An outstanding corrective surgical plan needs to be based on thorough clinical assessment, clear doctor patient communication and frank discussion of the pros and cons of surgery. In addition, a well informed consent, smooth in-patient care and close follow-up are mandatory in order to lessen the patients fear and anxiety, limit complications and cut down the medicolegal cases.
Practical guidelines are presented as follows:
- Clinical examination
- Computer imaging
- Informed consent
- Preoperative investigation
- In-patient management
- Hospital admission
- Immediate postoperative care
- Instructions and follow-up
Ask the patient about:
- The main complaint: shape and or function.
- What he/she dislikes about his/her nose.
- What he/she likes about his/her nose.
- Any airways obstruction.
- Any previous nasal surgery.
- Any medication for nasal obstruction or allergies.
- Any other illnesses (diabetes, asthma, heart, hypertension, etc.) and other medications or previous surgeries.
Fig. 2 – 1. The rule of fifths. The width of the base of the nose is approximately equal to the distance between the eyes. This is used as a guide in alar wedge resection
B. Clinical examination
- Skin type
Skin type is evaluated by inspection and palpation. The physician should roll the skin over the bony dorsum and gently pinch the skin between the fingers. The quality of skin is an essential indicator of the surgical outcome and plays a significant role in preoperative planning. Extremely thick skin is the least likely to achieve the desirable refinement and definition. The thick skin may fail to contract favourably on the newly reshaped cartilages and lead to excessive soft tissue scar. Also, very thin skin provides almost no cushion to mask even the minute skeletal irregularities or contour imperfections. The ideal skin type falls somewhere in between these two types. There needs to be enough subcutaneous skin to provide adequate cushioning over the nasal skeleton, but still allow critical definition to the nasal tip.
Straight _ deviated _ twisted _ depressed _ saddling _ bony collapse _ supratip collapse.
True or false
Cartilagenous, bony or both
Bony, cartilagenous or both.
Long or short.
Any grafts or implants.
Wide, bulbous, trapezoid, asymmetry, bifid, drooped, overprojected, underprojected, pointed or deviated, double break, facets.
Tip recoil is defined as the inherent strength and support of the nasal tip. This can be evaluated by depressing the tip towards the upper lip and watching for the tip’s supportive structure to spring back into position. If the recoil is good, and the tip cartilages resist the deforming influence, then tip surgery can usually be performed without fear of substantial support loss. The size, shape, attitude and resilience of the alar cartilages should be assessed by palpation of the lateral crus between two fingers. Any asymmetry of the alar cartilage should be noted.
Flared, wide floor, asymmetry, scar.
Collapse, dimpling, pinching, notching, alar retraction or wide rim.
Straight, deviated, bifid, short, long hanging, retracted, caudal dislocation, wide thick columella or scar.
Collapse or pollybeak or supratip break.
Deep or flat.
- Nasolabial angle:
Normal, acute, shallow.
- Bony vault:
Wide, narrow, depressed.
- Examination of other facial features:
Chin, eyelids, eyebrows and facial skin.
- Endoscopic nasal examination
Deviated septum, enlarged turbinates, nasal polyps or chronic sinusitis.
- Psychological assessment:
During the consultation and discussion with patient, the psychological motivation and status will become clear. Patients with high expectations should be well informed about the limitations of surgery. If convinced, they should double sign the consent form. Psychiatric patients or patients on drugs are best avoided as they may be very unhappy in spite of quite satisfactory results
The surgeon should understand the emotional state of his patients. Most patients seeking rhinoplasty are emotionally stable. However, the surgeon should be aware of the three personality types which may present: 1. The hysterical personality shows himself through helplessness and an inability to make his own decisions. 2. The depressed patient blames his nose for his own sadness
- and inadequacies. 3. The paranoid personality supposes himself to be the centre of people’s attention because of his abnormal nose. It is essential that the patient is absolutely honest about his motives for rhinoplasty in order to avoid misunderstandings after surgery.
C. Computer Assisted Imaging
- In our practice we perform computer imaging as the next step following clinical examination. The patient is asked if he wishes to have this advanced technology and move to the computer imaging room. The procedure is started by our technician and once she finishes I am called for final touch modification. Then the procedure is discussed in detail with the patient.
- The patient has the opportunity to visualize the possible surgical modification of the nose.
- The patient has the option to accept or reject these modifications prior to surgery.
- At the same time the patient has the opportunity to visualize additional facial procedures such as chin implants, blepharoplasty and facelifting.
- Implants can be selected, measured and ordered according to the required size.
- Teaching and education purposes.
- Documentation and medicolegal records.
- Marketing advantages:
Almost all patients nowadays ask about the availability of computer imaging at the time of booking a consultation. The availability of such a facility will definitely encourage patients to come for a consultation.
In our practice we used the following Computer Imaging consent form:
I certify, it has been explained to me that the purpose of the Computer Imaging is to be used as an illustration to show to some extent the changes that might be possible by surgery. I understand that there is no guarantee whatsoever that the result of surgery will be similar to the changes illustrated by Computer Imaging. I certify that the Computer Imaging has no clinical or official legal value.
Patient Name : ……………………………….
Signature : ……………………………….
Date : ……………………………….
- Preoperative photographs are mandatory. Rhinoplasty or any other plastic procedures should never been performed if preoperative photographs are not available.
- Advantages of photographs:
- Medicolegal documentation:Many patients may claim that their noses were better before the operation, unless you have the preoperative photographs you can not defend yourself.
- Preoperative discussion guide with the patient:
To show the patient what has been achieved by the procedure.
- Self teaching and education:
A comprehensive view of pre and postoperative photographs will keep the surgeon motivated and looking for improvement of his techniques.
- Lens : Macro 105.
- Camera: Nikon F70.
- Slide films R-100.
- Appropriate Macro flash and lightning.
Nikon macro speedlight S-B 21.
- Green or blue background behind the patient.
Recently, we started using the new advanced Digital camera, the Nikon 990.
- Stand in front of the patient about one metre away. It is desirable to include: the face with the hair and part of the neck in the frame.
- Take the following views: – anterior / posterior view – lateral view – oblique view – base view.
- Use the best camera and lenses to achieve the best quality slides and photographs.
E. Informed Consent
- Once the patient has requested a booking for an operation, more detailed communication and informed consent are mandatory to avoid future misunderstanding, dissatisfaction and medicolegal problems.
The pros and cons and objects of surgery should be fully discussed. The limitation of septorhinoplasty, the factors that affect surgery, listed abnormalities to be corrected and possible postoperative problems should be all made very clear to the patient and should be written in the consent form and signed by the patient.
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