Ebook Rhinology and skull base surgery: Part 2

Section III Rhinoplasty and Nasal
Framework Surgery
23

Assessment of the Rhinoplasty Patient .............. 413

24

Cosmetic Rhinoplasty .......................................... 436

25

Revision Rhinoplasty ........................................... 456

26

Functional Nasal Surgery .................................... 478



413

23

Assessment of the Rhinoplasty Patient
Christos Georgalas

Summary ..................................................................... 413

Skin/Subcutaneous Tissue/SMAS Layer ............................421

Rhinoplasty: Social and Ethical Issues ........................ 414

Muscles of the Nose: Dynamic Anatomy ..........................422

Value and Meaning of Beauty ...........................................414

Nasal Aesthetics and Assessment ............................... 422

Meaning and Range of the Principle of Autonomy ...........414

Surface Anatomical Landmarks ........................................422

Proper Goals of Medicine .................................................414

Facial Proportions.............................................................422

Issue of Publicly Funded Health Care ................................414

Frontal View .....................................................................424

Patient Selection and the Rhinoplasty Consultation..... 414
Patient’s Motivation for Surgery, Stability, and
Overall Psychological Profile.............................................415

Lateral View .....................................................................424
Smiling Lateral Views .......................................................426
Oblique View....................................................................426

Body Dysmorphic Disorder ..............................................415

Basal View ........................................................................426

The Defect .......................................................................417

Documentation in Rhinoplasty:
Photography and Computer Imaging ........................ 427

Patient’s Wishes and the Surgeon’s Capabilities...............417
Written Material/Web Site Referral/
Second Consultation ........................................................417

Image Acquisition ............................................................428
Image Storing ..................................................................429

Surgical Anatomy of the External Nose ..................... 417

Image Viewing .................................................................429

Anatomy of the Bony Pyramid..........................................417

Image-manipulating Software .........................................429

Anatomy of the Cartilaginous Pyramid ............................418

The Future........................................................................431

Blood Supply to the Nose .................................................420

Key Points .................................................................... 433
Review Questions ........................................................ 433

Innervation of the Nose....................................................421

Beauty is a form of genius—is higher, indeed, than
genius, as it needs no explanation. It is of the great facts
in the world like sunlight, or springtime, or the reflection in dark water of that silver shell we call the moon.
Oscar Wilde1
Beauty is a currency system like the gold standard.
Like any economy, it is determined by politics, and in
the modern age in the West it is the last, best belief
system that keeps male dominance intact.
Naomi Wolf2

Summary
The preoperative assessment of a rhinoplasty patient
includes several considerations that are unique in this
type of surgery. Social and ethical issues must be taken

into account, while during the outpatient consultation
the patient’s motivation for surgery, his or her stability and overall psychological assessment, with a special
emphasis on body dysmorphic disorder (BDD) must be
assessed. BDD is an increasingly recognized disorder of
self-perception associated with significant psychiatric
comorbidity, high rates of suicide and self-harm, and
following cosmetic surgery, high rates of dissatisfaction,
occasionally manifesting as aggressiveness. Assessment
of the defect (both objectively and subjectively) should be
complemented with a clear and honest discussion of the
patient’s wishes and the surgeon’s capabilities. The use of
imaging and image-manipulating software can enhance

communication as well as provide useful medicolegal
documentation and facilitate audit and self-improvement. Several software programs, including shareware
and widely available photo-editing software, can be used
for this purpose.


23 Assessment of the Rhinoplasty Patient

Rhinoplasty: Social and Ethical Issues
By virtue of being a (primarily) aesthetic rather than functional procedure, rhinoplasty is unique among rhinologic
operations. As such, it raises moral, philosophical, and social issues that no other procedure does. There has been an
exponential increase in the number of cosmetic procedures
performed over the last 2 decades (a 162% increase since
1997 in the United States), with over 1.3 million procedures
performed in 2009,3 and a 300% increase in the United
Kingdom since 2002 with 34,000 aesthetic plastic surgery
procedures performed in 2008,4 while 17 million cosmetic
procedures were performed worldwide in 2009.5 These
data reflect the wider availability of surgical interventions
but equally testify to a universal culture increasingly focused on appearance. In modern societies, where mobility
and large networks of short-time acquaintances are the
norm, “first impression” becomes crucial.6 Men as much as
women are realizing the importance of an appealing external appearance in social life, work, and personal relations,
and are more likely to use cosmetic surgery to achieve it.
However, although it would be wrong to dismiss some
well-established universal, “objective” norms of beauty, it
would be equally naive to ignore the context within which
specific ideals of beauty are created and circulated, that is,
our mass media culture. Within this context, the concept
of patient empowerment becomes controversial. As the

European Union Bioethics Commission report established,7
there are four important elements to be considered: the
value and meaning of beauty, the meaning and range of the
principle of autonomy, the proper goals of medicine, and
the issue of publicly funded health care.

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414

Note
Core ethical issues in aesthetic surgery:
1. The value and meaning of beauty
2. The meaning and range of the principle of autonomy
3. The proper goals of medicine
4. The issue of publicly funded health care

■

Value and Meaning of Beauty

Although a cross-cultural, universal typology of beauty undoubtedly exists, there is equally a broader context within
which this is applied; this includes the character, performance, and relational capabilities of the person assessed.

■

Meaning and Range of the Principle of
Autonomy

Although most patients with chronic rhinosinusitis (CRS)
will seek medical help, the same is not true of patients with

a less than ideal nose. There are external and social factors
at play for patients who decide to undergo an aesthetic procedure, including social norms and the dominant ideal of
beauty. These underline the importance of the promotion
of diverse beauty ideals, by governments and the media. Of
course, one can argue that it is not external factors per se
but the way the individual interacts with them that define
whether the patient’s decision is a fully autonomous one.
Healthy, mature patients possess this autonomy, whereas
vulnerable, psychologically unstable patients do not.

■

Proper Goals of Medicine

Medicine is supposed to be about treatment and disease,
whereas aesthetic surgery is about nondisease and enhancement. However, the drawing of clear lines between
medicine and aesthetic surgery has been shown to be
philosophically impossible. Serious suffering that deserves treatment is within the domain of aesthetic surgery as much as in traditional medicine.

■

Issue of Publicly Funded Health Care

All systems have limitations, and in an era of rationing,
what criteria can be used to justify a procedure? Different
countries have different guidelines, and there is an urgent

need of harmonization of procedures within the European
Union (EU). Purely aesthetic surgery is theoretically not
covered by the social health care system of any country
in the EU. However, there are many exceptions that differ from country to country and that are not always clear.
In summary, however, appearance that falls outside some
range of what is socially acceptable, that hampers the possibilities to get a job, or that causes dysfunction is covered
(United Kingdom, Germany, Belgium, and the Netherlands). In countries where health insurance is primarily
provided by the private sector (e.g., the United States), the
issue is less acute, although similar issues exist within the
private insurance framework. What emerges in this way as
one single criterion underlying these exceptions is patient
suffering, often but not exclusively caused by social norms.

