Assessment of the Rhinoplasty Patient
Beauty is a form of genius—is higher, indeed, than genius, as it needs no explanation. It is of the great facts in the world like sunlight, or springtime, or the reflection in dark water of that silver shell we call the moon.
Oscar Wilde1
Beauty is a currency system like the gold standard. Like any economy, it is determined by politics, and in the modern age in the West it is the last, best belief system that keeps male dominance intact.
Naomi Wolf2
Summary
The preoperative assessment of a rhinoplasty patient includes several considerations that are unique in this type of surgery. Social and ethical issues must be taken into account, while during the outpatient consultation the patient′s motivation for surgery, his or her stability and overall psychological assessment, with a special emphasis on body dysmorphic disorder (BDD) must be assessed. BDD is an increasingly recognized disorder of self-perception associated with significant psychiatric comorbidity, high rates of suicide and self-harm, and following cosmetic surgery, high rates of dissatisfaction, occasionally manifesting as aggressiveness. Assessment of the defect (both objectively and subjectively) should be complemented with a clear and honest discussion of the patient′s wishes and the surgeon′s capabilities. The use of imaging and image-manipulating software can enhance communication as well as provide useful medicolegal documentation and facilitate audit and self-improvement. Several software programs, including shareware and widely available photo-editing software, can be used for this purpose.
Rhinoplasty: Social and Ethical Issues
By virtue of being a (primarily) aesthetic rather than functional procedure, rhinoplasty is unique among rhinologic operations. As such, it raises moral, philosophical, and social issues that no other procedure does. There has been an exponential increase in the number of cosmetic procedures performed over the last 2 decades (a 162% increase since 1997 in the United States), with over 1.3 million procedures performed in 2009,3 and a 300% increase in the United Kingdom since 2002 with 34,000 aesthetic plastic surgery procedures performed in 2008,4 while 17 million cosmetic procedures were performed worldwide in 2009.5 These data reflect the wider availability of surgical interventions but equally testify to a universal culture increasingly focused on appearance. In modern societies, where mobility and large networks of short-time acquaintances are the norm, “first impression” becomes crucial.6 Men as much as women are realizing the importance of an appealing external appearance in social life, work, and personal relations, and are more likely to use cosmetic surgery to achieve it. However, although it would be wrong to dismiss some well-established universal, “objective” norms of beauty, it would be equally naive to ignore the context within which specific ideals of beauty are created and circulated, that is, our mass media culture. Within this context, the concept of patient empowerment becomes controversial. As the European Union Bioethics Commission report established,7 there are four important elements to be considered: the value and meaning of beauty, the meaning and range of the principle of autonomy, the proper goals of medicine, and the issue of publicly funded health care.
Note
Core ethical issues in aesthetic surgery:
1. The value and meaning of beauty
2. The meaning and range of the principle of autonomy
3. The proper goals of medicine
4. The issue of publicly funded health care
Value and Meaning of Beauty
Although a cross-cultural, universal typology of beauty undoubtedly exists, there is equally a broader context within which this is applied; this includes the character, performance, and relational capabilities of the person assessed.
Meaning and Range of the Principle of Autonomy
Although most patients with chronic rhinosinusitis (CRS) will seek medical help, the same is not true of patients with a less than ideal nose. There are external and social factors at play for patients who decide to undergo an aesthetic procedure, including social norms and the dominant ideal of beauty. These underline the importance of the promotion of diverse beauty ideals, by governments and the media. Of course, one can argue that it is not external factors per se but the way the individual interacts with them that define whether the patient′s decision is a fully autonomous one. Healthy, mature patients possess this autonomy, whereas vulnerable, psychologically unstable patients do not.
Proper Goals of Medicine
Medicine is supposed to be about treatment and disease, whereas aesthetic surgery is about nondisease and enhancement. However, the drawing of clear lines between medicine and aesthetic surgery has been shown to be philosophically impossible. Serious suffering that deserves treatment is within the domain of aesthetic surgery as much as in traditional medicine.
Issue of Publicly Funded Health Care
All systems have limitations, and in an era of rationing, what criteria can be used to justify a procedure? Different countries have different guidelines, and there is an urgent need of harmonization of procedures within the European Union (EU). Purely aesthetic surgery is theoretically not covered by the social health care system of any country in the EU. However, there are many exceptions that differ from country to country and that are not always clear. In summary, however, appearance that falls outside some range of what is socially acceptable, that hampers the possibilities to get a job, or that causes dysfunction is covered (United Kingdom, Germany, Belgium, and the Netherlands). In countries where health insurance is primarily provided by the private sector (e.g., the United States), the issue is less acute, although similar issues exist within the private insurance framework. What emerges in this way as one single criterion underlying these exceptions is patient suffering, often but not exclusively caused by social norms.
