Rhinoplasty and Surgery of the Nasal Valve

Introduction

Rhinoplasty includes functional, cosmetic, and reconstructive surgery to address the function and appearance of the nose. Functionally, the airway begins at the nostril, and issues such as static or dynamic collapse (collapse on inspiration) may present at the level of the external or internal nasal valve. The nose is the central facial aesthetic unit that is divided into nine subunits, and its structure has a great impact on an individual’s overall appearance. The anterior projection of the nose on the face makes nasal reconstruction an art that combines the functional and aesthetic aspects of rhinoplasty. True mastery of rhinoplasty, with all its aesthetic and functional nuances, requires a long learning curve and the dedicated focus of a developing surgeon.

Key Operative Learning Points

For cosmetic rhinoplasty, the patient’s motivations and expectations from surgery must be carefully explored. A realistic patient with sensible expectations is the foundation for a positive outcome.
Patients with functional complaints may be best managed with concurrent septoplasty and inferior turbinate reduction.
Altering the relative lengths of the medial crura and lateral crura will have predictable effects on nasal rotation and projection.
All rhinoplasty should be performed with careful consideration of the aesthetic and functional consequences of the surgical manipulations being carried out.

Preoperative Period

Careful evaluation of patient motivations for surgery is critical to surgical success, as unrealistic goals or aesthetic alterations that are not surgically feasible should be discussed beforehand. Managing patient expectations is critical to the preoperative and postoperative course. A detailed anatomic evaluation of the patient’s nasal anatomy including a full facial evaluation must be carried out.

History

History of Present Illness and Past Medical History

Motivations for surgery
History of prior nasal surgery or trauma
Presence of nasal obstruction and, if it is present, at rest or with inhalation (static vs. dynamic collapse)
Presence of anosmia
History of easy bleeding or bruising
Patients should be screened for psychiatric disorders at the surgeon’s discretion.

Medications

Antiplatelet and anticoagulants should be discontinued for 2 weeks preoperatively, as medically indicated.
Patients should all be screened for over-the-counter and herbal medications that may increase bleeding risk, such as high-dose fish oil.

Physical Examination

A complete examination of the head and neck should be carried out, with particular attention to the external nasal anatomy.
- The height of the nasion and rhinion should be noted, as well as the relative lengths of the nasal bones to the cartilaginous midvault.
- The nasal bones should be palpated for irregularity and signs of prior trauma.
- The thickness of the skin should be noted.
- The shape of the medial crura and lateral crura should be noted, as well as their relative support.
- The nasal-columellar relationship should be noted, as should the nasal projection.
- The tip should be evaluated for bulbousness, and the cause of this should be investigated (thick skin vs. shape of cartilaginous skeleton).
- The base of the nose should be evaluated for the shape and symmetry of the nostrils.
Patients with nasal obstruction should have an endoscopic nasal examination to visualize the anatomic cause of obstruction, as the entire septum and inferior turbinates should be evaluated for deviation and hypertrophy, respectively.
Examination of the patient during nasal inhalation (at a normal inhalation excursion and at a slightly elevated excursion) to evaluate for static and dynamic collapse of the internal and external nasal valves

Imaging

Any imaging that the patient had prior to consultation should be reviewed for bony anatomy and evidence of trauma, but imaging is not typically ordered when considering rhinoplasty alone. A full panel of rhinoplasty photographs should be taken, including frontal, oblique, basal, lateral, and lateral smiling.

Indications

Improving the appearance of the nose
Improving nasal obstruction from static or dynamic collapse of the internal or external nasal valve
Reconstruction after trauma or resection of cancer

Contraindications

Medical comorbidities that would increase the risk of anesthesia or postoperative bleeding
Unrealistic patient expectations or psychologic disorders that would place the patient at higher risk of postoperative dissatisfaction
Active chronic nasal vasoconstrictor (rhinitis medicamentosa) use can increase the risk of intraoperative bleeding and interfere with the ability to use vasoconstrictors intraoperatively for hemostasis.

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