The Interview

Begin the interview by welcoming the patient and asking him to explain how he would like you to help him. During this meeting you will have to do a fair amount of the talking, but it is vital that you understand what he wants from you and what motivates him to desire it. To do this you must sit back and really listen to him. This can take time, and rhinoplasty consults should be given enough of it on your schedule. If you feel rushed during these meetings, it is crucial that you instruct your staff to allot more time.

You will review the medical history, looking at the patient’s overall health and issues that could affect his ability to withstand surgery and heal, such as diabetes, hypertension, cardiac issues, immunocompromised states, and so on. It is particularly important to understand the medical history of the nose as it relates to issues such as continual or episodic obstruction, nasal pain, allergy, epistaxis, sinusitis, and smell/taste disorders. If the functional issues are significant, it is wise to enlist the help of specialists in the particular problems the patient is having prior to committing yourself to operate on the nose. You do not want to either exacerbate or be blamed for an existing medical problem.

You will also review the surgical history thoroughly, looking for any personal or familial problems with anesthesia, wound healing, and excessive bleeding. It is important to know if the patient has had orthognathic procedures or facial fractures in the past, as the presence of hardware in the nasal area or maxilla could complicate the contemplated rhinoplasty.

If the patient has had nasal surgery in the past, it is vital to understand all that you can about what was done. This can be difficult because often the patient has only a rudimentary understanding of what happened at the previous surgery. He will, however, usually be able to tell you why he had it, that is, what the goals were, and how pleased he is with the outcome. This is a good time to pay attention to his attitude toward his previous doctor. If it seems unreasonably harsh, this is a red flag for you to take note of and should be a consideration in deciding whether or not to operate on the patient.

Take meticulous notes about when and where previous surgeries were performed. The where is particularly important if the patient had surgery in a different country. The patient may have an implant or permanent injectable material in the nose that is unusual or never used in your own country.

Physical Examination

Start by looking at the overall appearance of the nose in the context of the patient. Does it fit the face and the person? A relatively large nose with a slightly high dorsum might seem out of place on a patient of small stature with delicate features, but such a nose might complement the appearance of a larger person with bolder facial bone structure nicely. Conversely, a short nose with a fair amount of rotation in the tip might look good on the face of a smaller, more delicately featured person, but embarrass a taller patient with larger facial bone structure as being out of place on his visage. [Note: Throughout this book I will observe the widely used convention of terming upward rotation of the nasal tip “rotation” and downward rotation of the tip “counter-rotation” or (and this is a blinding flash of the obvious) “downward rotation.”]

Observe also the quality of the patient’s skin. Any cancerous or suspicious lesions must be taken care of prior to contemplating rhinoplasty. Is there evidence of an ongoing inflammatory, systemic or autoimmune situation such as rosacea, liver disease, or discoid lupus? If there are plentiful telangiectasias on the nasal skin, you must photograph them and point out to the patient that undermining the nasal skin during rhinoplasty will do nothing to help these and may bring more. If scarring is present, from whatever cause, it will certainly affect the consistency and plasticity of the skin and may limit the amount of benefit the procedure can bring.

Pay particular attention to the thickness of the skin. It is a major determinant of the result you can hope to achieve from rhinoplasty. In the thick-skinned patient, you can often do quite a bit to the cartilaginous and bony framework of the nose and end up seeing very little change. This is because at the end of the day, the newly sculpted nasal skeleton must lie under a thick blanket of skin and soft tissue. Conversely, every tiny imperfection and irregularity you leave behind in surgery can become painfully obvious after swelling has gone down and healing progresses in the thin-skinned patient. But with a thin skin–soft tissue envelope comes the opportunity to effect more significant changes that the patient will enjoy.

Patients of both skin types, as well as all those in between, can be satisfied by rhinoplasty. To be pleased, however, they need to know from you what type of result they can expect. We will deal with the all-important role of the patient’s expectations later in this chapter.