Patient Selection and the Rhinoplasty Consultation
The wider social and moral context of rhinoplasty raises considerable issues. However, for the average rhinoplasty surgeon, these issues are often distilled into a single decision—to operate or not—that he or she has to make in a relatively limited time frame: the rhinoplasty consultation. During this consultation, the surgeon must make an objective assessment of the real or perceived defect, understand how the patient views it and what he or she wants to be done about it, decide and explain to the patient what can be accomplished, and, most importantly, assess the patient′s motivations, inner stability, and overall psychological profile.
Tips and Tricks
An initial rhinoplasty consultation should include the following:
Assessment of the patient′s motivation for surgery, stability, and overall psychological profile
Objective assessment of the real or perceived defect itself
Discussion of the patient′s wishes and the surgeon′s capabilities
Offering of informative printed material and/or Web site referral, as well as arrangement for a second consultation
Patient′s Motivation for Surgery, Stability, and Overall Psychological Profile
(How can I help you? What brought you here today? How long have you been thinking about surgery? What caused you to begin thinking about surgery? Why do you want to do the operation at this particular time? What is the attitude of your family to your operation? Whose idea was it to have the surgery? How many previous operations have you had? Were you happy with the results of the previous operations? What do you think this operation will do for you? 8)
The surgeon has the duty to assess the patient′s motivation for the operation and his or her mental and physical ability to deal with the stress of surgery and potential complications, as well the stress of a nonreversible change in his or her appearance (including that brought about by a successful result). Only a patient who fully understands the goals, risks, and limitations of the operation can provide real informed consent. Although several studies have shown improvement in patients’ quality of life, as well as improvement on many psychosocial well-being indicators after rhinoplasty,9–11 recent large-scale observational studies have also shown that there is a higher risk of suicide in patients who undergo cosmetic surgery and a vastly increased rate of psychiatric disorders.6 Although this is not to say that all cosmetic surgery patients have psychological problems, it does mean that a disproportionately larger number of such patients tend to undergo cosmetic surgery.
Body Dysmorphic Disorder
Thus, it is vital to screen potential rhinoplasty candidates; indeed, several studies have been performed using various psychological criteria. What is emerging as a major issue in many (if not most) problematic patients is body dysmorphic disorder (BDD), or dysmorphophobia. BDD is a relatively common obsessive-compulsive spectrum disorder defined by a constant, impairing preoccupation with imagined or slight defects in appearance.12 It is associated with poor quality of life, high rates of suicide, and, following cosmetic surgery, increased rates of dissatisfaction, occasionally manifesting as aggressiveness. An algorithm has been suggested by Jakubietz et al for screening plastic surgery candidates for BDD.13 According to this algorithm, patients are divided into three groups:
Those with a correctable deformity and reasonable expectations who can be treated by plastic surgery
Those with no deformity and unreasonable behavior who would be inappropriate candidates for surgery and instead should be referred for psychiatric evaluation
Those with minimal deformity and inadequate behavior who should be considered for referral and rescheduled for a second appointment and reevaluation
The diagnosis of BDD is established after psychiatric consultation, where a 34-item Body Dysmorphic Disorder Examination may be used. For screening purposes, the Body Dysmorphic Diagnosis Questionnaire (BDDQ) can be used.14 The BDDQ has been shown to have, depending on the sample, a sensitivity of 100% and specificity of 89 to 93%.15
Body Dysmporphic Diagnosis Questionnaire
Are you very worried about your appearance in any way?
Does this concern preoccupy you? That is, do you think about it a lot and wish you could worry about it less? How much time do you spend thinking about it? (More than 1 hour per day is suggestive and more than 3 hours highly specific for BDD.)
What effect has this preoccupation with your appearance had on your life? Has it
Significantly interfered with your social life, school-work, job, other activities or other aspects of your life?
Caused you a lot of distress?
Affected your family or friends?
For the busy clinician, the Dysmorphic Concern Questionnaire (DCQ), a seven-item screening questionnaire, can be used for the initial assessment of patients. DCQ has good psychometric properties, including internal consistency, unidimensional factor structure, and strong correlations with distress and work and social impairment;16 a cutoff value of 9 has been shown to have excellent discriminative validity, correctly classifying 92% of patients and controls.17
Note
Using the DCQ in the outpatient setting can be an easy and convenient way of screening patients for BDD.
The characteristics of BDD are shown in Table 23.1 .
