Patient Consultation

Medical History, Photographic Documentation, Patient Goals

The patient is greeted and, if he or she has not done so already, is asked to fill out a detailed history form. He or she is then taken to the photography room by a nurse assistant, who takes digital photographs and escorts the patient to the examination room. The nurse then downloads the photographs into the network computer.

I then meet the patient. I ask what he or she does not like about his or her nose and what the patient would like me to fix. After the patient explains the goals, I review any prior medical records. After a review of the patient’s medical history, I then perform an examination.

Aesthetic Nasal Examination

Detailed anatomic analysis of the nose is an essential first step in achieving a successful surgical outcome. My approach to rhinoplasty analysis in a primary rhinoplasty is well described.10 I use this organized approach to aesthetic analysis for revision rhinoplasty as well (Table 18-1). The nasal analysis in revision rhinoplasty is made more complex by the fact of prior surgical intervention, with subsequent distortion of the pre-existing anatomy.

The first, critical factor is the skin-soft tissue envelope – its thickness, its quality, its integrity, and its mobility in relation to the underlying nasal structures. As analysis proceeds, a critical question that guides examination of each area is, “was it underresected, overresected, asymmetrically resected, or appropriately treated?” Any unoperated areas of the nose are identified. In addition, the presence of possible grafts or implants is considered throughout the examination. A partial list of specific considerations is discussed here.

For the bony dorsum, I examine the osteotomies and assess their position. Are they too high, normal, or too low? Is the bony dorsum straight or twisted, wide or narrow? Will revision osteotomies be required? I look for the presence of open roof deformity or rocker deformity. In addition, I judge whether the bony hump was underresected or overresected. In addition, I palpate the bony hump for irregularities.

For the middle vault, I assess the middle vault width, with special attention directed to the presence of an inverted-V deformity. A narrow middle vault with an inverted-V deformity suggests a need to restore middle vault structural support (i.e., spreader grafts). I make a judgment as to whether the cartilaginous profile was
underresected, overresected, or irregularly resected and whether the middle vault is straight or deviated. In addition, I palpate carefully to ascertain whether the dorsal septum at the anterior septal angle was underresected, contributing to a pollybeak deformity.

For the tip, I carefully examine and assess tip symmetry, projection, rotation, alar-columellar relationship, and lower lateral crural characteristics such as overresection and bossae formation. I palpate to assess tip support. I examine the caudal septum to see if it is straight or twisted. I examine all incisions, both endonasal and external. I examine carefully for the presence of possible grafts.

Functional Nasal Examination

Static and dynamic nasal valve collapse are commonly encountered in revision rhinoplasty patients.11-16 In Becker et al.’s report, 19 of 21 patients with nasal valve collapse reported a history of rhinoplasty.16

Pinching of the nasal sidewall and alar retraction are hallmarks of nasal valve collapse (Fig. 18-2). Observing the patient performing normal and deep nasal inspiration may lead directly to the diagnosis of nasal valve collapse. A “modified” Cottle maneuver, in which the lateral nasal sidewall is supported and elevated slightly with a cerumen curette of similar device, is strongly supportive of the diagnosis when the maneuver results in the patient’s report of significant subjective improvement in nasal breathing.

Anterior rhinoscopy is undertaken and may help identify abnormalities such as deviated septum, inferior turbinate hypertrophy, synechiae or scar bands, septal perforation, and other abnormalities. Examination also includes nasal endoscopy when there is a complaint of nasal obstruction.17,18 If indicated, a sinus computed tomography scan may also be obtained.

Pownell et al. described diagnostic nasal endoscopy in the plastic surgical literature.17 They traced the historical development of nasal endoscopy, explained its rationale, reviewed anatomic and diagnostic issues including the differential diagnosis of nasal obstruction, and described the selection of equipment and correct application of technique, emphasizing the potential for advanced diagnostic potential.

Levine18 reported that 39% of patients with a complaint of nasal obstruction had findings on endoscopic examination that were not identified with traditional rhinoscopy. Many of Levine’s patients had seen other physicians for this problem and had not received appropriate treatment.

Becker et al. described that, in patients seeking cosmetic nasal surgery who also had nasal obstruction, nasal endoscopy (Fig. 18-3) allowed the diagnosis of additional pathology not seen on anterior rhinoscopy, including obstructing adenoids, enlarged middle turbinates with concha bullosa, choanal stenosis, nasal polyps, and chronic sinusitis.19,20 In their series, additional surgical therapy was undertaken in 28 of 96 rhinoplasty patients because of findings on endoscopic exam. Thirteen patients had endoscopic sinus surgery. Nine patients had a concha bullosa
requiring partial middle turbinectomy. Three patients – all revision surgeries – had persisting posterior septal deviation requiring endoscopic septoplasty. Two patients underwent adenoidectomy. One patient required repair of choanal stenosis.

Table 18-1 Simplified Algorithm for Visual and Manual Nasal Examination in Revision Rhinoplasty*


General

Primary concerns

Identify primary concerns leading patient to seek revision rhinoplasty.

Skin quality

Integrity, vascularity, mobility, skin thickness (thin, medium, or thick).

Problems

For each issue and anatomic area, is problem because of underresection, overresection, asymmetric resection?

Frontal

 

Width

Narrow, wide, normal, “wide-narrow-wide”?

Dorsum

Twisted or straight (follow brow-tip aesthetic lines)?
Open roof?
Rocker deformity?
Visible or palpable deformities?
Prior osteotomies? If so, normal or abnormal?

Middle Vault

Assess width. Inverted V? Underresected? Overresected?
Asymmetric?

Tip

Deviated, bulbous, asymmetric, amorphous?
Symmetry, bossae?
Tip support (palpate)?
Status of all prior incisions.
Assess for presence of grafts.
Alar sidewall pinching or retraction?

Base

 

Tip

Deviated, wide, bulbous, bifid, asymmetric?
Symmetry, bossae?
Status of caudal septum, projection, tip support (palpate).
Status of all prior incisions.
Assess for presence of grafts.
Triangularity: good versus trapezoidal?

Base

Wide, narrow, or normal?
Inspect for caudal septal deflection.
Assess status of all external incisions.

Columella

Columellar-lobule ratio (normal is 2:1 ratio).
Status of medial crural footplates.

Lateral

 

Nasofrontal angle

Shallow or deep?

Nasal starting point

High or low?

Dorsum

Straight, concave, or convex: bony, bony-cartilaginous, or cartilaginous (i.e., is convexity primarily bony,
cartilaginous, or both)?
Visible or palpable irregularities?
Overresected, underresected, or both?
Pollybeak?
Saddle nose?

Nasal length

Normal, short, long?

Tip

Projection (normal, increased, decreased)?
Rotation (nasolabial angle), double break, alar-columellar relationship, Bossae?
Status of caudal septum and tip support. Status of all prior incisions.
Assess for presence of grafts.

Oblique

 

Does it add anything, or does it confirm the other views?

**There are many other points of analysis that can be made on each view, but these are some of the vital points of commentary.

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