CC
The patient is a 26-year-old male. His main concern is the shape of his nose. He believes it is badly deviated and is a little bit bulky, which causes difficulty in breathing and an unpleasant appearance.
HPI
The patient has had a bulky big nose since he remembers. About 5 years ago, he had an accident with facial trauma that caused a nasal fracture. His nose was reduced in an outpatient setting. He claims that deviation was corrected for some time and relapsed gradually.
PMHX/PDHX/medications/allergies/SH/FH
The patient has a previous history of closed reduction of the fractured nose. He has no history of cosmetic rhinoplasty. (Previous nasal surgery is particularly important because the anatomy may be altered. If the septal cartilage has been previously harvested or adjusted and there is a need for cartilage grafting, ear or rib cartilage can be used.) He denies any seasonal or drug allergies. (It is important to note symptoms of allergic rhinitis or recent upper respiratory tract infections.) There is no history of psychiatric disorders or treatment. (Patients with certain psychiatric disorders may not be candidates for elective cosmetic procedures.) There is no history of smoking or cocaine or other drug use. (Cocaine-induced vasoconstriction compromises wound healing and increases the risk of septal perforation.) He also has no history of granulomatous or autoimmune disorders (e.g., Wegener granulomatosis, which can affect the nasal mucosa) or of epistaxis. (A history of unexplained epistaxis should be investigated for blood dyscrasias, such as von Willebrand disease.)
Examination
A clinical examination is usually initiated with a comprehensive interview to find out the expectations of the patient and detect any unrealistic demands.
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Physical evaluation should encompass the entire face, but for planning the rhinoplasty, the nose can be examined in six regions: the skin, radix, dorsum, tip, nostrils, and alar base ( Fig. 85.1 ).
• Fig. 85.1 Anatomy of the nasal structures as seen from profile.
Each region is evaluated in three dimensions. The nose is palpated to assess the thickness of the skin and bony–cartilaginous framework of the nose. Then the external nasal valve is assessed by a forced respiration test. The patient is asked to make deep respiration while the nostrils are monitored ( Fig. 85.2 ).
Internal nasal is evaluated by the Cottle test. This examination is a simple test that gives essential information about the competency and function of the internal nasal valve ( Fig. 85.3 ).
Finally, the nasal septum is visualized by a speculum and adequate light.
Imaging
Preoperative and serial postoperative photoimaging is mandatory for cosmetic procedures. Standard photography for cosmetic rhinoplasty includes frontal, right and left lateral, right and left oblique, and basal (“worm’s eye”) views. Photographs should be standardized to allow optimal preoperative and postoperative comparisons ( Fig. 85.4 ).
Computed tomography is not necessary for cosmetic rhinoplasty, but it can be used in selected cases to delineate the severity of septal deviation and identify sinus pathology.
Labs
No routine laboratory testing is indicated for cosmetic rhinoplasty unless dictated by the medical history.
Assessment
The patient desires a smaller but normal-looking nose (not operated look). The skin is thick, and the tip is bulky. A 2- to 3-mm excessive hump is seen. The nasal septum is dislocated from the maxillary crest. The assessment shows that the nasal framework needs to be reinforced, and a considerable amount of cartilage graft is needed that may be provided from septoplasty.
Treatment
An open approach septorhinoplasty was planned and performed after general anesthesia. A 6-cc amount of local anesthetic (lidocaine + epinephrine 1/200,000) was precisely injected into incision lines, dissection planes, and the septum. After 10 minutes, a stair-step midcolumella incision was made and connected to infracartilaginous incisions. Wide subperichondrial and periosteal dissection was made. After skeletonization, the following steps were performed:
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3-mm cephalic trimming of lower lateral cartilage
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Intradomal suture
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Interdomal sutures
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Component hum reduction
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Septoplasty and graft harvesting
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Lateral osteotomy
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External taping and internal splinting ( Fig. 85.5 )
