Gunter and Gorney ³^–⁵ have both commented on ‘danger signs’ that may be exhibited (Box 11.1). Individuals who meet these criteria should be approached with caution because surgical intervention may not be in the best interests of either the patient or the surgeon.

• the first uses the acronym SIMON (single immature males overly expectant, narcissistic) to describe certain worrisome traits;

• the second plots the patient’s concern on one axis and the degree of deformity on the other (Fig. 11.1) – patients who have an appropriate level of concern relative to their degree of deformity are excellent candidates for treatment, but those who have minimal deformity and a disproportionate level of concern should be avoided because their expectations may exceed the amount of aesthetic improvement possible.

Fig. 11.1 Graphic relationship between perceived and actual deformity. This indicates that a disproportionate amount of concern should yield caution (red zone) for the surgeon.

If the level of skill and expertise required to perform the rhinoplasty exceeds the surgeon’s ability, the patient should be referred to another more proficient surgeon.

The surgeon must rely on both subjective and objective findings when considering the relative indications and contraindications for performing a rhinoplasty; the skills required to accomplish this develop with time and experience.

Preoperative History and Considerations

Patient Factors

When initially assessing a patient for potential rhinoplasty, the surgeon should concentrate on evaluating the patient’s desires and expectations prior to performing the comprehensive facial analysis. Although there are different methods for integrating the patient into the surgical process, we find that computer imaging provides an excellent way for patients to gain a realistic understanding of the anticipated outcome. Although the images are not a guarantee of surgical results, they do provide a visual representation and a means for patient education. These images, combined with standardized anterior, lateral, oblique, and basal photographs, provide the basis for the preoperative surgical plan.

To identify potential ‘problem patients’ preoperatively, we ask the patient to first describe what issues they have. We encourage them to be as specific as possible, listing their concerns in order of importance in their own words. A handheld mirror is useful in this situation. The patient’s desires are then documented in the chart verbatim. Frequently, the patient will state in general terms, ‘I just want a better nose. What would you do?’ This has been a red flag in our practice because it is usually a reflection of general dissatisfaction, poorly thought-out desires, or a poor self-image. We politely redirect these patients in an attempt to ascertain their specific concerns about their nose. Again, a disproportionate amount of concern in the presence of a minimal deformity is a cause for concern.

Other red flags in rhinoplasty include:

• those patients who desire a result that cannot be predictably or reliably delivered or that is outside the realm of the ‘aesthetic norm’;

• individuals who seem litigious as a result of a previous rhinoplasty, or who harbor hostility toward previous healthcare providers.

This second criterion is vague, but we place tremendous importance on the development of our interpersonal relationship with our patients, and if this cannot be forged, for whatever reason, we decline to perform the operation. In other words, ‘do not operate on a patient you don’t like’.

It should be noted that men tend to have a poorer understanding of their deformity than women and have a more difficult time elucidating the changes they want.⁶^–⁸

A second follow-up consultation is recommended to reiterate the patient’s desires, develop a realistic operative plan, and reaffirm the patient’s understanding of the anticipated procedure.

Anatomic Features

Having determined that the patient is an appropriate candidate for surgery, the next element to proper preoperative surgical planning is critical facial analysis.^9,¹⁰

Each individual nose has different proportions, morphology, and relative relationships with the surrounding face. To preserve nasofacial harmony, it is crucial to perform a systematic and meticulous analysis of the nose and face. The evaluation is performed in a systematic manner cultivated by the surgeon to assure consistency.¹¹^–¹³

Accurate diagnosis of the deformity(s) determines the optimal surgical plan for correction. The surgeon should point out natural facial asymmetries preoperatively so that the patient gains a better understanding of what is present before any operative intervention.

Skin type

The native skin quality influences the operative plan and subsequent techniques performed.

First, skin type, thickness, and texture are assessed.

Thicker skin will tend to camouflage changes to the underlying osseocartilaginous framework, and may therefore allow a more ‘aggressive’ surgery to demonstrate an appreciable change. Patients who have thicker skin that has a more sebaceous character tend to have more postoperative edema, especially in the tip or lobule area.

Thinner skin tends to reveal even minor changes to the underlying framework. Therefore patients who have thinner skin can be more challenging because there is less margin for error.

Systematic analysis of the nose and face

Next, a systematic analysis of the nose and face is undertaken.

Look for potential anomalies of the underlying facial skeleton

Initially we evaluate potential anomalies of the underlying facial skeleton, including the maxillomandibular relationship.

We divide the face into thirds using horizontal lines adjacent to the:

• hairline;

• brow (at the level of the supraorbital notch);

• nasal base;

• menton.

The upper one-third is the least important because it is the most variable.

