Identify the patient’s interest in surgery (function, appearance, or both?)

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  Difficulty with breathing or history of snoring

  
  
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  Specific concerns with appearance of nose

Prior history of allergic disorders: Asthma, hay fevers, sinusitis, and vasomotoric rhinitis. Inferior turbinate hypertrophy with secondary nasal obstruction is typically found in patient with long-standing history of allergic rhinitis.

Prior nasal surgeries or trauma

Social history: Smoking, alcohol consumption, and illicit drug use, especially cocaine

Medications: Anticoagulation, nonsteroidal anti-inflammatory drugs (NSAIDs), or fish oil may increase risk of bleeding and postoperative ecchymosis

Skin quality: Identify Fitzpatrick skin type (Table 22.1) and skin thickness

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  Thin skin will show underlying framework better than thick

Appearance of the nose

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  Assess overall shape and symmetry of dorsum and tip

  
  
  
  
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    Deviation, dorsal hump, and contour irregularities

  
  
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  Bony vault: Width, symmetry, and length of nasal bones

  
  
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  Mid-vault: Width, possible collapse, inverted-V deformity, and hump

  
  
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  Dorsal aesthetic lines: Straightness, symmetry, and well or ill defined

  
  
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  Tip assessment: Evaluate bulbosity, tip-defining points, and size and shape

  
  
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  Nostrils: Evidence of notching or retraction and alar base width

Facial angles

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  Nasolabial angle: 90 to 100 degrees in women, 90 degrees in men

  
  
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  Nasofrontal angle: 115 to 130 degrees

Nasal function

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  Cottle maneuver to assess internal nasal valve competence

  
  
  
  
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    Compress opposite nostril and pull cheek laterally to open nostril

    
    
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    Test is positive if breathing improves as finger pulls cheek laterally

    
    
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    Indicates benefit for spreader grafting on affected side

  
  
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  Breathe Right® strip test: Similar to Cottle maneuver in testing

  
  
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  Nasal septum: Midline, C- or S-shaped deviation

  
  
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  Inferior turbinates: Consider reduction/outfracture if enlarged/protuberant

Surrounding facial assessment

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  Hypoplastic/retruded chin: May affect overall balance of face; can consider concurrent genioplasty

  
  
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  Upper lip: Long or short, dynamic depressor septi muscles, upper lip crease