You will want to palpate the bony and cartilaginous structures of the external nose. By feeling the nasal bones, you will get a sense of their true width, exclusive of the thickness of the skin. You will also be able to feel any irregularities or “step-offs” caused by previous trauma. Feeling the tip of the nose gives very helpful information as to the strength of the tip cartilages and their relationship to the septum. There is a huge amount of variability in the size and strength of human nasal tip cartilages, and appearance alone can sometimes be misleading in this regard. Feeling the cartilage will bring a truer understanding of the nose and the challenges it may present.

Another excellent technique to increase your understanding of what the rhinoplasty should entail is to watch the nose and mouth as the patient breathes quietly ( Fig. I.1 ). It is essential that the patient breathes gently during this part of the examination. Virtually everyone can cause his nose to close during forceful inspiration, so a demonstration of that phenomenon is not helpful.

Observe the nose for several breaths. Note if patients have to open their mouth to breathe. Patients with severe obstructions will. Many patients will tell you they absolutely cannot breathe through the nose and then proceed to do so right in front of you with the mouth closed during this part of the exam! In most patients you will be able to see both the external and internal nasal valves and determine if they are patent during quiet respiration. Look for any valve collapse or lateral wall weakness that may require correction

Observe the nasal tip and dorsum when the patient smiles. Many patients will accentuate the prominence of the dorsum and counter-rotate the nasal tip while smiling. Such patients may notice a difference in their smile after rhinoplasty, so it is best to discuss this issue with them prior to surgery.

Perform an intranasal exam with a light source and speculum. Turning the room light off may be helpful in seeing the nasal interior well. The examination room door should be left ajar in this case to provide a bit of light and make the patient feel comfortable. Also, from a medicolegal standpoint, it is always a good practice to always have the door slightly open when you are alone with the patient in an examination room. Look for septal deviations, mucosal scars, perforations of the septum, signs of irritation, lesions, discharge, internal nasal valve problems, synechiae, and webs, and document anything out of the ordinary.

Finally, gently palpate with the end of a Q-tip to determine the presence and quality of septal cartilage. If you are gentle, the patient will not need topical anesthesia for this. Feeling the septum is especially important to do in previously operated patients who may have little septal cartilage left in their nose. In such cases you will have to talk with the patients about obtaining cartilage needed for their revision rhinoplasty from other sources such as their ear (s), rib, or a cartilage bank.

Photography

The rhinoplasty surgeon must have a good camera. Photographs are crucial to document the state of the nose before surgery and changes resulting from the procedure. They are also essential for creating an operative plan. They are helpful in growing a practice; prospective patients want to see actual results achieved in other patients. And finally, they are indispensable in the surgeon’s growth; it is only by analyzing our successes and failures in the operating room (OR) that we continue to improve.

There is an abundance of excellent and inexpensive camera bodies on the market. A digital single lens reflex (SLR) body will accommodate a good lens, which is where things can get expensive. The 105-mm macro-lens is offered by several manufacturers; it takes distortion-free portraits of a size and quality suitable for displaying to patients as well as using in scientific publications. This is also an excellent lens for taking close-up images from a comfortable distance in the OR.

The well-equipped office has one or more photographic backgrounds and may feature a room devoted to photography with special lighting for that purpose. Such an elaborate setup is nice but not necessary. The cameras lenses, light meters, and on-board flashes available today are good enough to provide presentation-quality images with proper use.

The surgeon may elect to have an assistant take photographs, but in doing so may miss out on seeing the patient in a slightly different and sometimes more revealing way through the camera lens. The standard views for rhinoplasty are front, base, oblique right and left, and lateral right and left. A near-front view adds additional helpful information. A reverse-nasal or cephalic view is helpful in showing nasal deviation and should be obtained when significant nasal asymmetry exists.2 The front, near-front, oblique, and lateral views must be shot with the patient in the Frankfort plane ( Fig. I.2 ). This orientation aligns the inferior orbital rim and top of the external auditory canal horizontally, that is, parallel to the floor and exactly perpendicular to the vertical plane. Figure I.3 provides good examples of the standard photographic views the surgeon must have to properly analyze and document the appearance of the patient’s nose before surgery. Figure I.4 demonstrates the near-front and reverse-nasal views.

A staff member may be needed to help support the patient’s head and neck if the patient lacks the flexibility or balance to position himself for this particular view ( Fig. I.5 ).