The lower one-third of the face is then subdivided into thirds by visualizing a horizontal line between the oral commissures (stomion):

• the upper third of this subdivision lies between the nasal base and the oral commissures;

• the lower two-thirds lies between the commissures (stomion) and the menton.

If there are disproportions, the patient may have underlying craniofacial anomalies (e.g. vertical maxillary excess) that necessitate correction.

The nasal length (radix to tip [RT]) should be equivalent to the stomion-to-menton distance (SM), as described by Byrd and Hobar.

A natural horizontal facial plane is determined by drawing a line perpendicular to a plumb line superimposed over the head in repose and the eyes in straightforward gaze. This will serve as a future point of reference (Fig. 11.2).

Fig. 11.2 A natural horizontal facial plane. This is determined by drawing a line perpendicular to a plumb line superimposed over the head in repose and the eyes in straightforward gaze.

The lip-chin relationship is assessed by dropping a vertical line from a point one-half the ideal nasal length tangential to the vermillion of the upper lip. The lower lip should lie no more than 2 mm behind this line (Fig. 11.3). The ideal chin position is gender dependent. The female chin should be slightly posterior to the lower lip, but equal to the lower lip in men. Discrepancies in these relationships may warrant orthodontics, orthognathic surgery, or a chin implant.

Fig. 11.3 The lip-chin relationship. This is assessed by dropping a vertical line from a point one-half the ideal nasal length tangential to the vermillion of the upper lip. The lower lip should lie no more than 2 mm behind this line.

Nasal features

Frontal view

Nasal deviation is evaluated by drawing a line from the mid-glabellar area to the menton, bisecting the nasal ridge, upper lip, and Cupid’s bow. This line will also pass between the central incisors when occlusion is normal. Any deviation of the nose from this line will likely require septal surgery.

The nasal dorsum is then assessed. The curvilinear dorsal aesthetic lines are traced from the origin at the supraorbital ridges to the tipdefining points, slightly diverging from each other along the dorsum during their course. Ideally, the width of the dorsal aesthetic lines should match the width of either the tip defining points or the interphiltral distance.

A relationship between the bony base width and the alar base is then assessed. The bony base width should be 80% of the normal alar base width, and a normal alar base width 2 mm wider than the inter-canthal distance, or the width of one eye (Fig. 11.4A&B). If the bony base is greater than 80% of the alar base width (assuming the alar base width is normal), osteotomies will be required to narrow the dorsum. Males tend to have a wider bony base than females and it is important not to over-narrow the male dorsum creating a feminized result.

Fig. 11.4 The width of the bony base relative to the alar base is then assessed.

A, The bony base width should be 80% of the normal alar base width. B, A normal alar base width is equal to the intercanthal distance or the width of one eye.

Next the alar base and alar rim are analyzed. If the alar base width is over 2 mm and greater than the intercanthal distance, it must be determined whether the cause is a narrow intercanthal distance, a true increased interalar width, or alar flaring:

• if the intercanthal distance is smaller than one eye width, it is better to maintain a slightly wider alar base;

• if there is true increased interalar width, a nostril sill resection may be indicated;

• if the increase in width is secondary to alar flaring (>2–3 mm outside the alar base), an alar base resection should be considered.

The alar rims should also be assessed for symmetry, and should flare slightly outward in the inferolateral direction.

The tip is assessed to determine:

• the supratip break;

• the tip-defining points;

• the columellar-lobular angle (Fig. 11.5).

Fig. 11.5 Frontal view of the nose. The tip is assessed to determine the supratip break, the tip-defining points, and the columellar-lobular angle. These points serve as landmarks to draw two equilateral triangles with their bases opposed.

These points serve as landmarks to draw two equilateral triangles with their bases opposed. If these triangles are asymmetric, the underlying reason should be investigated, and the patient will likely require tip modification.

The final assessment on frontal view is of the outline of the alar rims and the columella, which should resemble a seagull in gentle flight, with the columella lying just inferior to the alar rims. If the curve is too steep, the patient likely has an increased infratip lobular height, which will need correction. If, on the other hand, the curve is flattened, it is likely the patient has decreased columellar show which may require columellar augmentation or alar rim modification.

Patient Counseling

After the initial history and physical examination, the procedure is fully discussed with the patient. The risks and benefits of the procedure are detailed, and all questions answered. The patient is provided with a written, detailed estimate of surgical charges with complete explanations. It is recommended that patients sign a form accepting financial responsibility. A second clinic visit is encouraged to review the previous discussions. The deformities are reiterated, questions answered, and the consent reviewed and signed. A preoperative instruction sheet and a list of medications to be avoided are also provided (Box 11.3).

