Pearls
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While knowledge of a positive history of excessive bleeding during a previous nose or other surgery is very helpful, lack of such a history does not exclude the potential for bleeding disorders during the upcoming rhinoplasty.
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One of the most important requirements for the success of any cosmetic surgery, especially rhinoplasty, is full understanding of the patient’s concerns and having matching objectives between the surgeon and the patient.
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A large number of patients may state that they do not have any breathing problems; however, keen observation may reveal that their lips are apart and they are complete or partial mouth-breathers.
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If the nature of an underlying airway compromise is not detected and corrected, a reduction rhinoplasty may result in deterioration of the underlying condition.
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Over 60% of patients who have migraine headaches have a rhinogenic trigger site.
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Rhinogenic migraine headaches usually start from an area behind the eyes, the patient often wakes up with a headache in the middle of the night or early morning, and the headaches are commonly triggered by changes in the atmospheric pressure.
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Patients who have daily migraine or sinus headaches have contact points between the septum and turbinates or have concha bullosa.
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An overprojected nose and prominent chin create an enigma. Reduction of one structure may actually exaggerate the disharmony of the other.
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Since the nose is harmonized with the other facial structures, detection of other facial disharmonies is of paramount importance in achieving a successful outcome.
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The smile view can reveal a horizontal line on the upper lip, result in significant widening and cephalic distraction of the ala, clearly demonstrating the deviation of the nose, and prove hyperactivity of the depressor nasi septi muscle causing the tip to rotate towards the lip.
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The base of the ala is located 2 mm cephalad to the junction of the upper 2/3 and lower 1/3 of the distance from the medial canthus to the stomion.
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Proper patient selection for plastic surgery is not about diagnosing psychological disorders, since we, as plastic surgeons, are not qualified to make such a diagnosis. The skill lies in avoiding hasty surgery on patients who may be displeased with the rhinoplasty no matter how good the outcome is.
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Merely declining the surgery and failing to facilitate psychological advice when appropriate, will invariably result in the patient finding a different surgeon who will offer surgery, and an unhappy outcome will ensue.
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Statements such as ‘I would like my nose to look the way it did prior to the last rhinoplasty’ made by someone undergoing a secondary procedure should alert the surgeon.
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Comparing the patient’s and the surgeon’s assessments, on a scale of 1–10, of the magnitude of concern with the nose may help in ensuring that there is parity in understanding of the dysmorphology.
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A narrow and higher vaulted palate with posterior dental cross bite usually is an indication of a narrow maxilla and a very limited nasal airway, whereby a reduction rhinoplasty may further sacrifice the nasal air flow.
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A tip that is hanging from a large hump is destined to lose a good portion of its projection immediately upon lowering the caudal dorsum.
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Many patients who have deviated noses pluck their eyebrows differentially to camouflage the nasal deviation. Using the inter-eyebrow distance as the midline of the upper face on these patients can create a wrong foundation from which to start the surgical planning.
General Health
In evaluating a patient for rhinoplasty, one has to take into consideration the general medical conditions that may pose additional risks for the surgery or may cause suboptimal results. The most common medical entity that influences the course of surgery, recovery, and the outcome of rhinoplasty is abnormal coagulation. A whole host of coagulation abnormalities may cause excessive bleeding, especially during rhinoplasty. What makes rhinoplasty more dependent on normal coagulation is the robust arterial circulation due to an abundance of blood vessels within the external and internal nasal structures.
To detect the common coagulation abnormalities, specific inquiry regarding bleeding and easy bruising history is of cardinal value. Reviewing the course of previous surgical procedures and the incidence of excessive bleeding can be extremely informative. The power of observation of the previous operating surgeon, however, plays a salient role in the reliability of this information. What would be normal oozing for one surgeon could be considered excessive bleeding by another more discerning surgeon. Thus, while knowledge of a positive history of excessive bleeding during previous surgery is very helpful, lack of such a history does not exclude the potential for bleeding disorders. History of bleeding after certain surgical procedures such as third molar extraction or tonsillectomy, which are very much dependent on normal coagulation, would be much more informative than after procedures such as appendectomy where there is not much of a raw surface and most vessels are ligated or cauterized during the surgery.
In the past, the most common reason for excessive bleeding was ingestion of pharmaceuticals or food products that had deleterious effects on coagulation. With vigorous patient education, this trend has been altered. Today, at least in our experience, the most common reason for excessive bleeding in the absence of hypertension is an inherited coagulopathy such as von Willebrand disease. Careful inquiry to rule out or establish this condition can avoid intraoperative frustration and poor postoperative outcomes.
A history of hypertension in a patient who is to undergo a rhinoplasty is also important since many such patients become hypotensive during surgery and blood pressure rises postoperatively upon awakening from anesthesia, resulting in bleeding from the nose, even though there was no noticeable bleeding during surgery. Control of the blood pressure postoperatively may prevent an emergency visit due to epistaxis and the associated inconveniences for the patient and the surgeon alike because of bleeding.
