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An outstanding corrective surgical plan needs to be based on thorough clinical assessment, clear doctor patient communication and frank discussion of the pros and cons of surgery. In addition, a well informed consent, smooth in-patient care and close follow-up are mandatory in order to lessen the patients fear and anxiety, limit complications and cut down the medicolegal cases.
Practical guidelines are presented as follows:
- Clinical examination
- Computer imaging
- Informed consent
- Preoperative investigation
- In-patient management
- Hospital admission
- Immediate postoperative care
- In-patient management
- Instructions and follow-up
Ask the patient about:
- The main complaint: shape and or function.
- What he/she dislikes about his/her nose.
- What he/she likes about his/her nose.
- Any airways obstruction.
- Any previous nasal surgery.
- Any medication for nasal obstruction or allergies.
- Any other illnesses (diabetes, asthma, heart, hypertension, etc.) and other medications or previous surgeries.
Fig. 2 – 1. The rule of fifths. The width of the base of the nose is approximately equal to the distance between the eyes. This is used as a guide in alar wedge resection
B. Clinical examination
- Skin type
Skin type is evaluated by inspection and palpation. The physician should roll the skin over the bony dorsum and gently pinch the skin between the fingers. The quality of skin is an essential indicator of the surgical outcome and plays a significant role in preoperative planning. Extremely thick skin is the least likely to achieve the desirable refinement and definition. The thick skin may fail to contract favourably on the newly reshaped cartilages and lead to excessive soft tissue scar. Also, very thin skin provides almost no cushion to mask even the minute skeletal irregularities or contour imperfections. The ideal skin type falls somewhere in between these two types. There needs to be enough subcutaneous skin to provide adequate cushioning over the nasal skeleton, but still allow critical definition to the nasal tip.
Straight _ deviated _ twisted _ depressed _ saddling _ bony collapse _ supratip collapse.
True or false
Cartilagenous, bony or both
Bony, cartilagenous or both.
Long or short.
Any grafts or implants.
Wide, bulbous, trapezoid, asymmetry, bifid, drooped, overprojected, underprojected, pointed or deviated, double break, facets.
Tip recoil is defined as the inherent strength and support of the nasal tip. This can be evaluated by depressing the tip towards the upper lip and watching for the tip’s supportive structure to spring back into position. If the recoil is good, and the tip cartilages resist the deforming influence, then tip surgery can usually be performed without fear of substantial support loss. The size, shape, attitude and resilience of the alar cartilages should be assessed by palpation of the lateral crus between two fingers. Any asymmetry of the alar cartilage should be noted.
Flared, wide floor, asymmetry, scar.
Collapse, dimpling, pinching, notching, alar retraction or wide rim.
Straight, deviated, bifid, short, long hanging, retracted, caudal dislocation, wide thick columella or scar.
Collapse or pollybeak or supratip break.
Deep or flat.
- Nasolabial angle:
Normal, acute, shallow.
- Bony vault:
Wide, narrow, depressed.
- Examination of other facial features:
Chin, eyelids, eyebrows and facial skin.
- Endoscopic nasal examination
Deviated septum, enlarged turbinates, nasal polyps or chronic sinusitis.
- Psychological assessment:
During the consultation and discussion with patient, the psychological motivation and status will become clear. Patients with high expectations should be well informed about the limitations of surgery. If convinced, they should double sign the consent form. Psychiatric patients or patients on drugs are best avoided as they may be very unhappy in spite of quite satisfactory results
- Skin type
The surgeon should understand the emotional state of his patients. Most patients seeking rhinoplasty are emotionally stable. However, the surgeon should be aware of the three personality types which may present: 1. The hysterical personality shows himself through helplessness and an inability to make his own decisions. 2. The depressed patient blames his nose for his own sadness
- and inadequacies. 3. The paranoid personality supposes himself to be the centre of people’s attention because of his abnormal nose. It is essential that the patient is absolutely honest about his motives for rhinoplasty in order to avoid misunderstandings after surgery.
C. Computer Assisted Imaging
- In our practice we perform computer imaging as the next step following clinical examination. The patient is asked if he wishes to have this advanced technology and move to the computer imaging room. The procedure is started by our technician and once she finishes I am called for final touch modification. Then the procedure is discussed in detail with the patient.
- The patient has the opportunity to visualize the possible surgical modification of the nose.
- The patient has the option to accept or reject these modifications prior to surgery.
- At the same time the patient has the opportunity to visualize additional facial procedures such as chin implants, blepharoplasty and facelifting.
- Implants can be selected, measured and ordered according to the required size.
- Teaching and education purposes.
- Documentation and medicolegal records.
- Marketing advantages:
Almost all patients nowadays ask about the availability of computer imaging at the time of booking a consultation. The availability of such a facility will definitely encourage patients to come for a consultation.
