Rhinoplasty remains one of the most challenging aesthetic procedures to master. Astute surgeons must consider a continually evolving societal perception of beauty with their own sense of aesthetic proportion when planning surgical intervention. Optimal results are achieved when the outcome is anticipated and satisfying to patient and surgeon. This requires a careful, thoughtful, systematic approach to preoperative analysis. Patients should leave with a clear understanding of the surgeon’s perspective of their nose, aesthetically and anatomically. Understanding the interplay of surface deformities and their underlying anatomic counterpart is critical, involving a systematic analysis to create a surgical plan that avoids landmines leading to a suboptimal result.
Rhinoplasty remains one of the most challenging aesthetic procedures to master. Astute surgeons must consider a continually evolving societal perception of beauty with their own sense of aesthetic proportion when planning surgical intervention. An optimal result is achieved when the outcome is anticipated and satisfying to the patient and surgeon. This requires a careful, thoughtful, systematic approach to preoperative analysis.
History
A focused history and physical examination is required to design a mutually agreeable operative plan. Information regarding past medical history, past surgical history (especially previous nasal surgery), medications (including herbals), allergies, social habits, and a personal or family history of coagulopathy is important. During the preoperative rhinoplasty history, it is essential to determine the patient’s motivation for surgery, expectations, and psychosocial stability.
Patients seeking rhinoplasty are motivated by several different factors. It is the surgeon’s responsibility to decide whether or not the factors have a positive or negative impact on a patient’s decision-making process. Those who desire surgery secondary to external pressures (ie, want to please others, are in a time of crisis, to salvage a relationship) are poor operative candidates. Patients who are self-motivated to change a nasal deformity are more likely to have a satisfactory outcome.
Expectations must be realistic. This involves clear communication between surgeon and patient, often in front of a mirror. Goals between surgeon and patient must be congruent.
Establishing a patient’s baseline psychological status may uncover red flags in surgical intervention. Personality disorders affect up to 10% to 15% of the United States adult population. Knowledge of these disorders assists with the psychological work-up ( Table 1 ). Obvious psychopathology necessitates a psychiatric evaluation.
| Disorder | Description |
|---|---|
| Dependent personality | Overly compliant, physician seen as a parental figure |
| Passive-aggressive | Willful incompetence, seeks to prove the physician wrong |
| Obsessive-compulsive | Rigid and precise, excessive attention to details |
| Histrionic | Seductive and narcissistic, overreaction to disappointment |
| Paranoid | Distrustful, expectation of disappointment |
| Schizoid | Distant and aloof, actions are socially inappropriate |
| Cyclothymic | Mood swings between mania and depression |
Special consideration is given to the pediatric and elderly population. In general, rhinoplasty is delayed until after pubertal growth, age 15 in girls and age 17 in boys. This is not a steadfast rule and many exceptions exist, particularly when the nose is clearly the adult size. Most warnings against early intervention are anecdotal. Minor functional changes may be appropriate at a younger age on a case-by-case basis. Teenagers are particularly susceptible to external pressures. Therefore, an in-depth discussion of their motivation is essential. Interviewing a patient without parental presence may be necessary to gather this information. Older patients, alternatively, have lived with a nasal deformity for a longer period of time, and it has become ingrained as part of their identity. Dramatic changes to their nose may have an untoward psychological impact. From an anatomic standpoint, their skin is thinner, nasal bones are fragile, and tip-supporting mechanisms are weaker. Conservative surgery is a rule for middle-aged patients.
Preoperative photoimaging assists with an accurate facial analysis. Pictures taken in the frontal, right and left lateral, right and left oblique, and basal views are useful in surgical planning. Standardizing these views allows for accurate comparison of the preoperative deformity and postoperative correction. They are another means of effective communication and preoperative counseling. The advent of computerized imaging has added yet another tool to the armamentarium of the rhinoplasty surgeon. The specifics of photographic and computerized imaging are discussed elsewhere.
Once an adequate history is obtained, an analysis is performed for the purpose of identifying the underlying anatomic abnormalities that result in the observed cutaneous deformities. Function must be considered when determining the desired aesthetic outcome.
Anatomy
The quality of the skin-soft tissue envelope varies among individuals and within the same individual. Thin skin leaves little room for error as even the most minor irregularities become visible. Conversely, very thick skin can hinder all attempts to refine the nasal tip and make a narrow and elegant contour nearly impossible. Skin is thinnest over the rhinion and thick over the lower third and nasion where a variable amount of fibroadipose tissue is found.
The underlying superficial musculoaponeurotic system is continuous with the mimetic nasal muscles and a critical surgical landmark. The avascular plane deep to this layer is the correct plane for dissection during any degloving of the nose.
The upper third of the nose consists of paired nasal bones that attach laterally to the ascending process of the maxilla, superiorly to the frontal bone, and posteriorly to the perpendicular plate of the ethmoid bone. They are thinnest along their caudal aspect, at the junction with the upper lateral cartilages (ULC). The periosteum insinuates into the internasal suture line, requiring sharp dissection to tease the tissue out during elevation.