Diabetes may cause delayed healing for rhinoplasty patients. These patients also have more potential for infection and often heal poorly with excessive scar formation. An external incision may not always heal as favorably in such a patient as in those who do not have diabetes. Judicious use of prophylactic antibiotics pre- and postoperatively may reduce the potential for postoperative infection.
Immunosuppressed patients are not good candidates for cosmetic rhinoplasty, although septoplasty and turbinate surgery may be considered, like any other medically indicated surgery. A consultation with the immunologist who is caring for the patient is prudent.
Consideration of Patient Concerns
One of the most important requirements for the success of any cosmetic surgery, especially rhinoplasty, is full understanding of the patient’s concerns. Disparity between what the patient dislikes and the flaws that the surgeon sees is far more common than is realized. Therefore, it is of paramount importance to ask patients to describe their reasons for the visit and list the specific concerns clearly, preferably on more than one occasion. If the imperfections that the patient observes do not match what the surgeon sees, additional visits are imperative until the sources of the patient’s concerns are explicitly understood by the surgeon and the patient’s goals precisely match the surgeon’s.
History of Nasal Trauma
It is important to ascertain whether any part of the nose deformity is related to a previous nose injury. Specific questions should be asked of the patient to elicit information that otherwise may not be volunteered. These should include whether there was an episode of nose injury, the approximate date, and the nature of the injury. One should ascertain whether the patient was attended by a medical professional, whether any images were obtained, and the nature of the treatment provided at the time of the accident and/or subsequently. The availability of any images acquired at the time of initial injury, or since that time, should be explored. Review of these images may provide additional valuable information.
Airway Symptoms
It is very important to inquire about the breathing difficulties that the patient experiences. This is an intriguing question and answers should be interpreted with prudence. A large number of patients may state that they do not have any breathing problems. However, keen observation may reveal that their lips are apart and that they are complete or partial mouth-breathers ( Figure 2.1 ). These patients have never experienced any other way of breathing and do not realize that they can breathe differently. Additionally, there are patients who consistently breathe only through one side of the nose and examination may demonstrate that one side is completely or significantly obstructed. The patient may be unaware of this condition since most patients do not try to breathe through each nostril independently. These two situations should not be missed because they can have serious consequences. However, a clear majority of patients with breathing difficulties, although they may not volunteer the information, will provide enough information when asked specific questions to enable the surgeon to reach a proper conclusion related to any breathing abnormalities.
Requiring the patient to complete a comprehensive questionnaire similar to the one included in this chapter (the functional nose form – Table 2.1 ) will provide an opportunity for thorough documentation of the nose dysfunction. There are some additional questions that will lead to a better diagnosis of the condition causing the nasal obstruction. These include the frequency of airway problems, consistency, laterality, and whether there are any allergy-related symptoms such as rhinorrhea, sneezing, watery eyes, itching, and loss of sense of smell and taste. Nose-related allergies are very common and nasal airway obstruction may be the only symptom, since sometimes allergies are purely nasal and may not be very obvious. Additionally, other conditions such as vasomotor rhinitis are reasonably common and can cause breathing difficulty or compound a mechanical or valvular nose obstruction. Since the majority of successful rhinoplasties are reductive in nature, if there is an undetected and uncorrected underlying airway compromise, rhinoplasty on these patients may cause deterioration of the breathing problems and convert an aesthetic concern to a functional predicament.
| Yes | No | |
|---|---|---|
| Do you have any difficulty breathing through your nose? | □ | □ |
| Do you experience sinus headaches? | □ | □ |
| Are you a mouth breather? | □ | □ |
| Do you experience sore throats and dry chapped lips in the morning as a result of mouth breathing? | □ | □ |
| Do you snore? | □ | □ |
| Do you find that it is harder to breathe through your nose when lying down? | □ | □ |
| Do you find it necessary to prop your head up on more than one pillow? | □ | □ |
| Do you use any of the following? | □ | □ |
| Nasal irrigations or sprays? | □ | □ |
| Vaporizer? | □ | □ |
| Humidifier? | □ | □ |
| Do you take over-the-counter nose sprays and decongestants? | □ | □ |
| If yes, please list them: | ||
| Do you wake up at night due to difficulty breathing through your nose? | □ | □ |
| Do your breathing problems limit your participation in activities such as running, sports, or other forms of exercise? | □ | □ |
| If yes, does this interfere with your daily function or job performance? | □ | □ |
| Have you seen a medical doctor for treatment of the breathing problem through your nose? | □ | □ |
| Doctor’s name_________________________________________ | ||
| Address_______________________________________________ | ||
| Treatment dates ________________________________________ | ||
| What treatment was advised?_____________________________ | ||
| _______________________________________________________ | ||
| Did you benefit from the treatment? | □ | □ |
Sinus Infections, Sinus and Migraine Headaches
Abnormal flow of air due to any anomaly in the turbinate or septal structures can result in mild, moderate, or severe headaches. Correction of these structural abnormalities frequently results in functional improvement and elimination of headaches. In this scenario, if the patients are also pleased with the aesthetic outcome, the surgery will be regarded as very successful. Conversely, a patient who experiences mild periodic sinus headaches may notice more frequent and more serious sinus headaches and infections if the existing abnormalities are not corrected during a reductive rhinoplasty. If the presence of any sinus infections and headaches is not recorded preoperatively, the patient may attribute these conditions to the rhinoplasty, not recalling that the headaches existed prior to surgery.