Although 80% of plastic surgeons in the United States report that they would not operate on a patient with BDD, 84% also state that they had unwillingly operated on at least one.24 Several studies22,25 have shown that up to 66% of patients with BDD undergo cosmetic interventions, with the most common being rhinoplasty.22 Indeed, in a U.K. rhinoplasty practice, the use of a screening questionnaire for BDD identified a 20.7% prevalence rate.26 Cosmetic surgery is unlikely to be helpful in such patients. In a study of 26 patients undergoing 46 procedures in the United Kingdom, rhinoplasty was associated with marked dissatisfaction and an increase in the degree of preoccupation and handicap, with the worst outcome in those with repeated operations.22 Phillips et al23 reported on 58 patients with BDD seeking cosmetic surgery. The large majority (82.6%) reported that symptoms of BDD were the same or worse after cosmetic surgery. Although 31% of patients with BDD reported an appearance improvement following the procedure, only 1% reported a decrease in their preoccupation with the defect. What is potentially alarming is that these patients, who may belong in the delusional spectrum of this obsessive-compulsive disorder, may become threatening; 40% of plastic surgeons report that they have been threatened by a patient with BDD.24
Although patients with BDD may have trouble accepting it, often choosing instead to self-refer to another surgeon, their management should be psychiatric, not surgical. A recent Cochrane review showed that cognitive behavioral treatment and selective serotonin reuptake inhibitors (SSRIs; fluoxetine/clomipramine) are effective and should be the treatment of choice.27
Tips and Tricks
Failing to recognize and operating on patients with BDD can be a reason for litigation.
Interestingly, a recent study26 showed that psychiatric patients with BDD seeking rhinoplasty are different from “normal” (or mild BDD) rhinoplasty patients in a variety of ways: they are significantly younger, more depressed, more anxious, more preoccupied by their nose, and have more compulsive behaviors (e.g., mirror checking, feeling their nose with their fingers, and even self-mutilation). It also appears that they are significantly handicapped in their occupation, social life, and intimate relationships. Patients with BDD are especially more likely to have been discouraged from surgery by friends or relatives, more likely to believe that there will be dramatic changes in their life after surgery, and have dissatisfaction with other areas of their body. All of these characteristics are not new. Before the description of BDD, several surgeons used similar terms to describe bad rhinoplasty candidates. The mnemonic SIMON (single, immature, male, overexpectant or obsessive, and narcissistic) was coined for the male high-risk patient who was more likely to be dangerous, whereas SYLVIA (secure, young, listens, verbal, intelligent, and attractive) applied to a good candidate.28
Similarly, Adamson and Chen29 noted several categories of inappropriate patients for rhinoplasty:
Patients having a life crisis
Unhappy patients
Cross-cultural patients (with family friction)
Psychologically estranged patients (those with obsesive-compulsive and borderline personality disorders)
Patients with BDD (dysmorphophobia)
Sexually dysfunctional patients
Patients with “package of pictures” syndrome (unrealistic expectations)
Patients with exceptionalism syndrome (narcissistic personality)
Patients with “my theory” syndrome (poor listeners)
Patients with Goldilocks syndrome (perfectionists)
Patients with “exhausted surgeon” syndrome (patients who go “doctor shopping”)
Patients with unfocused personality
A recent systematic review of 37 studies on the psychosocial aspects of aesthetic surgery showed that there is a distinction between expectations regarding the self (e.g., to improve body image) and expectations in terms of external parameters (e.g., enhancement of one′s social network, establishing a relationship, or getting a job).30 Patients with external motivation are less likely to be satisfied. The same study, after pooling the results from all assessed studies, found that common factors associated with dissatisfaction and poor psychosocial outcome include
Young
Male
Unrealistic expectations of the procedure
Previous unsatisfactory cosmetic surgery
Minimal deformity
Motivation based on relationship issues
History of depression
Anxiety
Personality disorder
The common threads in all of these appear to be difficulty to engage meaningfully and lack of mental stability. The bottom line, as expressed succinctly by Goode,31 could be distilled as follows: listen to your gut feelings and to your staff—a patient who appears unsuitable for rhinoplasty during the first minutes of the consultation most likely is.
The Defect
(When you look [in] the mirror, what is it that you don′t like? What view of your nose bothers you the most? What specific feature do you want corrected? If you can have only one thing changed, what would it be? 8
During the initial consultation, there should be enough time for the patient to describe the defect. It is said that 80% of patients require less than 2 minutes to express their main concern6 (although this may not be strictly true for rhinoplasty patients). Open-ended questions are preferable. The use of a mirror and/or photographs is vital. Clear and specific complaints are easier to deal with, especially if they are based on observations shared by the doctor. Computer imaging may be useful to screen patients with unrealistic expectations. Patients who are not satisfied with a reasonable computer-produced manipulated image are unlikely to be satisfied with surgical results.32
There are objective and universal canons of facial beauty, and we know that what the rhinoplasty patient perceives as an “ideal” nose does not differ from what is perceived as such by the surgeon and the general public.33 However, the surgeon should be careful to avoid suggestive questioning. It is counterproductive, and some patients may be insulted if the discrepancy between their nose and the ideal nose is analytically described. Although a surgeon must be able to perform an objective aesthetic facial analysis, this analysis should not always be shared with the patient.