Discussing the Nose in Detail

Once the surgeon has taken the history, performed the examination, and obtained the photographs, it is time to discuss the nose in detail with the patient. This is best done in a quiet setting free of distractions. Now is the time for the patient to state in his own words why he has come and what his specific concerns are with the nose. It is indispensable to have the images available for this discussion. A computer, digital card reader, and large monitor are standard equipment for this part of the consultation. Go through each view with the patient and ask him to point out the specific nasal features that he would like to see improved. Very often the patient will ask you for your opinion of the nose at the outset of the discussion; it is best to defer judgment and find out what changes he desires.

Determine how long the patient has been thinking about changing his nose. Is this a whim or a carefully reasoned decision? Also try to gauge his level of maturity. This is particularly important with younger patients who may lack the internal fortitude to calmly withstand the postoperative healing period, particularly if there is a complication. As you let the patient speak, sit back and listen carefully. Strive to truly understand, and then ask yourself: “Does what he is saying sound reasonable?” The answer will go a long way in helping you decide whether or not to operate.

And this is no small decision. An unhappy or litigious rhinoplasty patient can be very difficult to deal with. It is never worth operating on a patient who cannot be satisfied. Part of the art of our field of medicine is identifying these patients. There are some negative characteristics that should be particularly significant to the surgeon who is evaluating a patient for rhinoplasty; I call them the seven deadly traits ( Table I.1 ). Any of these characteristics should give the surgeon pause when deciding to operate. In the end it is always a judgment call. Trust your instincts and defer surgery if you are uncomfortable with the patient. A maxim of surgery that has stood the test of time and will serve the surgeon well is: “A cosmetic surgeon makes his living from the cases he does and his reputation from those he declines to do.”3

Nasal Analysis

To enhance beauty and function, the surgeon must first have a firm idea of what is beautiful and what is required for the nose to work well. In rhinoplasty this translates to a mastery of normal nasal anatomy and a finely developed sense of nasal aesthetics. It is through the assiduous study of detail in lectures, courses, books, journals, and in the OR and anatomy laboratory that the proper knowledge base begins to develop. Close observation of family, friends, patients, and all types of noses helps to develop the aesthetic sense. If a woman is beautiful or a man handsome, what is it about the facial aesthetic that makes this so? How does the nose blend with the surrounding facial features and what is its inherent shape? How can so many different types of noses all be beautiful? This is a fascinating game for surgeons to play in their mind, which pays dividends for their patients in the OR.

As with the rhinoplasty procedure itself, nasal analysis is at its most basic level a comparison. It involves having an image in the mind of the optimal nasal shape for the patient who presents for consultation. The analysis compares the patient’s individual anatomic components and overall facial aesthetic to the ideal and determines how his nose may be brought closer to it.

There are many different methods for analyzing the nose, but they all involve dividing the nose into components or compartments and studying each. For example, surgeons may study the upper, middle, and lower nasal thirds or divide the nose into bony and cartilaginous components and separately analyze each one. They may focus on the various photographic views, or think in terms of nasal attributes such as projection, rotation, orientation (straight or crooked), angles, or contours. In practice, our minds consider all of these factors in a complex way to arrive at a consensus or gestalt of what the nose is and could be. It is nonetheless worthwhile for surgeons to adopt a disciplined method of nasal analysis that works for them and their patients.

The patient expects and is usually keenly interested in such an analysis at his first visit with a rhinoplasty surgeon. After he has fully explained what bothers him about his nose, it is now his turn to listen. The surgeon will find the patient’s photographs to be of great help in explaining his opinions of the nose and may wish to use anatomic diagrams to give the patient an understanding of what the structural issues are ( Fig. I.6 ).

Once the surgeon has a firm understanding of what the patient would like to see and has analyzed the nose thoroughly, he may discuss what the goals of rhinoplasty would be if it were to be performed. Note that at this point there has still been no commitment or decision to perform surgery for the patient. The wise surgeon will defer this determination until the end of the interview when he has the maximum amount of information about the patient at his disposal. It can even be deferred to another meeting as we will shortly discuss.