The lower two-thirds of the nose are comprised of cartilaginous structures that include the ULC, lower lateral cartilages (LLC), sesamoid cartilage, and quadrilateral septal cartilage. Cephalically, the paired ULCs attach to the caudal aspect of the nasal bones. Medially, they attach to the septum and are free floating laterally. The paired LLCs may be divided into the medial, intermediate, and lateral crura. Medial crura form the pods, contributing anteriorly to the shape of the infratip lobule. Intermediate crura form the dome, within which are the tip-defining points. Lateral crura are responsible for the overall width of the tip and help form the supra-alar creases. The paired sesamoid cartilages are lateral to the ULCs, providing support to the fibromuscular tissue between the ULCs and pyriform aperture. The quadrilateral septal cartilage attaches to the vomer posteriorly and nasal spine inferiorly. An important landmark is the anterior septal angle, identified in the supratip as the edge of the dorsal septal cartilage. The posterior septal angle is located at the attachment of the septum to the nasal spine. The internal nasal valve represents the space between the caudal end of the ULC and the dorsal septum. The external nasal valve is defined as the area within the nasal vestibule, under the alar lobule. It is lined with vibrissae and is bordered by the alar lobule, anterior nasal spine, membranous septum, and caudal septum. The intervalve area is under the nasal sidewall corresponding to the lateral aspect of the lateral crus and the lateral fibroareolar tissue extending to the bony pyriform aperture. It is here that a majority of functional problems arise.
The skin and soft tissue of the nose are supplied by the dorsal nasal, lateral nasal, angular, and columellar arteries. The septum and nasal mucosa are supplied by branches of the external (sphenopalatine, greater palatine, and superior labial) and internal (anterior and posterior ethmoidal) carotid arteries.
Tip support mechanisms delineate important anatomic relationships that provide structure to the tip. They are divided into major and minor mechanisms.
Anatomy
The quality of the skin-soft tissue envelope varies among individuals and within the same individual. Thin skin leaves little room for error as even the most minor irregularities become visible. Conversely, very thick skin can hinder all attempts to refine the nasal tip and make a narrow and elegant contour nearly impossible. Skin is thinnest over the rhinion and thick over the lower third and nasion where a variable amount of fibroadipose tissue is found.
The underlying superficial musculoaponeurotic system is continuous with the mimetic nasal muscles and a critical surgical landmark. The avascular plane deep to this layer is the correct plane for dissection during any degloving of the nose.
The upper third of the nose consists of paired nasal bones that attach laterally to the ascending process of the maxilla, superiorly to the frontal bone, and posteriorly to the perpendicular plate of the ethmoid bone. They are thinnest along their caudal aspect, at the junction with the upper lateral cartilages (ULC). The periosteum insinuates into the internasal suture line, requiring sharp dissection to tease the tissue out during elevation.
The lower two-thirds of the nose are comprised of cartilaginous structures that include the ULC, lower lateral cartilages (LLC), sesamoid cartilage, and quadrilateral septal cartilage. Cephalically, the paired ULCs attach to the caudal aspect of the nasal bones. Medially, they attach to the septum and are free floating laterally. The paired LLCs may be divided into the medial, intermediate, and lateral crura. Medial crura form the pods, contributing anteriorly to the shape of the infratip lobule. Intermediate crura form the dome, within which are the tip-defining points. Lateral crura are responsible for the overall width of the tip and help form the supra-alar creases. The paired sesamoid cartilages are lateral to the ULCs, providing support to the fibromuscular tissue between the ULCs and pyriform aperture. The quadrilateral septal cartilage attaches to the vomer posteriorly and nasal spine inferiorly. An important landmark is the anterior septal angle, identified in the supratip as the edge of the dorsal septal cartilage. The posterior septal angle is located at the attachment of the septum to the nasal spine. The internal nasal valve represents the space between the caudal end of the ULC and the dorsal septum. The external nasal valve is defined as the area within the nasal vestibule, under the alar lobule. It is lined with vibrissae and is bordered by the alar lobule, anterior nasal spine, membranous septum, and caudal septum. The intervalve area is under the nasal sidewall corresponding to the lateral aspect of the lateral crus and the lateral fibroareolar tissue extending to the bony pyriform aperture. It is here that a majority of functional problems arise.
The skin and soft tissue of the nose are supplied by the dorsal nasal, lateral nasal, angular, and columellar arteries. The septum and nasal mucosa are supplied by branches of the external (sphenopalatine, greater palatine, and superior labial) and internal (anterior and posterior ethmoidal) carotid arteries.
Tip support mechanisms delineate important anatomic relationships that provide structure to the tip. They are divided into major and minor mechanisms.
Analysis
Although this issue of Clinics in Plastic Surgery is dedicated to rhinoplasty, it is essential that surgeons analyze the entire face. Analysis should be based on accepted cultural standards; different aesthetic facial proportions exist in patients of different ethnic descent. The goals of analysis, alternatively, remain the same: define external deformities, predict the underlying anatomic variations, and determine the appropriate surgical intervention. Preoperative evaluation includes observation, inspection, and certainly palpation, in a systematic fashion. Completing this comprehensive assessment prior to surgical planning helps avoid pitfalls and assists in identifying common nasal deformities that require surgical intervention ( Table 2 ).
| View | Deformity |
|---|---|
| Frontal | Inverted V Twisted dorsum Bifid tip Pinched tip Parenthetic tip |
| Lateral | Low or high radix Inadequately positioned nasion Dorsal hump Saddle nose Pollybeak Under- or overprojection Alar notching Ptotic tip Tension nose |
| Base | Boxy tip Bulbous tip Bifid tip Amorphous tip Caudal septal deviation |
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