Over 60% of patients who have migraine headaches have a rhinogenic trigger site. Migraine headaches afflict approximately 12% of the population (18% of females). If the presence of this type of headache is uncovered and the condition is eliminated, it may provide an extremely successful aesthetic and functional outcome for the patient. Learning about the nature of the patient’s headaches, where they start from and how long they last, is very important. Rhinogenic migraine headaches usually start from an area behind the eyes, the patient often wakes up with a headache in the middle of the night or early morning, and the headaches are commonly triggered by changes in the atmospheric pressure. Frequently, the patient develops rhinorrhea at the time they are suffering from these headaches. Many such patients complain of chronic daily headaches that may not respond to triptans and are not responsive to injection of botulinum toxin A. Discovery of this constellation of symptoms will help to diagnose and effectively serve patients who are suffering from rhinogenic migraine headaches.
Observations of the Face
The Skin Quality
One should assess the entire face prior to focusing on the nose. Consequently, observation of the quality of the skin will be the first area of assessment. Patients who have either thick or thin skin present a challenge for the rhinoplasty surgeon. This should be noted and discussed with the patient. Patients with thick, oily skin often present difficulty in achieving proper definition. On the other hand, thin skin introduces difficulty in hiding minor imperfections, and the outline of grafts may also appear too harsh.
Assessment of Facial Structures Other Than the Nose
For a successful rhinoplasty outcome, there should be a perfect harmony between the nose and the surrounding structures. Therefore, the first step in achieving a proper congruity between the nose and the rest of the face is familiarity with the entire face. The analysis of the face should take place in an organized manner by dividing it into three segments – upper, mid, and lower zones – and reviewing each zone on front and profile views ( Figure 2.2 ). Initially, each zone is assessed separately. The degree of harmony between the three zones is then evaluated.
When assessing the front view of the forehead, one should observe the length and width of the forehead and the position and arch of the eyebrows. In the mid-face zone, one pays attention to the eyes first. Intercanthal and interpupillary distances are assessed first during mid-face analysis. The normal intercanthal distance is approximately 31–33 mm. As we will discuss in later chapters, this distance becomes crucial in managing the nasal bones, the dorsal projection, and the radix. In order to create a proper balance in the midface, there must be an optimal relationship between the malar and nasal bones. Therefore, flatter malar bones may benefit from augmentation in order to achieve the best harmony in the zone. Perinasal hypoplasia may require augmentation of the other structures surrounding the nose.
An over-projected caudal nose may result in a short and tense upper lip ( Figure 2.3 ). Reduction of the nose projection will reduce this tension and elongate the lip. In an ideal face, the length of the nose matches the distance from the stomion to below the chin. Therefore, having a normal lower face length is essential for restoration of facial harmony. Vertical alignment of the chin, lip and nose is examined carefully.
The profile view of the forehead and its projection plays a significant role in planning the rhinoplasty. In order to judge the depth of the radix, one has to first ascertain whether the glabellar projection is optimal. Frontal bossing or flatness of the glabella may be misleading when judging the radix depth.
The prominence of the malar bones can be better assessed on the profile view.
On this view, one also assesses the length of the upper lip and its proportion in relation to the rest of the face. The projection of the chin becomes important in judging the projection of the nose ( Figure 2.4 ). The nose and chin may have a paradoxical relationship whereby a patient may have an overprojected nose and at the same time an underprojected chin ( Figure 2.5 ). This nose will not look optimal without correction of the chin deficiency. The reverse could be true: the nose could be underprojected while the chin is overprojected. Here, one has to reduce the chin and augment the nose at the same time to achieve a better balance to the face. Of even greater importance is an overprojected nose and a prominent chin occurring simultaneously. In this case, reduction of one structure may exaggerate the other disharmony ( Figure 2.6 ). In such a case the correction of both abnormalities is imperative. Correction of coexisting orthognathic abnormalities will enormously enhance the overall rhinoplasty outcome.
