Pre operative Assessment for Rhinoplasty

👃 Pre operative Assessment for Rhinoplasty

Rhinoplasty is an elective, aesthetic procedure, so a thorough pre-operative assessment is essential before taking up a patient for surgery.

📝 Initial Consultation

Points to be assessed and discussed with the patient:

1- Patient's Motivation

• Why is the patient seeking surgery?
• What are they actually seeking?
• Are their demands based in reality?

2- Patient's Expectations

• Are the expectations realistically achievable?

Which grouo of patients are more difficult to treat for Rhinoplasty and why?

3- Assessment of the Deformity

• Is the patient's concern about the deformity real or exaggerated?
• Patients may request only limited changes, such as hump removal or straightening of the nose, while ignoring issues of the tip or septum
• The surgeon must assess the patient fully and explain all the changes that should be made

4- Grafts

If augmentation is required, discuss the need for a graft and the possible donor sites.

5- Surgical Approach

Discuss the open versus closed technique, with:

• Pros and cons of each
• Possible complications

6- Internal Nose

Any internal nasal deformity, such as a septal deviation causing a functional issue, should be corrected at the same time.

7- Post operative Discussion

• Pattern of healing
• Type of anaesthesia to be used

📐 Analysis of Facial Proportions

The face is analysed from the frontal view using:

1️⃣ Rule of Thirds (horizontal division)

2️⃣ Rule of Fifths (vertical division)

Rule of Thirds

The face is divided horizontally into three approximately equal parts by four lines at the following landmarks:

• Trichion
• Glabella
• Subnasale
• Menton

What is Trichion?

What is Glabella?

What is Subnasale?

What is Menton?

What is the Rule of Fifths in Analysis of Facial Proportions?

What is Frankfort Line? What is it's clinical significance?

⭐ Proportions of the Nose

The nose ideally occupies:

• One-third of the length of the face
• One-fifth of the width of the face

👁️ Inspection of the External Nose

1- Skin

Assess the quality of the skin: thick, thin or sebaceous.

⭐ Skin quality also influences healing.

Why is it difficult to deal with thin skin and thick skin of nose?

2- Deviations

The nose is first divided into three parts.

👉 The deviation is described by direction in each third.

Types of deviation:

• C-shaped deviation
• One-sided deviation
• S-shaped deviation

What is the surgical anatomy of the external nose?

What are the 3 parts of the external nose?

3- Nasal Length

⭐ Nasal length = 1.6 times the distance between the nasal tip and the stomium.

How do you measure the Nasal length?

4- Tip Projection

🔍 What is it?

A measure of how far the nasal tip lies anterior to the face.

What is Goode's Ratio? What is it's clinical significance?

What are the 4 tip defining points?

5- Lip and Chin Relationship

• The horizontal distance between two parallel lines running along the surfaces of the upper and lower lips should be about 2 mm
• The anterior surfaces of the upper and lower lips rest on the nasomental line in an aesthetic face

What is Nasomental line?

How does the Lip and Chin Relationship vary in a Retrognathic face and a Prognathic face?

6- Dorsum of the Nose

Assessed from the frontal view and the lateral view.

What is the Brow Tip Line? What i sit's clinical significance?

Height of the Dorsum (Lateral View)

7- Tip Configuration

Assess the size and shape of the lower lateral cartilages, looking for:

• Asymmetry
• Bifid deformity
• Rotation

What are the different types of tip deformity seen?

8- Tip Rotation

Describes the position of the tip along an arc, with its radius centred on the nasolabial angle.

What is nasolabial angle? What is it's normal value in men and women?

9- Columellar Show

🔍 What is it?

The distance between two parallel lines drawn at:

• The most anterior part of the nasal vestibule
• The most posterior part of the nasal vestibule

What is the clinical significance of Columellar show?

What is the Ideal columellar show?

What are the causes of Increased Columellar Show?

