Profile management in the tension nose encompasses almost all aspects of rhinoplasty. There is considerable work required within the bony and cartilaginous dorsum, nasal tip, caudal septum and dorsal septum, and frequently the anterior maxillary spine (Fig. 16.1). Thin skin covering the underlying skeletal abnormalities makes the care of these patients even more complex.

Reduction rhinoplasty will be necessary to correct the tension nose. This can be a disruptive procedure with interruption in the confluence of the cartilaginous dorsum (keystone), separation of the support mechanisms, and continuity of the lower lateral cartilage with division of the dome, as well as the possible resection of the anterior maxillary spine and caudal septum. All of these maneuvers create an unstable support system that must be recreated, reinforced, and redefined to achieve an ideal result.

Patients presenting with a high nose dorsum and tension nasal deformity must be able to identify and articulate their concerns and dislikes regarding their nose. If the patient cannot reasonably provide the surgeon with insight regarding what they perceive as unattractive, then it is unlikely that the surgeon will be able to correct their concerns. These concerns need not be expressed in an anatomically accurate description, but they do need to be able to describe their problems in layman’s terms, even if vague. If they are unable to identify what makes their nose unattractive, then they will not be able to appreciate the results of a surgical intervention.

It is important to obtain an accurate head and neck history as well as general medical history. Nasal symptoms including obstruction, epistaxis, and rhinorrhea should be solicited as they may indicate an underlying pathology such as a deviation of the nasal septum, allergic rhinitis, nasal polyps, turbinate hypertrophy, or major extensive underlying pathology. A history of nasal trauma and previous nasal surgery could alter the course of surgical management and possibly require autologous grafting for structural support and reinforcement. General medical considerations such as hypertension, diabetes, bleeding disorders, or previous difficulty with anesthesia should be solicited. In the patient who has never undergone an anesthetic, a thorough family history regarding anesthesia complications is important.

Beyond the general medical history, it is imperative to assess three specific areas of the candidate for rhinoplasty: motivation, expectations, and psychological background. The patient should be self motivated and not seeking a rhinoplasty to please another individual. Expectations can be elicited by asking the patient to identify the unattractive portion of their nose and describe how they feel that it should be changed. Keeping the expectations realistic preoperatively will avoid hours of postoperative discussion. Communication throughout the entire course of patient care is important to ensure realistic expectations. The characteristics of the skin and the presence of preexisting facial asymmetries can frequently be overlooked in the preoperative discussion. If there are hints of psychological disorders, they should be pursued,
not avoided. When the impression exists that a patient needs a more thorough psychological evaluation I make every effort to dissuade the patient from undergoing surgery because it becomes nearly impossible to discharge these patients from your practice postoperatively. Although rhinoplasty may help self-esteem, it will not correct true psychological disorders.

Preoperative planning is nothing if not repetitive. This repetition occurs in private, during review of the history and physical examination as well as with the photographs. During the consultation, a plan is developed that explains the overall need to reduce the nasal dorsum and release tension on the nasal tip. The fundamental surgical principles are discussed in an effort to educate the patient regarding the seriousness and complexity of undertaking a rhinoplasty. Their photographs are reviewed with the patient in order to demonstrate the changes that will occur and the possible need for other more subtle changes to the nose that will contribute to the overall result. This is also an opportunity to point out associated facial abnormalities such microgenia, malar hypoplasia, and facial asymmetries that may or may not have been previously perceived by the patient. Digital imaging is almost always performed as part of my surgical planning exercise with the rhinoplasty patient. When altering

the image with the computer, some subtleties of the existing deformity may become more evident such as alar retraction, a subtly deep radix that is camouflaged by a hump, an open nasolabial angle, broad alar base, and the more commonly observed broad bony pyramid and the nasal facial junction. The entire process of assessment and planning is repeated during the preoperative visit, in the holding area prior to surgery, and in the operating room prior to infiltration of local anesthesia.

From a more holistic standpoint, preoperative planning includes the elimination of nonsteroidal antiinflammatory agents, nutritional supplements that may alter the coagulation pathway such as vitamin E, St. John’s wort, ginger, ginkgo biloba, fish oil, and any other nonprescription medication at least 2 weeks (preferably 4 weeks) prior to surgery. Appetite suppressants, metabolic stimulants, and nasal decongestants should also be discontinued. The consumption of alcohol and the use of tobacco products must also be stopped. Excessive sun exposure is to be avoided.

Patients are counseled to arrange for postoperative care, around the clock, for 24 hours and to have someone available to assist them for 72 hours postoperatively. They are advised regarding postoperative diet, activities, and wound care and are encouraged to purchase the appropriate over-the-counter medications and supplies including food and beverages. All acute postoperative follow-up visits are scheduled at the time of scheduling the surgery.