Patient Selection and the Rhinoplasty
Consultation
The wider social and moral context of rhinoplasty raises
considerable issues. However, for the average rhinoplasty surgeon, these issues are often distilled into a
single decision—to operate or not—that he or she has to
make in a relatively limited time frame: the rhinoplasty


Patient Selection and the Rhinoplasty Consultation

Tips and Tricks
An initial rhinoplasty consultation should include the following:
• Assessment of the patient’s motivation for surgery,
stability, and overall psychological profile
• Objective assessment of the real or perceived defect itself
• Discussion of the patient’s wishes and the surgeon’s
capabilities

• Offering of informative printed material and/or Web site
referral, as well as arrangement for a second consultation

■

Patient’s Motivation for Surgery, Stability,
and Overall Psychological Profile
(How can I help you? What brought you here today?
How long have you been thinking about surgery?
What caused you to begin thinking about surgery?
Why do you want to do the operation at this particular
time? What is the attitude of your family to your operation? Whose idea was it to have the surgery? How
many previous operations have you had? Were you
happy with the results of the previous operations?
What do you think this operation will do for you?8)

The surgeon has the duty to assess the patient’s motivation for the operation and his or her mental and physical
ability to deal with the stress of surgery and potential complications, as well the stress of a nonreversible
change in his or her appearance (including that brought
about by a successful result). Only a patient who fully understands the goals, risks, and limitations of the operation can provide real informed consent. Although several
studies have shown improvement in patients’ quality of
life, as well as improvement on many psychosocial wellbeing indicators after rhinoplasty,9–11 recent large-scale
observational studies have also shown that there is a
higher risk of suicide in patients who undergo cosmetic
surgery and a vastly increased rate of psychiatric disorders.6 Although this is not to say that all cosmetic surgery
patients have psychological problems, it does mean that
a disproportionately larger number of such patients tend
to undergo cosmetic surgery.

■

Body Dysmorphic Disorder

Thus, it is vital to screen potential rhinoplasty candidates; indeed, several studies have been performed using

various psychological criteria. What is emerging as a
major issue in many (if not most) problematic patients is
body dysmorphic disorder (BDD), or dysmorphophobia.
BDD is a relatively common obsessive-compulsive spectrum disorder defined by a constant, impairing preoccupation with imagined or slight defects in appearance.12 It
is associated with poor quality of life, high rates of suicide,
and, following cosmetic surgery, increased rates of dissatisfaction, occasionally manifesting as aggressiveness.
An algorithm has been suggested by Jakubietz et al for
screening plastic surgery candidates for BDD.13 According
to this algorithm, patients are divided into three groups:
1. Those with a correctable deformity and reasonable
expectations who can be treated by plastic surgery
2. Those with no deformity and unreasonable behavior
who would be inappropriate candidates for surgery and
instead should be referred for psychiatric evaluation
3. Those with minimal deformity and inadequate behavior who should be considered for referral and rescheduled for a second appointment and reevaluation
The diagnosis of BDD is established after psychiatric consultation, where a 34-item Body Dysmorphic Disorder
Examination may be used. For screening purposes, the
Body Dysmorphic Diagnosis Questionnaire (BDDQ) can
be used.14 The BDDQ has been shown to have, depending
on the sample, a sensitivity of 100% and specificity of 89
to 93%.15

Body Dysmporphic Diagnosis Questionnaire
1. Are you very worried about your appearance in any way?
2. Does this concern preoccupy you? That is, do you

think about it a lot and wish you could worry about it
less? How much time do you spend thinking about it?
(More than 1 hour per day is suggestive and more than
3 hours highly specific for BDD.)
3. What effect has this preoccupation with your appearance had on your life? Has it
a. Significantly interfered with your social life, schoolwork, job, other activities or other aspects of your life?
b. Caused you a lot of distress?
c. Affected your family or friends?
For the busy clinician, the Dysmorphic Concern Questionnaire (DCQ), a seven-item screening questionnaire, can be
used for the initial assessment of patients. DCQ has good
psychometric properties, including internal consistency,
unidimensional factor structure, and strong correlations
with distress and work and social impairment;16 a cutoff
value of 9 has been shown to have excellent discriminative
validity, correctly classifying 92% of patients and controls.17

!

consultation. During this consultation, the surgeon must
make an objective assessment of the real or perceived defect, understand how the patient views it and what he
or she wants to be done about it, decide and explain to
the patient what can be accomplished, and, most importantly, assess the patient’s motivations, inner stability,
and overall psychological profile.

Note
Using the DCQ in the outpatient setting can be an easy and
convenient way of screening patients for BDD.

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23 Assessment of the Rhinoplasty Patient

Table 23.1 Characteristics of body dysmorphic disorder
Prevalence

Community: 0.7–1.1%18
Cosmetic surgery: 6–15%
Rhinoplasty: 20.7%

Mean age of onset/
Gender distribution

Clinical: 16.2 years
Subclinical: 13.1 years
Ratio, female to male: 1.5:1 to 1:1

Comorbidity

Obsessive-compulsive disorder: 6–30%
Depression (lifetime): 80%
Social phobia (lifetime): 39.3%
Suicidal ideation: 78%
45-fold increased risk of suicide
(twice as much as for major depression)19

Areas of concern20

Skin: 80%
Hair: 57%
Nose: 39%
Stomach: 32%
Teeth: 29%

Use of surgical
cosmetic
interventions

23–40%

Success of cosmetic
surgery

0.7–1.5%

Rates of
dissatisfaction with
cosmetic surgery

48–76%21,22

Other risks

High rates of aggressiveness toward
treating surgeon21,23

The characteristics of BDD are shown in Table 23.1.
Although 80% of plastic surgeons in the United States
report that they would not operate on a patient with
BDD, 84% also state that they had unwillingly operated
on at least one.24 Several studies22,25 have shown that
up to 66% of patients with BDD undergo cosmetic interventions, with the most common being rhinoplasty.22
Indeed, in a U.K. rhinoplasty practice, the use of a screening questionnaire for BDD identified a 20.7% prevalence
rate.26 Cosmetic surgery is unlikely to be helpful in such
patients. In a study of 26 patients undergoing 46 procedures in the United Kingdom, rhinoplasty was associated with marked dissatisfaction and an increase in the
degree of preoccupation and handicap, with the worst
outcome in those with repeated operations.22 Phillips
et al23 reported on 58 patients with BDD seeking cosmetic surgery. The large majority (82.6%) reported that
symptoms of BDD were the same or worse after cosmetic
surgery. Although 31% of patients with BDD reported an
appearance improvement following the procedure, only
1% reported a decrease in their preoccupation with the
defect. What is potentially alarming is that these patients, who may belong in the delusional spectrum of this
obsessive-compulsive disorder, may become threatening;

40% of plastic surgeons report that they have been threatened by a patient with BDD.24
Although patients with BDD may have trouble accepting it, often choosing instead to self-refer to another
surgeon, their management should be psychiatric, not
surgical. A recent Cochrane review showed that cognitive
behavioral treatment and selective serotonin reuptake
inhibitors (SSRIs; fluoxetine/clomipramine) are effective
and should be the treatment of choice.27

Tips and Tricks
Failing to recognize and operating on patients with BDD can
be a reason for litigation.