🔬 Inspection of the Internal Nose

⭐ Important to identify abnormalities needing correction, for planning a septorhinoplasty, and for assessing donor cartilage sites.

Performed by:

• Anterior rhinoscopy
• Nasal endoscopy

1- Septum

2- Lateral Nasal Wall

What do you look for in septum and lateral nasal wall during pre operative assessment for Rhinoplasty?

3- Internal Nasal Valve

⭐ Very important, as it determines functional nasal obstruction.

⚠️ Assessment must be done during normal quiet respiration at rest.

Exaggerated breathing may precipitate a transient internal nasal valve collapse even in a normal individual.

What are the boundaries of Internal nasal valve?

What is Cottle's test?

4- Alar Collapse

A measure of external nasal valve collapse.

5- Endoscopy

Excludes:

• Polyps
• Purulent discharge
• Residual adenoid tissue

What is the anatomy of the internal nose?

✋ Palpation of the Nose

1- Skin

• Texture
• Elasticity

2- Irregularities

Arising from:

• Skin
• Soft tissue
• Cartilage
• Bone
• Previous graft material

3- Nasal Bone

• Size
• Position
• Presence of palpable steps

4- Tip Recoil

What is Tip recoil? What is it's clinical significance?

5- Alar Cartilages

6- Spine and Septum

📐 Important Angles in Rhinoplasty

1- Nasofacial Angle

📌 Also known as the Angle of Nasal Projection

Formed between:

• A line touching the nasion and the chin
• The dorsal plane of the nose

What is the ideal normal value of Nasofacial Angle?

2- Nasolabial Angle

Formed between:

• The columella
• The plane of the upper lip

What is the ideal normal value of Nasolabial Angle in men and women?

3- Nasofrontal Angle

Formed between:

• A line passing along the glabella
• A line passing along the dorsum of the nose

What is the ideal normal value of Nasofrontal Angle?

📷 Pre-operative Photographs

⭐ Importance

• Planning the surgery
• Assessment of surgical changes
• Record keeping and documentation
• Evidence for medicolegal and litigation purposes
• Teaching

Standard Views

Four standard views are taken:

1- Frontal view

2- Right lateral view (Profile view)

3- Left lateral view (Profile view)

4- Basal view

What is the proper position for taking the Frontal view photograph? What are all the points assessed in the Frontal view?

What is the proper position for taking the Profile view photograph? What are all the points assessed in the Profile view?

What is the proper position for taking the Basal view photograph? What are all the points assessed in the Basal view?

⭐ Technical Points for Photography

• Pre-operative and post-operative photographs must be taken under the same light, intensity, position, angle and distance
• Face must be photographed without makeup, as contouring can distort the real appearance
• Hair must be arranged so that it does not cover any part of the face
• Camera position must be kept straight at the level of the nose
• A digital camera is preferred over a single lens reflex camera, because of better quality, no film, automated flash intensity judgment and immediate transferability to the computer

🧠 Psychological Assessment

⭐ Very important, as patients may seek corrective rhinoplasty for very minor deformities while having an underlying psychological disturbance.

Such patients may link their body image and life problems to a minor nasal deformity, and remain unhappy after surgery.

👉 Whenever in doubt, do not hesitate to refer for psychological evaluation.

⭐ Male patients have been seen to be psychologically more difficult for any cosmetic surgery.

List down all the Problem Seeking Patients in Rhinoplasty.

How do you evaluate an External Nasal Deformity? What are the tools used?

What are the Investigations done for Pre operative Assessment for Rhinoplasty?

⭐ Exam Pearls

• Rule of thirds → Trichion, Glabella, Subnasale, Menton
• Nose occupies one-third of the length and one-fifth of the width of the face
• Nasal length = 1.6 times the tip to stomium distance
• Tip projection assessed by Goode's ratio
• Chin posterior to nasomental line → Retrognathic, gives illusion of an over-projected nose
• Four standard photographic views → Frontal, right lateral, left lateral, basal
• Basal view → Nasal base appears as an equilateral triangle

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