In our practice we used the following Computer Imaging consent form:
I certify, it has been explained to me that the purpose of the Computer Imaging is to be used as an illustration to show to some extent the changes that might be possible by surgery. I understand that there is no guarantee whatsoever that the result of surgery will be similar to the changes illustrated by Computer Imaging. I certify that the Computer Imaging has no clinical or official legal value.
Patient Name : ……………………………….
Signature : ……………………………….
Date : ……………………………….
- Preoperative photographs are mandatory. Rhinoplasty or any other plastic procedures should never been performed if preoperative photographs are not available.
- Advantages of photographs:
- Medicolegal documentation:Many patients may claim that their noses were better before the operation, unless you have the preoperative photographs you can not defend yourself.
- Preoperative discussion guide with the patient:
To show the patient what has been achieved by the procedure.
- Self teaching and education:
A comprehensive view of pre and postoperative photographs will keep the surgeon motivated and looking for improvement of his techniques.
- Lens : Macro 105.
- Camera: Nikon F70.
- Slide films R-100.
- Appropriate Macro flash and lightning.
Nikon macro speedlight S-B 21.
- Green or blue background behind the patient.
Recently, we started using the new advanced Digital camera, the Nikon 990.
- Stand in front of the patient about one metre away. It is desirable to include: the face with the hair and part of the neck in the frame.
- Take the following views: – anterior / posterior view – lateral view – oblique view – base view.
- Use the best camera and lenses to achieve the best quality slides and photographs.
E. Informed Consent
- Once the patient has requested a booking for an operation, more detailed communication and informed consent are mandatory to avoid future misunderstanding, dissatisfaction and medicolegal problems.
The pros and cons and objects of surgery should be fully discussed. The limitation of septorhinoplasty, the factors that affect surgery, listed abnormalities to be corrected and possible postoperative problems should be all made very clear to the patient and should be written in the consent form and signed by the patient.
Postoperative instructions and follow-up
- The following postoperative instructions are given to the patient on discharge from the hospital. The first ten instructions are carefully read by our staff nurse:
- Take your antibiotics regularly as indicated.
- Do not expose yourself to any visitors with common colds or infections.
- Stay at home for five days to avoid dust and contamination of the nose by the outdoor atmosphere.
- Do not swim for six weeks.
- Remain upright and moving around at home as much as possible.
- Avoid bending over, lifting heavy things and climbing up stairs in a hurry.
- Do not play with young children in order to avoid bumping the nose.
- Sleep on your back with head elevated for the next two weeks.
- Report frank bleeding, headache or fever to our clinic or hospital.
- Avoid pushing hand tissue into the nostril or rubbing the nostril.
- If the nose continues to drain blood, use moustache dressing with light paper adhesive tape.
- Avoid excessive sneezing. If sneezing is troublesome it should come out through the mouth and use decongestant and antihistamine.
- Avoid the type of clothing that must be pulled over the head to avoid injury to the nose.
- Brush the lower teeth as usual and clean the upper teeth with toothpaste on a face cloth.
- Do not smile excessively or pull down the upper lip.
- Avoid exposure to sun for one month.
- Avoid getting the nasal cast and tapes wet.
- Avoid using glasses for one month. Use contact lenses. Glasses may cause depressions or dorsum deviation.
- Avoid jogging and tennis for six weeks.
- Avoid diving and skiing for two months and avoid contact sports for four months.
- Body bathing allowed and the hair washed in the sink as in the salon and avoid cast and bandage becoming wet.
- Avoid decongestant nasal sprays.
- Discolouration: usually bluish below the eyes. Alleviated by the use of Reparil or Herudoid gel and may be covered by make-up. Usually disappears in two weeks.
- Patient should keep busy by reading and doing other activities during first few days postoperative to avoid depression which may be due to swelling, discolouration and the hangover effects of anaesthesia, analgesics and antihistamine.
- Mild nose swelling and oedema may last for one year. 80% of the swelling will subside during the first six weeks and remaining 15% within the next six months and the last 5% up to twelve months. The swelling and oedema may last more (up to two years) in patients with thick skin and a wide nose. These patients should be well informed and reassured.
- During the first three weeks the tip may appear over-rotated and turned up too much. This is due to the swelling over the tip of the nose and in the upper lip. Our patients are usually concerned about this temporary over-rotation and overprojection but we reassure them that this will go away in three weeks.
- The upper lip may look longer and feel stiff and interfere with smiling. This always bothers the patient and he/she usually says, “My smile has changed”. This will disappear in two months .
- Numbness over the tip of the nose may bother the patient. This too will eventually disappear.