It is helpful to go through each photographic view again as you tell the patient what changes you think are possible. It is at this point that digital image modification may be helpful. Many fine surgeons use image morphing software as a tool for educating the patient and even planning surgery. Many others do not use it. If you as the surgeon decide to alter the patient’s digital images to show him what changes you will try to make, there are two precautions you should take. Remember that the patient may be profoundly affected by seeing the altered image and believe that this is exactly what the result will be. In fact, he may see the morphed image as a kind of promise on your part of the outcome of surgery. For this reason a strong disclaimer is mandatory. The patient must be made to understand that the morphed image is for discussion purposes only and that his result may vary substantially from it. The second precaution is that it is not advisable to print the morphed images and give them to the patient to take home. Repeated study of the altered image may cement in the patient’s mind that particular result as the only acceptable one. If the actual result varies from it, there may be dissatisfaction after surgery.

Regardless of whether or not digital image modification is used, it is crucial for the surgeon to communicate the changes in the nose that he feels are appropriate for the patient and for him to determine if the patient agrees.

Now is also the time to discuss additional procedures aside from the nose, if they would be helpful. This is easily done if the patient raises the subject, and should be put delicately if the surgeon feels he must bring up the subject. Blepharoplasty, especially of the lower lid, should be performed with caution, if at all, at the same time as rhinoplasty. If the eyelids are to be operated at the same time as the nose, the patient should be warned that swelling in the nose can compromise drainage of fluid from the eyelid area and result in prolonged edema and disfigurement.

Chin augmentation is the procedure most commonly performed at the same time as rhinoplasty. It should be considered in all patients with retrusive chins, especially when the nose is prominent ( Figs. I.7 and I.8 ). The surgeon who shies away from mentioning the procedure to a patient with a small chin that can benefit from augmentation is actually doing the patient a disservice. Placement of a chin implant through a small submental or intraoral incision is a low risk procedure that carries with it a high probability of satisfying the patient.4 It is imperative that any issues of dental malocclusion or temporomandibular joint dysfunction be addressed before proceeding with cosmetic mentoplasty. It is the author’s preference to use a preformed expanded polytetrafluoroethylene (ePTFE) implant for chin augmentation, although Silastic implants have also been used by many surgeons with great success. Either implant type may be carved to an optimal shape for the specific patient who is to receive it. Pre-formed ePTFE implants became unavailable in the American market when W.L. Gore and Associates withdrew from the cosmetic surgery market, but are now available again through other manufacturers5 (see Disclosure at the beginning of this book). It is also possible to roll, suture, and carve an excellent chin implant of any desired thickness from 2 mm ePTFE sheeting if a preformed solid implant is not available.

It is helpful to show the patient results you have obtained for other patients during the initial consultation. This gives the patient confidence that you have performed the procedures under discussion successfully for others. Of course, you will need signed permission from the past patients whose photographs you want to show for promotional purposes. It is a simple matter to include this specific use permission language in your surgical consent. You will find that in most cases patients appreciate being shown photographs of others and will feel it is only fair that they give permission for you to do the same with their own photos. There are cases in which patients legitimately do not want their pictures shown, and you must honor this request and strike out that section of the consent form. In the author’s experience, however, patients who refuse simply because they dislike the idea may prove to be more troublesome after surgery. Review the language that you would like to include in your consent form granting permission for use of photographs and videos for promotional or scientific purposes with a qualified attorney before adopting it into your practice.

You can create a “highlights reel” of cases you have performed that display some of your best results to show to prospective patients. Although it is frequently written that cosmetic surgeons should show their average results, it is doubtful that many do. What must be made clear to patients is that what they are seeing are some of your best results, and that their outcome can vary from what you are showing them. Nonetheless, examples of your work serve to educate and impress new patients. It is best to show a wide range of nasal types in the presentation. Surgical patients of different ages, sexes, and races should be included. Primary and revision cases should be displayed. Include a wide variety, but do not overwhelm prospective patients with too many cases.

As the consultation comes to a close, the surgeon should describe the normal sequence of events that the patient will experience in going through a rhinoplasty. Almost everyone wants to know how much work or school he will miss, how long he will not be presentable to the public, whether intra-nasal packing or splints are likely to be used, and how much discomfort he can expect. The surgeon should answer any questions related to these or any other topics raised during the consultation.