Interestingly, a recent study26 showed that psychiatric patients with BDD seeking rhinoplasty are different from “normal” (or mild BDD) rhinoplasty patients in a variety of ways:
they are significantly younger, more depressed, more anxious, more preoccupied by their nose, and have more compulsive behaviors (e.g., mirror checking, feeling their nose
with their fingers, and even self-mutilation). It also appears
that they are significantly handicapped in their occupation,
social life, and intimate relationships. Patients with BDD are
especially more likely to have been discouraged from surgery by friends or relatives, more likely to believe that there
will be dramatic changes in their life after surgery, and have
dissatisfaction with other areas of their body. All of these
characteristics are not new. Before the description of BDD,
several surgeons used similar terms to describe bad rhinoplasty candidates. The mnemonic SIMON (single, immature, male, overexpectant or obsessive, and narcissistic) was
coined for the male high-risk patient who was more likely to
be dangerous, whereas SYLVIA (secure, young, listens, verbal, intelligent, and attractive) applied to a good candidate.28
Similarly, Adamson and Chen29 noted several categories of inappropriate patients for rhinoplasty:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.

Patients having a life crisis
Unhappy patients
Cross-cultural patients (with family friction)

Psychologically estranged patients (those with obsesive-compulsive and borderline personality disorders)
Patients with BDD (dysmorphophobia)
Sexually dysfunctional patients
Patients with “package of pictures” syndrome (unrealistic expectations)
Patients with exceptionalism syndrome (narcissistic
personality)
Patients with “my theory” syndrome (poor listeners)
Patients with Goldilocks syndrome (perfectionists)
Patients with “exhausted surgeon” syndrome (patients
who go “doctor shopping”)
Patients with unfocused personality

A recent systematic review of 37 studies on the psychosocial aspects of aesthetic surgery showed that there is


Surgical Anatomy of the External Nose

a distinction between expectations regarding the self
(e.g., to improve body image) and expectations in terms
of external parameters (e.g., enhancement of one’s social
network, establishing a relationship, or getting a job).30
Patients with external motivation are less likely to be satisfied. The same study, after pooling the results from all assessed studies, found that common factors associated with
dissatisfaction and poor psychosocial outcome include
•
•
•
•
•
•
•

•
•

Young
Male
Unrealistic expectations of the procedure
Previous unsatisfactory cosmetic surgery
Minimal deformity
Motivation based on relationship issues
History of depression
Anxiety
Personality disorder

The common threads in all of these appear to be difficulty
to engage meaningfully and lack of mental stability. The
bottom line, as expressed succinctly by Goode,31 could be
distilled as follows: listen to your gut feelings and to your
staff—a patient who appears unsuitable for rhinoplasty
during the first minutes of the consultation most likely is.

■

The Defect
(When you look [in] the mirror, what is it that you don’t
like? What view of your nose bothers you the most?
What specific feature do you want corrected? If you
can have only one thing changed, what would it be?8)

During the initial consultation, there should be enough
time for the patient to describe the defect. It is said that

80% of patients require less than 2 minutes to express
their main concern6 (although this may not be strictly
true for rhinoplasty patients). Open-ended questions are
preferable. The use of a mirror and/or photographs is vital.
Clear and specific complaints are easier to deal with, especially if they are based on observations shared by the doctor. Computer imaging may be useful to screen patients
with unrealistic expectations. Patients who are not satisfied with a reasonable computer-produced manipulated
image are unlikely to be satisfied with surgical results.32
There are objective and universal canons of facial
beauty, and we know that what the rhinoplasty patient
perceives as an “ideal” nose does not differ from what is
perceived as such by the surgeon and the general public.33 However, the surgeon should be careful to avoid
suggestive questioning. It is counterproductive, and some
patients may be insulted if the discrepancy between
their nose and the ideal nose is analytically described.
Although a surgeon must be able to perform an objective
aesthetic facial analysis, this analysis should not always
be shared with the patient.

■

Patient’s Wishes and the Surgeon’s
Capabilities

At this stage, the surgeon must explain to the patient what
can and cannot be achieved by surgery on the basis of his or
her expertise. This can be complemented with computerimaging analysis and manipulation, as discussed later. The
goals and limitations of surgery should be made clear. Preand postoperative photographs of previous patients may
be helpful, although the surgeon must resist the temptation of focusing exclusively on “poster patients”; indeed,
the cases where he or she achieved a less than ideal result,
and even cases of patients who were unsatisfied and underwent revision surgery, should be shown and discussed.

The patient should be informed of all the potential complications of surgery, including the risk of revision surgery,
and the rates quoted should not come from literature reviews but from the surgeon’s own audit.

■

Written Material/Web Site Referral/
Second Consultation

Patients tend to use the Internet to gather information,
both before and after their consultation.34 A referral to
useful rhinoplasty/facial plastic surgery Web sites, including the surgeon’s personal Web site and reliable sources
of information (e.g., the European Academy of Facial Plastic Surgery, www.eafps.org, and the American Academy
of Facial Plastic and Reconstructive Surgery, www.aafprs
.org), can complement the information provided by the
surgeon. Printed material and handouts with information
that the patient can absorb at home are also important.
Indeed, in a recent study, the quality of printed handouts
and the information gathered from the Internet were the
factors most strongly correlated with overall patient satisfaction with the consent process.35

Surgical Anatomy of the External Nose
The external nose consists of the bony pyramid (the
bridge of the nose), complemented by the lateral (upper)
and alar (lower) nasal cartilages, supported in the midline
by the nasal septum. It is divided into the bony vault, the
cartilaginous vault, and the lobule.

■

Anatomy of the Bony Pyramid

The bony vault or pyramid is the upper one-third of the
nose and is formed by the nasal bones and the ascending
(frontonasal) process of the maxilla.

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23 Assessment of the Rhinoplasty Patient

Nasal bone
Radix

Medial canthus

Nasal bone

Ascending process
of maxilla

Rhinion
Upper lateral cartilage

Rhinion

Sesamoid cartilages

Accessory cartilages

Pyriform aperture

Supratip breakpoint
Supratip lobule
Pronasalae

Upper lateral
cartilage

Infratip lobule
Middle crus
Lateral crus
Medial crus

Alar cartilage
Columella

Tip-defining point

Alar margin

Infratip lobule Soft triangle

Fig. 23.1 Skeleton of the external nose. Visible are the bony
vault, consisting of the nasal bones and the frontonasal process of the maxilla, and the cartilaginous pyramid, consisting
of upper and lower lateral (alar) cartilages.

Lower

lateral
(alar)
cartilage

Anterior nasal
Fibroareolar tissue
spine of maxilla

Fig. 23.2 Skeleton of the external nose, lateral view.

Nasal Bones
The nasal bones are cephalically attached to the frontal
bone, laterally to the ascending process of the maxilla,
medially to each other, and posteriorly to the septum.
Their caudal end overlaps for a few millimeters the upper
lateral cartilage, like a roof tile. Caudally and laterally, they
form, together with the ascending process of the maxilla,
the pyriform aperture (Figs. 23.1, 23.2, and 23.3).

■

Anatomy of the Cartilaginous Pyramid

The lower two-thirds of the nose are formed by the cartilaginous pyramid. This is a unified, winged structure that
includes the upper lateral cartilage and the cartilaginous
septum, which articulate with each other in a T- or Yshaped configuration.36

2

3

1a

1c

Tips and Tricks
Excision of a cartilaginous hump should include the septum,
as well as the upper lateral cartilage, in a T configuration.