- The nose may be blocked for the first two weeks after the operation due to blood clots and swelling. Normal saline drops and gentle sniffing are encouraged to clear the nose.
- A mild degree of vasomotor rhinitis may occasionally last for a few months and eventually disappears.
- Patients with difficult noses, complications, severely crooked noses and revision cases should be advised to keep follow-up appointments at the clinic for at least twelve months postoperative because there is always the possibility of considering a secondary procedure.
- For the first two weeks eat easily chewed food such as soups, hamburger, potatoes, chicken and avoid steak and chewing gum.
- It is not unusual for the patient to feel dizzy or to get cold sweats for a few days postoperative.
- Return to work after seven to ten days according to the degree of swelling and discolouration.
- Avoid excessive sniffing which may cause some bleeding.
- Avoid sitting under the beauty salon’s hair dryer for two weeks. Use a hand held hair dryer.
- Swelling around eyes will reach its peak on the third day and then gradually subside.
- Patient should report by telephone any injury to the nose, and should see the doctor if haemorrhage and swelling occur.
- Remember that the nose is classified into five categories:
Only one procedure will improve the nose for a stage down to a stage up. We can not achieve a beautiful nose from an ugly nose. Sometimes the surgeon may be able to achieve two or three stages in one procedure (but not usually). The patient should wait at least eight months before considering a second procedure.
- Preoperative preparation
- Anaesthesia and sedation
- Immediate postoperative care
- Preoperative preparation of the patient
- Patient is admitted to the day case surgical center or to the hospital at 7 a.m.
- Patient receives clinical examination by the admitting doctor and nurse.
- Patient with his preoperative investigations reviewed by the anaesthetist at 8:30 a.m.
- Premedications are given. (p. 56)
- Decongestant nose drops and Emla cream (Lidocain) applied to the nose one hour pre surgery.
- Zinacef 1.5mg (Cefuroxim) IV give one hour pre surgery.
- Anaesthesia and sedation: It has been fully explained in the chapter on local anaesthesia.
- Immediate postoperative care
- The patient is kept in a semi-sitting position, 30° with head elevated.
- Ice pack applied to the forehead.
- Sedation and pain killers are considered to avoid excessive movement.
- Zinacef 1.5mg (Cefuroxim) every twelve hours.
- Voltaren (Diclofenac) 75mg. intramuscular every twenty four hours.
- Panadol two tablets every eight hours.
- 5% Dextrose IV every eight hours.
- Patient’s nasal packs are removed about 7 p.m. and then one hour later is discharged home on the following medicines:
- Zinnat (Cefuroxim) 500mg _ one capsule every twelve hours for seven days.
- Panadol two tablets every eight hours.
- Normal saline drops _ four drops in each nostril every two hours during daytime.
- Fucidine (Sodium Fusidate) ointment to be used on cotton tip applicator to paint the marginal incision and alar wedge incision.
- The above prescription and the use of ointment and nose drops are explained fully to the patient by our staff nurse.
- Postoperative instructions are read to the patient by our staff nurse and asked to follow strictly. A follow-up appointment is given in the clinic after seven days.
The following investigations are routinely performed to check the general health of the patient:
- CBC, RBS, Creatinine, Liver function test, Hepatitis, HIV.
- ECG and Chest x-ray.
- CT scan of nose as sinuses: if patient is going for both functional and cosmetic surgery.
Referral form is given to the patient for the hospital with map direction. The following instructions written clearly in the referral form and explained to the patients:
- Do not drink or eat after midnight before surgery or six hours before surgery for children.
- Bring to the hospital all the preoperative investigations and x-rays.
- If diabetic, asthmatic, on hypotensive drugs, anticoagulants or any medicines, please inform the hospital nurse and the anaesthetist.
- To take a shower on the morning of the day of the operation.
- If, for any circumstances, there is a change in operation date, please inform the clinic as soon as possible.
- Try to be in the hospital at the exact time indicated to avoid any delay in the operation time.
- Do not hesitate to contact the clinic for any further questions.
The following facts should be made clear prior to surgery:
- The aim of the operation is improvement and not perfection. The patient should not have realistic expectations.
- There is always the possibility of minor revision procedures two to six months postoperative.
- Factors that might affect the outcome and are out of the surgeon`s control:Infection, scarring, keloid, wound contracture, irregularities, the effect of age, diabetes, atherosclerosis and skin elasticity.
- The technical skills of the surgeon are limited by:
- Nature and thickness of the investing skin.
- Strength and contour of the nasal cartilages.
- The uncontrollable and unpredictable scar contracture during the healing process.
- The autografts availability.
- The thickness of fatty tissue and facial asymmetry.
- Patient should accept the known risks of surgery such as:
Infection, bleeding, numbness, swelling, discolouration, keloid and dissatisfaction.
