--- title: "Pre operative Assessment for Rhinoplasty" description: "ENT notes on pre-operative assessment for Rhinoplasty." source: "The ENT Resident" author: "Dr. Mausumi Das" canonical_url: "https://www.theentresident.com/ent-notes-lectures/preoperative-assessment-rhinoplasty" categories: ["Rhinology", "Surgery"] video: "https://www.youtube.com/watch?v=bMc45NvV_j4" image: "https://media.theentresident.com/og-images/preoperative-assessment-rhinoplasty.png" --- # Pre operative Assessment for Rhinoplasty ENT notes on pre-operative assessment for Rhinoplasty. Watch the full video lecture on YouTube: https://www.youtube.com/watch?v=bMc45NvV_j4 ## 👃 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)** | Sex | Normal Dorsum | | --- | --- | | Men | Straight line | | Women | Gentle curve with a supratip break delineating the dorsum from the nasal tip | --- #### 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** --- ## About This Note This free ENT note on Pre operative Assessment for Rhinoplasty was written by Dr. Mausumi Das and is paired with a corresponding video lecture. 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