1b

1d

Upper Lateral Cartilages
The articulation of the septum with the upper lateral cartilage forms an angle, usually 10 to 15 degrees, that is very important functionally, as it forms (at their cephalic edge and

Fig. 23.3 External rhinoplasty approach: 1 ϭ lower lateral
(alar) cartilage consisting of 1a ϭ lateral crus, 1b ϭ lobular
segment of middle crus, 1c ϭ domal segment of middle crus,
1d ϭ medial crus, 2 ϭ upper lateral cartilage, 3 ϭ scroll area.


Surgical Anatomy of the External Nose

Scroll of cephalic
edge of lateral crus
of alar cartilage

Fig. 23.4 The internal valve as seen endoscopically in a patient presenting with nasal obstruction: A, head of inferior
turbinate; B, septum; C, upper lateral cartilage; IV, internal
valve. The internal valve is created by the convergence of the

septum with the upper lateral cartilage at the level of the
head of the inferior turbinate corresponding to the supratip
breakpoint or depression (see Fig. 23.2).
together with the head of the inferior turbinate) the internal
nasal valve area. This is the narrowest part of the upper airway, and any degree of narrowing of this angle can lead to
nasal obstruction. This area is also significant histologically,
as it constitutes the interface between the (external) squamous epithelium and the (internal) nasal mucosa (Fig. 23.4).
Tips and Tricks
One of the roles of spreader grafts is the widening of the
angle formed by the articulation of the septum with the
upper lateral cartilage.

Caudally, the upper lateral cartilage articulates with the
alar cartilage in the scroll area. Usually the cephalic edge
of the alar cartilage overlaps the caudal edge of the upper
lateral cartilage, although several configurations have
been described (Fig. 23.5).

Alar (Lower Lateral) Cartilage
Although in traditional anatomical textbooks the alar cartilage was divided in medial and lateral crura, a third part is
increasingly recognized: the middle or intermediate crura.
The alar cartilage is thus comprised of the medial,
middle or intermediate, and lateral crura. They form two
arches, with the medial crus converging in the midline and
thus forming the columella, and the lateral crus supporting the lateral wall of the nasal vestibule. The medial crura
converge in the midline (columellar segment of the medial
crura) and diverge more inferiorly, toward the nasal spine
(medial crural footplates). Posterior to their convergence

Scroll of caudal edge

of upper lateral crus

Fig. 23.5 Articulation of the alar with the upper lateral
cartilage (scroll area).
and between them and the upper lateral cartilage there
is an area not supported by cartilage (the weak triangle
of Converse) corresponding to the supratip breakpoint or
depression (see Fig. 23.1). Lateral and caudally to the lateral crura, fibroareolar tissue lies between them and the
pyriform aperture, while laterally and cephalically, there
are a few small accessory cartilages. More cephalically (between the nasal bones and the pyriform aperture), there
are a few sesamoid cartilages. The lateral crus is the widest part of the alar cartilage and is tightly adherent to the
overlying nostril skin. The intermediate crus is divided into
a domal and a lobular segment (Figs. 23.6 and 23.7).

MIDDLE OR
INTERMEDIATE CRUS:
Domal segment
Lobular segment

Tip-defining point
Lateral genu
Medial genu

LATERAL CRUS

MEDIAL CRUS:
Columellar segment
Footplate segment

c

Fig. 23.6 Anatomy of the alar cartilage: frontal view. The lateral and medial crura articulate through the middle crus. The
middle crus consists of the domal segment, containing the
tip-defining point, and the lobular segment.

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23 Assessment of the Rhinoplasty Patient

LATERAL CRUS

MIDDLE CRUS:
Domal segment
Lobular segment
MEDIAL CRUS:
Footplate segment
Columellar segment

Fig. 23.7 Anatomy of the alar cartilage: anterior view.

Tips and Tricks
The domal segment of the intermediate crus of the alar cartilage can take various shapes, and its configuration defines
to a large extent the shape of the nasal tip (boxy, bifid, etc.).

The nasal tip is defined as the most prominent part of
the nasal lobule. The area cephalic to the tip is called
the supratip area and the area just under it, the infratip.
The domal segment of the intermediate crus and the
angle of the medial crura and their approximation of the

domes are all important factors that define the tip shape,
rotation, and projection.

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Fig. 23.8 Tripod theory of tip support. The projection and
rotation of the tip are regulated by the relative length of the
medial crura (anterior stand, A) and the two lateral crura
(lateral stands, B).

Tips and Tricks
Endonasal rhinoplasty may result in loss of tip support by disruption of the scroll area through an intercartilaginous incision, while external rhinoplasty disrupts the attachment of
medial crura to the septum, the interdomal ligaments, and
the soft tissue envelope.

Note
There are several major and minor tip support mechanisms:
• Major tip support mechanisms
– Attachment of medial crura to the septum
– Resilience of the alar cartilage
– Attachment of cephalic alar cartilage to caudal upper
lateral cartilage (scroll area)
• Minor tip support mechanisms
– Interdomal ligaments
– Cartilaginous and membranous septum
– Anterior nasal spine

– Skin and soft tissue envelope
– Lateral crural attachment to the pyriform aperture

A way to understand the support of the tip and how different techniques can produce different results in terms
of positioning of the tip is the tripod theory, as described
by McCollough and Mangat in 198137 and further refined
using the cantilever model recently.38 According to this
model, the position of the tip is defined by the length and
support provided by the three legs of the tripod formed
by the two lateral crura and the (fused) medial crura in
the midline, as shown in Fig. 23.8. Shortening or loss of
support of any of the above can lead to predictable movements of the tip.

Anatomy of the Septum
The nasal septum consists of a bony part posterosuperiorly
(perpendicular plate of the ethmoid bone and vomer) and
a cartilaginous part anteroinferiorly (quadrilateral cartilage). The bony septum is attached to the palatine bone by
the maxillary crest, while posterosuperiorly, it is attached
to the sphenoid via the rostrum; posteroinferiorly, between the two choanae lies its free edge. Superiorly, it is
attached to the cribriform plate. Only the cartilaginous
part plays a role in the support of the nose. It is attached
posteriorly to the bony septum and posterosuperiorly to
the nasal bones. Caudally, it is connected with the medial crura of the alar cartilage, lying either between them
(tongue in groove) or just cephalically to them (Fig. 23.9).

■

Blood Supply to the Nose

Blood supply to the nose comes from two main sources:

via the external carotid, through the facial artery, that


Surgical Anatomy of the External Nose

Ethmoid bone,
perpendicular plate
Frontal bone

Fig. 23.9 Bones of the nasal septum. (From
Baker E. Head and Neck Anatomy for Dental
Medicine. Stuttgart/New York: Thieme; 2010.)

