclosed before
informed consent is obtained for rhinoplasty and any other indicated proce-
,
dure.
performed aer year, and they are informed of the fees for which they may be
nancially accountable.
Patients are instructed that if revision surgery is necessary, it is usually
FINANCIAL ASPECTS
e pertinent nancial arrangements are generally addressed by the patient coordinator or other sta members. Patients should be provided with the exact
amount of the surgeon’s fees and an estimate of the surgical facility fees. To ensure
patient compliance, surgical deposits or payments are due weeks in advance
of the procedure. Patients sign documents accepting nancial responsibility at
the time of registration, along with the explanation of surgical billing practices.
Even if surgery is only being considered, the patient is informed about the surgical procedure, the fee, the location of the surgical facilities, and the preoperative
orders. Establishing these facts at the consultation saves time and money by reducing the need for repeated telephone conversations. When a date is set for the
surgery, the preoperative and postoperative visits are also scheduled.
Procedures with a medical component may require application for preapproval
by a medical insurance carrier. e patient is sent a copy of any correspondence
with the medical insurance carrier and is encouraged to provide assistance in
obtaining approval for the functional aspect of the rhinoplasty. Except when the
deformity is caused by documented nasal trauma, the improvements in appear
ance are considered cosmetic and must be paid for by the patient before surgery.
-
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All preoperative and postoperative instructions as well as prescriptions are sent
to the patient weeks before the date of the surgery.
Preoperative planning concludes with a review of the proposed surgical procedure
and goals, an accurate assessment of the surgical charges, and a detailed review
of the preoperative and postoperative instructions.
SECOND CONSULTATION
Some patients, especially secondary rhinoplasty patients, may benet from a second consultation that provides an opportunity to ask questions, review the results
of computer imaging, read the consent forms, discuss the surgical procedure and
its potential complications, and reconsider the decision to undergo surgery. is
visit also provides the surgeon with an opportunity to reevaluate the patient and
the surgical plan. In addition, the psychosocial status of the patient is again reviewed to determine his or her suitability for surgery. is is especially important
for a secondary rhinoplasty patient or a patient whose ability to understand the
goals and limitations of rhinoplasty is in question.
MORNING OF SURGERY
e morning of surgery is the nal opportunity for the surgeon to clarify nal
questions from the patient. e postoperative instructions are again explained
to the patient and to any caregivers who may be providing postoperative care.
e patient and caregiver are provided with an additional set of postoperative
instructions the morning of surgery. e rst postoperative visit is scheduled for
to days postoperatively.
e goal of patient management is to plan everything in advance, discuss each
step with the patient, and provide the patient with an opportunity to explore all
of the options.
Part One Basic Perioperative Concepts82
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KEY POINTS
■
Successful rhinoplasty begins with careful preoperative preparation and planning.
■
Essential elements of the nasal history include nasal airway problems, allergies,
medications, previous nasal trauma, and prior nasal surgery.
■
Nasal obstruction is frequently caused by abnormalities of the nasal septum,
nasal valves, or inferior turbinates, which normally regulate nasal airow.
■
Dysfunction of the nasal airway is frequently seen in secondary rhinoplasty
patients and should be carefully investigated.
■
Nasal obstruction is common amongst patients presenting for rhinoplasty.
However, many patients are unaware that they have this problem and may become more aware of symptoms postoperatively, if le untreated.
■
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 examinations.
■
Congruency between the patient’s and surgeon’s goals and expectations is critical to successful and satisfying outcomes following aesthetic surgery.
■
Patients who express anger toward previous surgeons or who have personalities
that are confrontational or controlling should not be operated on.
■
Photographs obtained using standardized techniques include frontal, lateral,
oblique, basal, and overhead views. ese are essential for detailed aesthetic
analysis and accurate preoperative planning.
■
All images that are viewed are only a representation of the result that could be
achieved through the proposed surgery. Imaging is used as an educational tool
to benet the patient and does not guarantee any result.
■
Computer imaging is useful for showing the patient what changes may be possible aer rhinoplasty.
■
Preoperative planning concludes with a review of the proposed surgical procedure and goals, an accurate assessment of the surgical charges, and a detailed
review of the preoperative and postoperative instructions.
■
e goal of patient management is to plan everything in advance, discuss each
step with the patient, and provide the patient with an opportunity to explore
all of the options.
Chapter Preoperative Concepts for Rhinoplasty 83
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REFERENCES
1. Rohrich RJ. Rhinoplasty planning. Dallas Rhinoplasty Symp :, .
2. Rohrich RJ, Byrd HS, Oneal RM, et al. Management of the rhinoplasty patient. Perspect Plast Surg
:, .
3. Courtiss EH, Gargan TJ, Courtiss GB. Nasal physiology. Ann Plast Surg :-, .
4. Gruber RP, Lin AY, Richards T. A predictive test and classication for valvular nasal obstruction
using nasal strips. Plast Reconstr Surg :-, .
5. Gorney M, Martello J. Patient selection criteria. Medical-legal issues in plastic surgery. Clin Plast
Surg :-, .
6. Rohrich RJ. Streamlining cosmetic surgery patient selection—just say no. Plast Reconstr Surg
:-, .
7. Rohrich RJ, Janis JE, Kenkel JM. Male rhinoplasty. Plast Reconstr Surg :-, .
8. Goin MK, Rees TD. A prospective study of patients’ psychological reactions to rhinoplasty. Ann
Plast Surg :-, .
9. Zijlder TD, Vuyk H, Adamson PA. Rhinoplasty: preoperative photographic analysis. Clin Otolar-
yngol :-, .
10. Waite PP, Matukas VJ. Indications for simultaneous orthognathic and septorhinoplastic surgery. J
Oral Maxillofac Surg :-, .
11. Gunter JP. Facial analysis for the rhinoplasty patient. Dallas Rhinoplasty Symp :, .
12. Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg :e-e, .
13. Fanous N. Mersilene tip implants in rhinoplasty: a review of cases. Plast Reconstr Surg :-
; discussion -, .
14. Horton CL, Matthews MS. Nasal reconstruction with autologous rib cartilage: a -year follow-up.
Plast Reconstr Surg :-, .
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