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The Initial Examination
The Problem
The initial examination is the most important step in the design and plan of a successful rhinoplasty surgery. During the initial visit, surgeons must obtain accurate data to determine if they can deliver a safe and successful outcome to the patient. The surgeon should obtain a thorough medical and surgical history to determine if any further medical clearances, consultations, or advanced diagnostics are required. Surgeons should especially focus on any previous aesthetic surgeries and compare their own objective assessment of the outcome to the patient perception of the results. This helps assess the psychological factors dictating patient expectations and any red flags during this interview should be documented. Moreover, complex facial analysis including skeletal examination and dental occlusion assessment should be performed or the patient referred to an appropriate specialist for further assessment.
The Background
The initial examination has evolved over the past several decades, due to experience shared through professional meetings and published articles. This is especially true for the possible complications of rhinoplasties and how to prevent and manage them. We now have more experience screening patients for alarming physiological factors. Also, with the ever-growing advancements in medicine, our preprocedure evaluation has evolved and has become more efficient. Photographic documentation is fully digital, and we are increasingly adopting surgical diagnostics such as ultrasound, endoscopy, and cone beam computed tomography (CBCT) scans to further assess the areas we would not be able to view in the past. Cosmetic surgery literature indicates that a simple clinical examination of the soft tissue nasal angles might not reflect the underlying bone angles encountered during rhinoplasty and anterior rhinoscopy, patient questionnaires, endoscopy, decongestant spray rhinomanometry, and nasal strips are important components of a nasal examination. Moreover, magnetic resonance imaging (MRI) is likely to improve presurgical evaluation, especially for the assessment of alar cartilages, interdomal distance, and valvular configuration. MRI also helps reliably assess the structures and anomalies that are difficult to evaluate by the rhinoscopy. These may include turbino-septal synechiae, perforations, and losses of bone-cartilaginous substance. Consistently, more sophisticated laser angiographic technology has been successfully used recently in evaluating reconstructive cases in which the viability of the tissue may be difficult to deduce from the initial clinical examination.
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