Box 11.3 Preoperative instruction sheet

Prior to surgery we convert our operative plan into a graphic re presentation (using Gunter Graphics ⁵) to assist us in the operating room. Modifications to the plan are documented intraoperatively, transposed to the graphic depictions postoperatively, and placed in the patient’s chart for future reference.

Operative Approach

Relevant Anatomy

A complete knowledge of anatomy is paramount to obtaining the superior result. The nose is divided into:

• external skin and soft tissue;

• underlying framework (bony and cartilaginous);

• ligamentous support.

The rhinoplasty surgeon must be familiar with each structure’s native morphology and its variants and have an appreciation for the dynamic interplay between these components.

Skin

The thickness, mobility, and sebaceous character of the nasal skin vary along its length, with the upper two-thirds being thinner, more mobile, and less sebaceous than the inferior one-third.¹⁸

The nasal dorsum thickness averages approximately 1300 μm, whereas the lobule skin thickness averages 2400 μm. A straight dorsum actually has a slight underlying convexity of its osteocartilaginous framework in the cephalic area; therefore a straight dorsal profile is actually produced by the combination of this convexity in the osteocartilaginous framework with the variation in dorsal skin thickness.

Some ethnic subgroups, such as Africans, Hispanics, and those of Mediterranean descent, can have thicker, more sebaceous skin. These differences are important because the skin over the underlying nasal framework can either reveal or mask changes depending on its characteristics. For instance, it is advisable to err on the conservative side when operating on a Caucasian woman with thin skin compared with a man of African descent who has thick, sebaceous skin. More dramatic changes to the underlying framework are tolerated in the patient who has thick skin to obtain an appreciable change in the external appearance.

Muscles

Two muscles, in particular, are important in rhinoplasty:

• the levator labii alaeque nasi, which assists in maintaining the patency of the external nasal valve;

• the depressor septi nasi, which can alter the upper lip length and tip projection (Fig. 11.15).^19,²⁰

Fig. 11.15 Levator labii alaeque nasi and the depressor septi nasi. These two muscles are important in rhinoplasty.

Evaluation of the depressor septi nasi is routine in our preoperative assessment. Its effect on depressing the nasal tip and shortening the upper lip can be appreciated in some patients on animation (especially when smiling). In the subgroup of patients in whom this muscle significantly alters the nasal appearance, we dissect and transpose the muscle. By doing so, several goals are achieved:

• enhancement of the tip-lip relationship;

• relative upper lip lengthening;

• relative fullness to the upper lip;

• maintenance of tip rotation/projection on animation.

Blood supply

The vascular supply to the nose is derived from branches of the ophthalmic and facial arteries (Fig. 11.16).

Fig. 11.16 Vascular supply to the nose. This is derived from branches of the ophthalmic and facial arteries.

It is important to note the vascularity to the nasal tip because an open rhinoplasty approach using a transcolumellar incision will transect the columellar vessels (when present), leaving the lateral nasal and dorsal nasal arteries as the remaining blood supply.

In our 1995 study,²¹ we found the lateral nasal arteries to be present (either singularly or bilaterally) in 100% of cases, with the columellar branches present 68.2% of the time.

The lateral nasal vessels are found approximately 2–3 mm above the alar groove, so extended alar resections to this level are prohibited because injury to these vessels after the transcolumellar approach would severely compromise blood flow to the nasal tip. Furthermore, be cautious when debulking the nasal tip after an open approach because the subdermal vascular plexus connecting the dorsal nasal and lateral nasal blood supplies may be damaged, leading to a similarly disastrous result.

Extended alar resections to the level of the alar groove are discouraged with the transcolumellar approach because injury to the lateral nasal vessels, which are approximately 2–3 mm above the alar groove, may severely compromise blood flow to the nasal tip.

Toriumi et al.²² studied the vascular and lymphatic anatomy of the nose and determined that the transcolumellar incision itself did not compromise major venous or lymphatic outflow. Furthermore, they recommend dissection just above the perichondrium in the deep areolar plane, leaving the musculoaponeurotic layer intact, which preserves the major arterial vascular supply and avoids damage to the venous and lymphatic vasculature that lies in a more superficial (subcutaneous) plane. In this way, bleeding and postoperative edema are minimized.

Nasal vaults

The osteocartilaginous nasal framework can be subdivided into three separate vaults: bony, upper cartilaginous and lower cartilaginous.

Bony vault

The bony vault (Fig. 11.17) constitutes the upper one-third to one-half of the nose and is made up of the paired nasal bones and the ascending frontal process of the maxilla. It is important to note that the nasal bones are narrowest and thickest above the canthal level. As a result, osteotomies are rarely indicated above this level.