Sphenoid
bone

Nasal bone
Occipital
bone

Septal or
quadrilateral
cartilage

Rostrum
Alar
cartilage

Vomer
Palatine bone

Maxilla

Maxillary crest

provides the superior labial artery, the (superior and
inferior) alar arteries, and the angular arteries, and via
the infraorbital artery (branch of the internal maxillary). The internal carotid system also contributes to
external nose blood supply via the ophthalmic artery,
which in turns provides the dorsal nasal anterior ethomoid branch as well as the external nasal branches of
the internal ethmoid artery. (For the blood supply to the
internal nose, see Chapters 1 and 27.) All these arteries
run under the superficial musculo-aponeurotic system
(SMAS) layer and can be preserved during rhinoplasty
(Fig. 23.10).

the fibromuscular layer (SMAS, which at the level of the
internal nasal valve is divided into a deep and a superficial
layer),39 the deep areolar layer, and the perichondral
(periosteal) layer.40
All the major arterial, venous, and lymphatic vessels
course either within or above the SMAS of the nose.41
The skin is thicker and more adherent over the nasofrontal angle and over the alar cartilage, thinner and

Supraorbital a.
Supratrochlear a.

■

Innervation of the Nose

Sensory innervation to the external nose is provided
mainly by the infraorbital (V2) (external nares) and
infratrochlear nerves (nasion, bony dorsum) (V1)
(Fig. 23.11). The medial part of the tip and dorsum are
supplied by the external nasal branch of the anterior
ethmoid nerve (V1—nasociliary branch of the ophthalmic branch of the trigeminal nerve). The motor innervation to the muscles of the nose is provided by the
facial nerve.

Dorsal nasal a.

External nasal branch
of anterior ethmoidal a.
Infraorbital a.
Lateral nasal a.
Columellar a.
Angular a.
Superior labial a.
Facial a.

■

Skin/Subcutaneous Tissue/SMAS Layer

Starting from superficial to deep, the layers over the
external nose are the skin, the superficial areolar layer,

Fig. 23.10 Blood supply of the external nose. Note the
multiple anastomoses between the internal maxillary, facial
(branches of external carotid), and ophthalmic (branch of the
internal carotid) arteries.

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23 Assessment of the Rhinoplasty Patient

III Rhinoplasty and Nasal Framework Surgery

422

Supraorbital n.
Supratrochlear n.

Procerus m.
Anomalus nasi m.

Infratrochlear n.

Transverse nasalis m.
Levator labii superioris alaeque nasi m.

External nasal branch
of anterior ethmoidal n.

Dilator naris
anterior m.

Infraorbital n.

Compressor narium

minor m.
Depressor septi m.
Alar nasalis m.
Orbicularis oris m.

Fig. 23.11 Innervation of the external nose.

Fig. 23.12 Musculature of the external nose.

looser over the dorsum, and thinnest over the nasion (the
junction of bony and cartilaginous septa).

always be with a Frankfurt plane, a virtual horizontal plane
defined by the roof of the external auditory meatus (or
tragus) and both inferior orbital rims (Fig. 23.14).
The important landmarks of the nose include the following (abbreviated designations relate to Fig. 23.14):

■

Muscles of the Nose: Dynamic Anatomy

The main muscles of the nose are divided according to their
action into four groups: the elevators (procerus and levator
labii superioris alaeque nasi), the depressors (alar nasalis
and depressor septi nasi), the compressors (transverse nasalis), and the dilators (dilator naris anterior and posterior).
From these muscles, only two are clinically important: the
depressor septi nasi, which can deproject the tip with animation, and the levator labii alaeque nasi, which assists in
keeping the nasal valve open (its paresis can cause valve
compromise and nasal obstruction) (Fig. 23.12).

Tips and Tricks
Surgical division of the depressor septa nasi can treat patients with a descending nasal tip and shortened upper lip.

Nasal Aesthetics and Assessment
■

Surface Anatomical Landmarks

As discussed in Chapter 24, a frontal view (with and without the subject smiling), two lateral views (right and left),
two three-quarter views (right and left), one basal view,
and potentially also a cephalic (skyline) half basal (supratip)
are required (Fig. 23.13). Facial aesthetic analysis should

• Nasion: the surface anatomical landmark corresponding to the bony nasofrontal angle (N)
• Glabella: the most prominent midline part of the
forehead (G)
• Radix: centered at the nasion, defines the nasal root
and represents where the nose has its origin from the
glabella (N)
• Rhinion: the soft tissue correlate of the osseocartilaginous junction of the nasal dorsum (R)
• Sellion: midline osseocartilaginous junction of the
nasal dorsum (R)
• Pronasale: tip-defining point—the most prominent
part of the nasal lobule (P)
• Subnasale: junction of the columella and upper lip (S)
• Trichion: anterior hairline in the midline (T)
• Pogonion: most prominent part of the chin (Pog)
• Alar sidewalls
• Supratip (Supra)

■

Facial Proportions

Although the nose is anatomically in the center of the face,
it should not be the center of attention; the focus should
always be the eyes. Hence, a successful rhinoplasty is one
that draws attention away from rather than to the nose.
The facial analysis should start by assessing the face
for any evidence of facial asymmetry (vertical thirds,
horizontal fifths), as well as the quality and thickness of


Nasal Aesthetics and Assessment

Fig. 23.13 A complete set of photos for the (pre- or postoperative) assessment of the rhinoplasty patient.
the skin. Additionally, the position and shape of the menton should be assessed, as these can influence the view
of the nose.
The preoperative assessment should include assessment of the dorsum, tip, columella, and nasal base in a
systematic way, as shown in Table 23.2.

T

Table 23.2 Preoperative assessment of the nose
Dorsum

• Width (wide/narrow)
• Symmetry (R-L deviation)
• Projection radix/rhinion (hump/saddle)

Tip

•
•
•
•

Columella

• Over-/underprojected
• Lobule-to-columella ratio
• Asymmetry

Trichion

G
N
R
Po

Glabella
N asion
R hinion
S Supra
P P ronasale

S

Subnasale

Pog

Pogonion

Fig. 23.14 Geometric points and lines used in profile analysis.
(From Behrbohm H. Ear, Nose, and Throat Diseases. 3rd ed.
Stuttgart/New York: Thieme; 2009.)

Projection (over-/underprojected)
Rotation (over-/underrotated)
Symmetry (right/left deviation)
Shape (bulbous/boxy/pinched/bifid/asymmetric)

Nasal base • Wide/narrow
• Asymmetry
• Alar sidewalls
Measurements
• Goode’s ratio: tip projection
• Nasolabial angle: tip rotation/nasal length
• Nasofrontal angle: radix projection/nasal length
• Nasofacial angle: nasal projection
• Horizontal thirds: facial symmetry
• Vertical thirds: facial symmetry
• Basal equilateral triangle: columella/alar/lobule symmetry

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23 Assessment of the Rhinoplasty Patient

Fig. 23.15a–f Different nasal types.
(From Behrbohm H. Ear, Nose, and
Throat Diseases. 3rd ed. Stuttgart/New
York: Thieme; 2009.)
a Hump nose.
b Overprojecting nose.
c Underrotated (drooping) nasal tip.
d Saddle nose.
e Short nose.
f Deviated nose.

