85 Rhinoplasty

85.1 Introduction

Rhinoplasty is defined as an operation to change the structure of the nose and is one of the more commonly performed facial plastic surgery procedures. The aim of the surgery is to improve the shape of the nose, the nasal airway or frequently both. A key concept in rhinoplasty surgery is that form and function are inter-related.

Surgery involving the external structure of the nose is generally referred to as a rhinoplasty, and surgery to the external structure and the nasal septum classified as a septorhinoplasty. In reality, almost all rhinoplasty procedures affect the septum to some degree and many surgeons refer to all these cases as a septorhinoplasty.

This chapter will focus on surgery to the external structure of the nose, where the aim is to improve the cosmetic appearance while maintaining the nasal airway.

85.2 Pre-Operative Management

85.2.1 Should the Patient Have a Rhinoplasty?

For the majority of patients, a rhinoplasty is a positive experience. However, this is not always the case, and a key decision is whether a surgery should be offered. Patients must have a realistic expectation about what can be achieved with surgery and be willing to accept the limitations of what is possible. In reality, a rhinoplasty can generally produce a good improvement, but certainly not perfection. To justify a rhinoplasty on cosmetic grounds, there must be a noticeable abnormality which can be improved with surgery, and where the benefits outweigh the risks.

A significant minority of patients should not be offered a rhinoplasty, and it is only possible to reach a correct decision by taking sufficient time to discuss surgery. For this reason, most surgeons will see patients on two occasions.

It is mandatory to take clinical photographs prior to a rhinoplasty. It is particularly helpful to review the images with the patient to ensure that both surgeon and patient have a clear understanding of what is intended, and indeed possible.

85.3 Body Dysmorphic Disorder

On occasion, patients exhibit excessive, disproportionate anxiety about the appearance of their nose. This is a recognised psychological disorder known as body dysmorphic disorder. These patients often describe minor abnormalities in dramatic terms, and their concerns have a very negative impact on their quality of life. Although they are often desperate to undergo surgery, this is almost invariably counter-productive and leads to more unhappiness. Referral to a clinical psychologist or psychiatrist with an interest in this field is the way forward, although in reality many of these patients reject this option and continue to seek surgery.

85.4 Clinical Examination

Clinical examination initially involves inspection of the external shape of the nose. Palpation is helpful to assess deviation, cartilaginous and bony prominences and support of the nasal skeleton. The patient’s skin type is particularly important in rhinoplasty, because thin skin tends to show irregularities, and thicker skin reduces the definition and contouring that can be achieved.

Anterior rhinoscopy is performed to examine the nasal septum and turbinates. The dynamic function of the nose should be examined, particularly any collapse of the nasal valves on quiet inspiration. Examination of the nasal cavity and post-nasal space with an endoscope is recommended, and is essential if the patient has airway obstruction or other rhinological symptoms.

85.5 Aesthetic Assessment

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