Patients seeking rhinoplasty span a wide range of ages and ethnicities. In addition, they may have an equally wide range of desired outcomes from the procedure. The initial rhinoplasty consultation is an opportunity for the surgeon to assess the patient. This assessment includes both that of the physical and psychological condition of the individual. In doing so, the surgeon can determine if the patient is an appropriate surgical candidate. Once this is determined the surgeon can proceed to further prepare the patient for surgery and manage expectations.
The practitioner’s goal during patient assessment for rhinoplasty is to determine if a successful surgical outcome can be achieved. Furthermore, the surgeon must then evaluate if this outcome would lead to a satisfied patient. This determination should be achieved, with a reasonable degree of certainty, prior to proceeding with surgery. The steps necessary to arrive at this decision begin during the initial patient encounter.
The rhinoplasty consultation begins with an attempt to understand the patient’s perceived physical deformity and desired changes. The surgeon must also attempt to understand the patient’s personal motivations for undergoing surgical correction. Understanding expectations of how a desired result will affect one’s life is important to achieving success with rhinoplasty. In these instances, a successful outcome perceived on a physical level may still result in an unhappy patient. A happy physician along with an unhappy patient will lead to a frustrating experience for both parties.
Understanding a patient’s surgical goals is facilitated through the use of open-ended questions. Patients are asked to describe what they do not like about their nose and what they are looking to achieve through surgery. The surgeon must do his best to elicit all of the information possible in order to best determine a psychologically sound surgical candidate.
During the consultation, the surgeon must determine if they can achieve the patient’s physical expectations through surgery. Patient goals are discussed and reviewed. The patient is asked to outline what he or she feels are the undesirable features of the nose. A mirror is useful as a communication tool between the surgeon and the patient.
After the patient interview is complete, a thorough medical and surgical history is obtained. Valuable information can be obtained about a patient’s physical and mental condition. Focus is also turned to reviewing the past surgical history, specifically to that of any prior nasal procedures.
Once the initial patient interview is complete, a thorough examination is performed which includes a facial and nasal analysis. The examination begins with the surgeon explaining to the patient what he will be doing prior to any physical contact. If any nasal sprays or decongestants are used, the patient is made aware of what is being placed in his or her nose and the effects it will have.
The nose is inspected from all angles, including the base view. The quality and attributes of the skin, cartilage and bone are noted. Digital palpation is also performed along the dorsum, sidewall, and the caudal septum. Palpation of the nose and septum gives the surgeon valuable information in regards to the shape of the cartilage/bone and how it impacts the nasal appearance.
Intranasal exam begins with a nasal speculum. A baseline view of the nose is first obtained prior to the placement of any decongestant within the nose. If necessary, decongestant is applied to further assess the appearance of the nasal mucosa, nasal septum, and turbinate bones. The septum is inspected for any deformities and its configuration, which may impact the external appearance of the nose. If necessary to evaluate the nose, a nasal endoscope is used to assess the septum and turbinate bones along the length of the nasal cavity.
Digital computer imaging has become a popular in-office tool and is requested by many patients. This tool is a helpful means of communication between the physician and patient. It allows the patient and physician to best understand each other’s goals for the procedure. This helps reduce miscommunication that can result from the use of rhinoplasty terminology that may be misinterpreted. The patient, however, must be counseled as to the limitations of the software program. They must understand that the goal of computer imaging is to foster communication and not necessarily to obtain an identical result as to what is shown on the screen.
When used appropriately, digital image morphing can give the prospective patient a better understanding of the surgical goals and aesthetic ideals that the surgeon envisions. At the same time, the surgeon can obtain a similar understanding of the ideal aesthetic result that the prospective patient desires. Care must be taken to manipulate only the nasal appearance with effects that sound surgical maneuvers can realistically achieve. Doing so will ensure that the patient is not misled as to what they can expect from surgery, and allows for the morphed image to be realistically attainable.
If the surgeon deems the prospective patient a good surgical candidate from both a physical and psychological standpoint, the next step is to communicate the goals and the limitations of surgery. Understanding the patient’s desires, the surgeon must communicate what may be achieved through surgery. Limitations of the rhinoplasty procedure must also be discussed especially in the context of the patient’s personal list of goals.
The patient must also understand the anatomic limitations, if any, on the potential outcome of the procedure. Anatomic variations and facial asymmetries must be carefully reviewed with the patient in order to enlighten them as to what can be corrected and what is part of his or her anatomy.
The importance of close follow up and examination after the procedure must also be stressed. Post-operative interventions and care instructions can help maximize surgical results and prevent healing related complications. The patient must understand that the final result is dependent upon his or her cooperation as well as the procedure itself.
Rhinoplasty can be one of the most rewarding cosmetic procedures performed by the facial plastic surgeon. Careful patient selection and counseling will ensure satisfaction for both parties. Communication is a cornerstone to the success of the procedure and must be established from the initial encounter. Any uncertainty by the surgeon must be alleviated prior to undertaking of the procedure. If necessary, repeat visits should be performed until both surgeon and patient are comfortable with the expectations of the procedure.
This is a sequence of photographs showing a patient before rhinoplasty (left), the digitally morphed image during the consultation (center), and the result 9 months after surgery (right).
1)Tardy ME. Rhinoplasty The Art and The Science. 1997. Philadelphia: WB Saunders, Co.