III Rhinoplasty and Nasal Framework Surgery

424

a

b

c

d

e

Overall Assessment
The surgeon can initially get an overall impression of the
nose and grossly classify the nose into one of the types:
tension, short, saddle nose, hump nose, or deviated nose
(Fig. 23.15). However, initial impression should always be

followed by more detailed analysis.

f

the glabella, the subnasale, and the menton should divide the
face into three equal parts. Similarly, on the vertical plane, the
intercanthal distance should be equal to the width of each of
the eyes, as well as the width of the alar base (Fig. 23.16).
There should be an unbroken, smooth line from the eyebrows to the tip-defining points (brow-tip aesthetic lines).

Specific Elements
Dorsum

Frontal View

■

Overall Assessment
At this plane, the face can be assessed for symmetry using the
rule of thirds: horizontal lines passing through the trichion,

The dorsum can be assessed at this view for symmetry,
deviation, and width. This should be further described
(upper, middle third, or lower third), taking into account
that a saddle deformity may produce the illusion of a
wide nose and a hump that of a narrow nose.

Tip
b
a

1/5

1/5

1/5

1/5

1/5

1/3

1/3

Normally, the dorsum ends before the tip in a small supratip depression, more obvious in women. The width of
the base of the nose should be assessed (ideally, it should
be equal to the intercanthal distance). The tip also can
be assessed for symmetry, deviation, and shape (amorphous, boxy, pointed, or bulbous) (Figs. 23.17 and 23.18).

■

Lateral View

Dorsum

1/3

Fig. 23.16 Lines dividing the face into vertical thirds (a)
and horizontal fifths (b). (From Behrbohm H. Ear, Nose, and

Throat Diseases. 3rd ed. Stuttgart/New York: Thieme; 2009.)

The dorsum can be assessed for contour, height, length,
and interfacing angles. The height (or projection) of the
dorsum is assessed at the nasion (radix projection), rhinion, and tip.42,43 Radix projection is the distance between
a vertical line tangent to the anterior corneal plane and
the nasion, whereas tip and rhinion projections are the
distances between a line tangent to the alar sulcus and
the tip or rhinion, respectively.
The dorsum can be assessed for underprojection, including a saddle deformity, or overprojection, including


Nasal Aesthetics and Assessment

Fig. 23.17 A patient with a boxy tip saddle nose resulting
from almost complete loss of the septal cartilage following a
septal hematoma and a (consequent) wide dorsum.

Fig. 23.18 Postoperative results after lateral and median osteotomies, reconstruction of the septum using auricular cartilage on PDS foil, transdomal and interdomal sutures, and a
columellar strut graft (external approach).

a hump. The precise size and location of these should be
noted. It should be taken into account that dorsal height
differs between different ethnic groups, being lower
in blacks. Another important angle to calculate nasal
projection is the nasofacial angle. This is defined by
the intersection of a line drawn from the nasion to the

tip-defining point and another drawn from the nasion to
the pogonion. Ideally, the angle formed by these two lines

should be 36 degrees.44
The nasofrontal angle is the angle defined by the
nasion–glabella and nasion–tip and is normally between
115 and 130 degrees (Figs. 23.19 and 23.20).

Fig. 23.19 Nasofacial angle (N) is normally ϳ36 degrees. The
nasal length (A) is normally 45 to 49 mm. The tip projection
is calculated by Goode’s ratio (B/A) and should be between
0.55 and 0.60.

Fig. 23.20 Nasolabial angle (NLA) is normally 105 to 120 degrees in women and 90 to 105 degrees in men. The nasofrontal angle (NFA) is normally 115 to 130 degrees. A, dorsum
projection; B, tip projection.

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23 Assessment of the Rhinoplasty Patient

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426

Fig. 23.21 Dorsal (mixed bony-cartilaginous hump) with
mild tip underrotation.

Fig. 23.22 The same patient after removal of the hump and
(mildly) increased tip rotation through an external rhinoplasty
approach.

Tip

■

Tip rotation is primarily assessed by the nasolabial
angle. The nasolabial angle is an angle formed by the columella and the plane of the upper lip, with its point at the
subnasale, and is normally between 105 and 120 degrees
in women and 90 and 105 degrees in men.
The projection of the tip can be assessed using
Goode’s method.44 In this method, the ratio of a line
from the nasal tip perpendicular to a line from the glabella to the menton to the nasal length is calculated: a
ratio higher or lower than 0.55 to 0.60 suggests overprojection or underprojection accordingly (ratio B:C ϭ
0.55–0.60).
The so-called columellar double break marks the
junction of the medial and intermediate crura.
Nasal length (the distance between the nasion and
the tip-defining point) is ideally between 45 and 49 mm
and is affected by both tip rotation (nasolabial angle) and
nasofrontal angle. A more obtuse nasolabial angle (overrotated tip) gives the impression of a shorter nose, as does
a more acute nasofrontal angle/deeper radix.
The lateral view is also important to assess columella projection (it should normally not extend Ͼ 4 or
Ͻ 2 mm from the nares). The columella and/or ala may be
normal, retracted, or hanging, resulting in nine possible
combinations that define how much columella is visible45
(Figs. 23.21 and 23.22).

Smiling Lateral Views

These are important to assess tip retraction associated
with an overactive depressor septi nasi.

■

Oblique View

The oblique view provides fewer objective data. However,
it is important as it brings into view elements from both
frontal and lateral views; it is vital in the assessment of
the brow-tip line and the overall tip and dorsal shape and
their interplay.

■

Basal View

The base of the nose ideally should have the shape of an
equilateral triangle. Divided in thirds, the nostrils should
take about two-thirds of the total height (ratio of columella to lobule 2:1). In this view, columella width and deviation can be better appreciated, as well as tip and caudal
septum asymmetry and deviation. The width and insertion of the alar base also can be assessed, as well as the


Documentation in Rhinoplasty: Photography and Computer Imaging

Fig. 23.23 Amorphous, wide tip with decreased projection
and relative widening of the alar base (patient from Fig. 23.17).

Fig. 23.24 The same patient after septal reconstruction, columellar strut graft, and interdomal and transdomal suturing.

alar sidewalls, for symmetry and for concavity/convexity
(Figs. 23.23, 23.24, and 23.25).

The use of digital imaging and morphing software can
do the following.

Documentation in Rhinoplasty:
Photography and Computer Imaging
Arguably, digital imaging and manipulation have come of
age. From the time of drawing on prints with markers and
rulers to the first (programmed) computer analysis systems in the early 1980s,46 the development of affordable
high-resolution digital cameras coupled with easy-to-use
computer programs has brought this technology to the
mainstream.

1. Improve Doctor–Patient Communication
Several studies have shown that the use of computer
image manipulation may lead to improved patient
satisfaction.32,47,48 Patients can communicate their wishes
in a concrete, clear way, while the surgeon can plan and
demonstrate the results of surgery. Patients who are unable to clearly formulate their wishes and are not satisfied
with realistic image manipulations can be identified early
and discouraged from surgery.32 As long as the surgeon
maintains a conservative outlook, avoids promises that
he or she cannot fulfill, and remains within the limits
of his or her surgical capabilities (ideally using the software to demonstrate the possibility of a less than ideal

Fig. 23.25 Basal view. The alar base
width (ABW) must be equal to the length
of the alar sidewalls.