Patient′s Wishes and the Surgeon′s Capabilities
At this stage, the surgeon must explain to the patient what can and cannot be achieved by surgery on the basis of his or her expertise. This can be complemented with computer-imaging analysis and manipulation, as discussed later. The goals and limitations of surgery should be made clear. Preand postoperative photographs of previous patients may be helpful, although the surgeon must resist the temptation of focusing exclusively on “poster patients”; indeed, the cases where he or she achieved a less than ideal result, and even cases of patients who were unsatisfied and underwent revision surgery, should be shown and discussed. The patient should be informed of all the potential complications of surgery, including the risk of revision surgery, and the rates quoted should not come from literature reviews but from the surgeon′s own audit.
Written Material/Web Site Referral/Second Consultation
Patients tend to use the Internet to gather information, both before and after their consultation.34 A referral to useful rhinoplasty/facial plastic surgery Web sites, including the surgeon′s personal Web site and reliable sources of information (e.g., the European Academy of Facial Plastic Surgery, www.eafps.org, and the American Academy of Facial Plastic and Reconstructive Surgery, www.aafprs.org), can complement the information provided by the surgeon. Printed material and handouts with information that the patient can absorb at home are also important. Indeed, in a recent study, the quality of printed handouts and the information gathered from the Internet were the factors most strongly correlated with overall patient satisfaction with the consent process.35
Surgical Anatomy of the External Nose
The external nose consists of the bony pyramid (the bridge of the nose), complemented by the lateral (upper) and alar (lower) nasal cartilages, supported in the midline by the nasal septum. It is divided into the bony vault, the cartilaginous vault, and the lobule.
Anatomy of the Bony Pyramid
The bony vault or pyramid is the upper one-third of the nose and is formed by the nasal bones and the ascending (frontonasal) process of the maxilla.
Nasal Bones
The nasal bones are cephalically attached to the frontal bone, laterally to the ascending process of the maxilla, medially to each other, and posteriorly to the septum. Their caudal end overlaps for a few millimeters the upper lateral cartilage, like a roof tile. Caudally and laterally, they form, together with the ascending process of the maxilla, the pyriform aperture ( Figs. 23.1 , 23.2, and 23.3 ).
Anatomy of the Cartilaginous Pyramid
The lower two-thirds of the nose are formed by the cartilaginous pyramid. This is a unified, winged structure that includes the upper lateral cartilage and the cartilaginous septum, which articulate with each other in a T- or Y-shaped configuration.36
Tips and Tricks
Excision of a cartilaginous hump should include the septum, as well as the upper lateral cartilage, in a T configuration.
Upper Lateral Cartilages
The articulation of the septum with the upper lateral cartilage forms an angle, usually 10 to 15 degrees, that is very important functionally, as it forms (at their cephalic edge and together with the head of the inferior turbinate) the internal nasal valve area. This is the narrowest part of the upper airway, and any degree of narrowing of this angle can lead to nasal obstruction. This area is also significant histologically, as it constitutes the interface between the (external) squamous epithelium and the (internal) nasal mucosa ( Fig. 23.4 ).
Tips and Tricks
One of the roles of spreader grafts is the widening of the angle formed by the articulation of the septum with the upper lateral cartilage.
Caudally, the upper lateral cartilage articulates with the alar cartilage in the scroll area. Usually the cephalic edge of the alar cartilage overlaps the caudal edge of the upper lateral cartilage, although several configurations have been described ( Fig. 23.5 ).
Alar (Lower Lateral) Cartilage
Although in traditional anatomical textbooks the alar cartilage was divided in medial and lateral crura, a third part is increasingly recognized: the middle or intermediate crura.
The alar cartilage is thus comprised of the medial, middle or intermediate, and lateral crura. They form two arches, with the medial crus converging in the midline and thus forming the columella, and the lateral crus supporting the lateral wall of the nasal vestibule. The medial crura converge in the midline (columellar segment of the medial crura) and diverge more inferiorly, toward the nasal spine (medial crural footplates). Posterior to their convergence and between them and the upper lateral cartilage there is an area not supported by cartilage (the weak triangle of Converse) corresponding to the supratip breakpoint or depression (see Fig. 23.1 ). Lateral and caudally to the lateral crura, fibroareolar tissue lies between them and the pyriform aperture, while laterally and cephalically, there are a few small accessory cartilages. More cephalically (between the nasal bones and the pyriform aperture), there are a few sesamoid cartilages. The lateral crus is the widest part of the alar cartilage and is tightly adherent to the overlying nostril skin. The intermediate crus is divided into a domal and a lobular segment ( Figs. 23.6 and 23.7 ).
Tips and Tricks
The domal segment of the intermediate crus of the alar cartilage can take various shapes, and its configuration defines to a large extent the shape of the nasal tip (boxy, bifid, etc.).
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