Rhinoplasty occupies a central and privileged position in contemporary facial plastic surgery. Alongside the desire for physical self-improvement, the demand for rhinoplasty in particular has grown over the past few decades to such an extent that it may now be considered the most important facial plastic operation. However, concomitant with its development and expansion, rhinoplasty has also faced major hurdles. The public is now better informed about the possible risks and pitfalls of surgery, and armed with information from the Internet, they are ready to challenge the rhinoplasty surgeon at every step with incremental levels of expectation. Rhinoplasty has now become a minefield for the novice surgeon due to increasing malpractice premiums and risks of legal action against the surgeon. This makes it absolutely critical for surgeons to be sufficiently trained in rhinoplasty before embarking on a career marked by frequent technical limitations and negative encounters with patients.

This chapter aims to lay the foundation for surgeons who seek to master the endonasal approach for dealing with both “standard” and challenging rhinoplasty patients. As the older and more rigid classification of rhinoplasty into external and endonasal has lost its luster, the reader is encouraged to think of rhinoplasty in terms of endonasal hybrid rhinoplasty, where the term “hybrid” implies the incorporation of anatomical concepts and sophisticated suturing-grafting techniques developed by “openers” into the theoretical and technical corpus of endonasal rhinoplasty. The end-result is a higher technical flexibility allowing a tailor-made procedure for each patient, while minimizing tissue trauma, unnecessary scarring, and tissue plane distortion. Technical evolution has made endonasal hybrid rhinoplasty a technical option even for the most challenging patients in both the primary and revision surgery.

The first encounter with the patient is the most important step in a journey that may take several months or years to reach its conclusion. The astute surgeon will have read the letter of referral and familiarized him- or herself with the important features before the patient enters the examination room. Always allow patients adequate time to express their concerns and ultimate goals. A full rhinologic history, including airflow, rhinorrhea, postnasal drip, sense of smell, facial pain, previous trauma or nasal surgery, allergy, asthma, and other allergies should be sought. The patient’s past medical history may reveal significant factors such as past experiences with aesthetic surgery, an active or previous psychiatric limitation, and the use of anticoagulants, nonsteroidal antiinflammatory agents, or herbal products. Patients may have a combination of aesthetic and functional problems, so the surgeon must make provision for medical therapy of nasal symptoms and be prepared for a combination of hybrid rhinoplasty and endoscopic sinus surgery. Additionally, with this in mind, a complete medical and surgical history are required for surgical clearance with considerations for anesthesia, such as cardiopulmonary clearance, as well as standard laboratory, pregnancy, and coagulation testing.

While photography marks the end of the first consultation, both the surgeon and the patient make constructive use of their time before their next obligatory meeting. The patients are encouraged to read the literature supplied to them and to ponder the impact of surgery on their personal and working life, the possible risks of surgery, and a potential for future revision. The surgeon uses the time between the two meetings for the most important step in rhinoplasty: facial and nasal analysis. The results of facial/nasal analysis based on the clinical photographs provide a list of aesthetic defects of the face in general, and of the nose in particular. Then, a strategy is tailor-made for that particular patient based on their specific anatomical and pathologic findings and desires for change. This unique plan is meticulously drafted, such that every step of the future surgical operation has already been thoroughly analyzed. The surgeon then produces computer simulations of proposed changes. Patients are told that these simulations are by no means a guarantee of the end result, but provide the patient and the surgeon points of discussion during their second meeting.

As both the patient and the surgeon have had time to think about the patient’s particular expectation in the intervening period, the second consultation is aimed at conveying the findings of the facial analysis, discussing the various options that may be possible based on the computer simulations, and allaying the patient’s fears and concerns about surgery. Practical advice regarding the do’s and don’ts of the postoperative period are of great importance to the patient as they often entail limitations in work and social engagement for a limited period of time. It is of utmost importance that the patient realizes that not every desire for change can be achieved, and that the possibility of revision surgery of about 10% is a real one even in the best of hands.