Dome
Lateral crus

Medial crus

Septum

ABW

of the lower
lateral cartilage

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III Rhinoplasty and Nasal Framework Surgery

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23 Assessment of the Rhinoplasty Patient

result), it is unlikely that patients will develop unrealistic
expectations.
2. Provide Useful Medicolegal Documentation
Many surgeons were concerned that the use of morphing
software may be misconstrued as an implicit “guarantee,”
and as such, increase patient dissatisfaction after the surgery and potentially expose the surgeon to legal liability
for breach of contract.49 However, initial fears that image
manipulation may lead to inflation of patient expectations and even create legal liability have been shown to
be largely unfounded.50 On the contrary, it can been argued that computer imaging when used appropriately
improves the consent process by enhancing patient education and actually protects the surgeon from subsequent
litigation.50 Whether printed manipulated images should
be handed to the patient is still a matter of disagreement.

Although most patients, retrospectively, think that the actual result is very close to the original imaging,51,52 should
hard copies be handed over to the patient, a limited liability notice should be clearly printed on the photos.
3. Facilitate Audit and Self-improvement
Using image-manipulating software, the surgeon can
mentally plan the procedure corresponding the planned
manipulations with specific techniques. There is a very
good correlation (better on the lateral than the frontal
views,51 better on the nasolabial and nasofrontal angle
and tip projection than on the columella tip angle52)
between the actual result and the preoperatively manipulated images. Indeed, it has been shown that surgeons
are more strict than patients and tend to overestimate
the differences, whereas patients tend to ignore minor
differences.51,53 In this way, a surgeon can look back and
assess the results in light of his or her initial planning and
expectations, as well as create a personal database useful
for patient education.
4. Enhance Presentation and Teaching
It is obvious that the wealth of images that can be effortlessly and inexpensively stored and shared can help
in the education of trainees and colleagues. Digital images can be easily incorporated in PowerPoint or Keynote
presentations, as well as printed in handouts, used for
books and chapters, or shared online. Obviously, patient
consent for the specific use must always be obtained. A
surgeon with a significant facial plastic practice can build
an extensive personal photographic library, which can be
used both to consolidate his or her practice and to attract
new referrals.
Surgeons who work in academic or large hospital
settings normally can use the services of the in-house
audiovisual department. However, for surgeons working
in smaller hospitals or in private practice, an investment in

appropriate equipment is more than worthwhile and will

pay for itself after a few years. Understanding the basics of
image capturing and manipulation is reviewed here.

■

Image Acquisition

Camera
A single lens reflex (SLR) camera, set on a tripod, with
either normal/telephoto lens or (preferably) a fixed
lens (85-mm focal distance), is typically used. The use
of the same focal length (as well as the same exposure
and lighting) is important if comparisons and measurements are to be made. SLR cameras are defined by a
moving mirror system that allows the photographer
to see exactly what will be captured. They are distinguished from compact cameras by their larger size
but also by interchangeable and generally much better
quality lenses, more accurate exposure systems, better
quality sensors, and compressing algorithms resulting
in overall significantly better image quality. They use
two types of recording sensors: a smaller Advanced
Photo System (APS) sensor Ͻ25.1 ϫ 16.7 mm in size
and a larger (full-format) sensor that is 36 ϫ 24 mm in
size and corresponds to the “classic” film format. The
larger size of the sensor produces a larger negative,
which means, for a given number of pixels, larger pixels and better quality images. Typical examples of fullformat semiprofessional SLRs include the Nikon D7800,
Canon EOS5D Mark 3, and Sony A900. Examples of APS
SLRs in the same category include the Nikon D90 and
D300s, Canon EOS50, and Pentax K-x.

Resolution
The camera resolution describes the number of pixels recorded by the sensor and in most current SLR cameras
ranges from 10 to 24 megabytes (MB). A higher number
of pixels means that a larger print can be made, but this
does not necessarily mean better picture quality. Other
factors potentially more important are the exposure
and the amount of noise during the conversion process.
Some of the best current computer displays may have a
resolution of up to 1920 ϫ 1200 (HD 1080) (2 MB), which
means that for images to be displayed on a monitor, any
resolution Ͼ 2 MB is more than adequate; any resolutions
Ͼ 10 MB should be able to produce a professional-quality
print up to A3 size at 300 ppi (pixels per inch). Another
important factor is the way the image is captured. Raw
format refers to the original image file, as captured by the
sensor, something very similar to the negative in analog
cameras. Like old film negatives, it is useless as it is, as
it needs special software to be displayed; however, like
film negatives, it can be easily stored and manipulated
to produce or print the images needed, while retaining


Documentation in Rhinoplasty: Photography and Computer Imaging

maximum quality. In contrast, many cameras produce
a compressed, or “edited,” form of negative (usually in
JPEG [Joint Photographic Experts Group] form), which,
although it may retain the quality of the original when
printing, cannot be enhanced or manipulated without

loss of quality. For professional imaging work, it is worth
working with raw files, although they may be significantly larger (e.g., a raw file of a 12-MB camera will be
exactly that, 12 MB, whereas a JPEG version, depending
on the camera and compressing software, will be Ͻ3 MB).
The larger size of the negative, however, requires more
storage space and more processing power.
A zoom or fixed focus portrait lens is preferable (80–
90 mm), ideally set on a tripod and a light blue artificial
background, using an on-camera flash with diffuser (or
bounced off the ceiling).

Views
The views to be taken should include
•
•
•
•
•

A frontal view (with and without the subject smiling)
Two lateral views (right and left)
Two three-quarter views (right and left)
One basal view
Potentially also a cephalic (skyline) half basal (supratip)

All of these should be captured with the head of the subject arranged so that the Frankfurt plane is horizontal
(see Fig. 23.14).
Most new SLRs have live view, which means that you
see the image as it is being captured. Cameras that support live view also support tethered shooting, in other
words capturing photos with the camera connected to

the computer, so you can see the image directly on the
computer screen during capture.

■

Image Storing

For saving the images, a large hard disk is necessary, and,
importantly, a second hard drive to serve as backup. Relying on remembering to back up is not always efficient;
given the price of a 1.5-terrabyte hard drive, it makes
sense to have a second hard drive permanently connected
making backups in the background (e.g., Time Machine in
Mac or Backup Center in Windows 7).

■

Image Viewing

The major generic image-editing and -viewing software currently are (shareware) Picassa and GIMP, as well as Adobe
Lightroom (currently in version 4), Adobe Photoshop CS5,

Adobe Bridge, and Aperture for Mac. All of them use “nondestructive editing,” meaning that any changes on the image
are not applied to the original raw digital negative file, which
means that the original quality is not reduced; furthermore
the digital negatives are maintained, which may be important for medicolegal issues. The advantage of the Aperture
and Iphoto is their close integration with other Apple programs, making it easier to include photos in videos, presentations, or emails. Lightroom, Aperture, and Bridge support
the use of keywords, including hierarchical trees, which can
be useful for archiving large sets of photographs.

■

Image-manipulating Software

Image manipulation includes both the use of software
for preoperative assessments and measurements and the
production of “virtual” rhinoplasty results.
A short list of such commercially available specialty
software includes
• Face Sculptor by Canfield Mirror Imaging (Fairfield,
New Jersey)
• Alterimage 3.3 (includes warp, stretch, and smooth
tool) by Seattle Software Design (Seattle, Washington)
• My Morphing by United Imaging Inc. (Winston-Salem,
North Carolina) (also by the same company: My
Archiving and MarketWise).
• Plastic Designer by Nautilus Software (St. Petersburg,
Russia)
An alternative is Adobe Photoshop, a program that many
surgeons already have in their computer.54 Using the liquefy filter, one can essentially rotate, expand, or reduce
any part of the nose. Any abnormalities produced can be
smoothened with the use of the healing brush tool. The
process should not take more than a few minutes. The
basic steps for using Photoshop in this way are summarized as follows:
1. Open image using Photoshop.
2. Copy image in separate layer (Ctrl/Command C and
Ctrl/Command V).
3. Select from the liquefy filter and adjust brush size.
4. Drag, rotate, and pull using the brush.
5. Use clone stamp (right menu) to correct any abnormalities.
6. Choose text edit to print disclaimer.

7. Flatten image.
An example of a manipulated image is presented in
Figs. 23.26, 23.27, and 23.28, and the actual postoperative result in Fig. 23.29.
An excellent online tutorial for the use of Photoshop
for rhinoplasty imaging manipulation can be found at
www.granthamilton.com/uifps/morph.html.55

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23 Assessment of the Rhinoplasty Patient

Fig. 23.26 Using the liquify
filter from the Filter tab.

Fig. 23.27 Adjusting the
size of the brush and then
dragging to achieve the desired effect.


Documentation in Rhinoplasty: Photography and Computer Imaging

Fig. 23.28a, b Original (a)
and manipulated (b) preoperative images.

a

b

Another high-quality software that belongs to the
GNU shareware family is GIMP (www.gimp.org). The
same process can be performed through GIMP using
the iwarp tool from the filters → distort → iwarp
option.
For image archiving and preoperative facial analysis,
an interesting program is Rhinobase,56 which is free to
download at www.rhinobase.net (Fig. 23.30).

Fig. 23.29 Postoperative result.

■

The Future

There is a current trend toward technology that is mobile, less intrusive, and lighter, and many experts have
predicted the end of desktop and laptop computers as
we know them. Mobile phones and tablet computers not
only are proving capable of doing most computer tasks,
but they are also increasing data storage and programs
that are run via the Internet. This has clear advantages in
terms of sharing data and working in different locations;
however, it creates new challenges in ensuring data privacy and confidentiality. Although there are already
some online rhinoplasty morphing sites, one can easily
imagine a future where image acquisition, morphing,
and planning will be done without the need for connections, cables, hard drives, and so on, with the whole
system operating online. Similarly, imaging until now

has been two-dimensional (2D), with surgeons having
to rely on static pictures. There are already programs
available for free download (www.osirix.com) that can
produce three-dimensional (3D) surface rendering from
standard Digital Imaging and Communications in Medicine (DICOM) computed tomography (CT) scans, and a
recent study used 2D scans for patient information and
surgical planning,57 although the extra radiation is a
considerable drawback (Fig. 23.31) (see Videos 28 and
29, Three-dimensional Surface Rendering from Standard DICOM CT Scans, one for normal viewing, one for
3D viewing with special glasses ). It is expected that
in the future such systems will play an increasing role as
3D technology comes of age.

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23 Assessment of the Rhinoplasty Patient

III Rhinoplasty and Nasal Framework Surgery

432

Fig. 23.30 Rhinobase is a software package that allows measurements and filing of rhinoplasty photos.

Fig. 23.31 An example of
three-dimensional surface
rendering (performed using
Osirix software) in a patient
who underwent computed
tomography (CT) for concomitant rhinosinusitis.

References

Key Points
• Rhinoplasty is unique among rhinologic operations
because of its cosmetic implication; hence, it raises
unique social and ethical issues.
• The assessment of a patient for rhinoplasty should
always include screening for body dysmorphic disorder, a relatively common disorder of self-perception
associated with psychiatric comorbidity and high
rates of dissatisfaction with surgery.
• Detailed knowledge of functional anatomy, including
the tip support mechanisms, articulation of upper and
lower cartilages, and the location of the SMAS layer, is
of vital importance for the rhinoplasty surgeon.
• The rule of thirds and fifths and the Frankfurt horizontal plane can help the surgeon to assess overall face
symmetry, while objective aesthetic assessment of the
nose should include measurement of the nasofacial,
nasofrontal, and nasolabial angle, as well as Goode’s
ratio, nasal length, and tip and dorsum projection.
• Imaging based on at least six views (frontal, laterals,
three-quarters, and basal) should always be performed prior to rhinoplasty, while the use of easily
accessible image-manipulating software can greatly
facilitate surgical planning and doctor–patient
communication.

Review Questions
1. Patients with body dysmorphic disorder (BDD)
a. Are almost exclusively female

b. Very rarely undergo rhinoplasty
c. Have increased psychiatric comorbidity and high
rates of suicide
d. Can be diagnosed by the ear, nose and throat (ENT)/
plastic surgeon on the basis of the Body Dysmorphic Disorder Questionnaire (BDDQ)
e. Represent ϳ1 to 2% of total rhinoplasty patients
2. Which of the following statements regarding tip support mechanisms is/are correct?
a. Tip support mechanisms are divided into major,
intermediate, and minor types.
b. Minor tip support mechanisms include the attachment of medial crura to the septum and the alar
cartilages themselves.
c. Tip support mechanisms are not damaged during a
standard endonasal rhinoplasty.
d. Major tip support mechanisms are the attachment
of medial crura to the septum, the strength of the
alar cartilages, and the scroll area.
e. Tip support mechanisms can be explained via the
monopod theory.

3. The blood supply to the external nose
a. Consists mostly of terminal branches
b. Includes the infraorbital artery, a branch of the
ophthalmic artery
c. Runs superficial to the superficial musculo-aponeurotic system (SMAS) layer
d. Includes an anastomosis between the external
carotid and the internal carotid arteries, through
the ophthalmic artery, supplying the dorsal nasal
branches and the external nasal braches of the
internal ethmoid artery
e. Is provided via the superior labial artery, a branch

of the internal maxillary artery
4. Which of the following statements regarding the
aesthetic assessment of a rhinoplasty patient is/are
correct?
a. The nasofrontal angle (normally 160 degrees) is a
good indicator of dorsum projection.
b. Goode’s ratio is the ratio of the line from the nasal
tip perpendicular to a line from the glabella to the
menton to the nasal length.
c. Goode’s ratio is the ratio of the line from the nasal
tip perpendicular to a line from the glabella to the
menton to the length of this (second) line.
d. For the projection of the tip, useful measurements
include Goode’s ratio, nasolabial angle, and nasofrontal angle.
e. Nasofacial angles are normally between 45 and
60 degrees.
5. Which of the following statements regarding imaging
in rhinoplasty is/are correct?
a. At least four views are necessary (frontal, two lateral, and basal views).
b. Imaging in rhinoplasty is only useful for legal
purposes.
c. Imaging in rhinoplasty can improve doctor–patient
communication and in this way help avoid litigation.
d. Image manipulation preoperatively should be
avoided, as it could lead to medicolegal problems.
e. When comparing the postoperative result with
preoperative manipulated images, patients are
stricter than doctors and tend to overestimate small
differences.

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