- Patient must accept as well the very rare risk of surgery and anaesthesia such as: Blindness, paralysis or even death.
- The patient should understand there is no guarantee whatsoever for surgery, because the surgeon has no control over the natural healing process of the body. However, we should emphasize and reassure the patient that we shall all do our best and use the best techniques that are available to achieve (by God`s help) the best possible results.
- Patient should be informed about possible airways impairments, and vasomotor rhinitis, which are usually transient but rarely persistent.
- Patient should accept using grafts from his ear, ribs, irradiated homografts and the use of necessary implants.
Signed informed consent and preoperative photographs are essential documentation that should be in the hands of the surgeons for good defense in medicolegal cases. Inform consent and good quality documented photographs with good doctor/patient relations will convince many unsatisfied patients to be satisfied and reduce medicolegal cases.
In our practice we use the following consent form:
I, the undersigned,_______________________________________________________
visited Dr. Bizrah’s clinic complaining of (all deformities should be listed)
I authorized Dr. Bizrah to perform the following procedures:
in relation to my case, these additional information explained clearly
I certify that it has been explained to me that the aim of the rhinoplasty operation is to achieve as much improvement as possible and perfection is not guaranteed. It has been explained that secondary procedures may be needed following primary procedures in order to achieve satisfactory results. I certify that it has been explained to me that the power of healing and wound contracture varies from person to person and that infections, fibrosis, scarring, irregularities, notching, pinching, retraction, collapse, deviations and keloids, may all occur due to some problems with wound healing and contracture and has nothing to do with the surgeons skills or surgical techniques. The skin and living tissue are not like wood or marble, so the living tissue may expand and contract and this is beyond the control of the surgeon. I understand that part of this surgery may require external skin incisions that might leave permanent scarring. I allow the surgeon to use cartilage or bony grafts from other areas of my body or from other people or to use medical implants. I understand that airway impairment may occur and might require medical or surgical treatment at a later date although this is rare. I understand and certify that it has been explained to me that the aim of functional nasal surgery is to improve the nasal airways but post nasal phlegm and allergies may persist. Complications of sinus surgery and surrounding structures have been explained clearly to me. Bleeding, septal perforation or adhesion may rarely occur. I allow the surgeon to take photographs and use them for teaching, research and academic purposes. Regarding the computer imaging, I certify that it has been explained to me that the service is only to provide illustrations and what changes might be possible through cosmetic surgery and no guarantees whatsoever are made to the specific outcome. I certify that I understand that complications of surgery and anaesthesia might occur which rarely may be serious. I am convinced that the surgeon and the anaesthetist will do their best and consider the highest possible care and management of my case. Therefore, I read and understand everything written in this consent and I authorize the surgeon and the anaesthetist to perform the required surgery and anaesthesia for my case. I certify that I have been given an informative booklet about my operation and postoperative instructions which I should follow.
Name of patient & signature Witness
- The first follow-up visit will be one week postoperative for cast removal. When removing the cast consider the following:
- Reassure the patient that there is no pain.
- Remove both sides of the tape at the same time and the cast from the middle. Do not remove side by side, the cast will cause pressure and bump the nose. Clean the nose with soapy wet tissue (Chubs wet pack).
- Remove blood clots from the nares. Trim long sutures but do not remove as the sutures will be absorbed.
- If pimples developed, they should be scraped and the nose cleaned with wet soap and hydrogen peroxide.
- Patient is allowed to use mirror to see the reshaped nose.
- Vasovagal attack may occur at this stage in some emotional patients, in particular when a big difference has been achieved as in preoperative crooked nose or patients with hump and long noses. Patient should lie flat with legs and feet elevated. The vagovasal attack will disappear in two minutes time.
- Nasal massage instructions:
We instruct the patient to use two types of massages:
- Bidigital massage:
- By using the two index fingers to achieve gentle pressure on the sides of the dorsum of the nose to keep the nose straight and to reduce oedema. The gentle pressure is applied for ten minutes three times a day. (Fig. 2 – 6)
- Index-thumb massage:
By using the thumb and index fingers of one hand for massaging the base of the bony pyramid of the nose in order to avoid nasal bone displacement and reduce oedema. The massage from down-up is repeated twenty strokes three times a day. (Fig. 2 – 7)
Fig. 2 – 6. Bidigital massage: By using the two index fingers to achieve gentle pressure on the sides of the dorsum of the nose to keep the nose straight and to reduce oedema. The gentle pressure is applied for ten minutes three times a day.
Fig. 2 – 7. Index-thumb massage: By using the thumb and index fingers of one hand for massaging the base of the bony pyramid of the nose in order to avoid nasal bone displacement and reduce oedema. The massage from down-up is repeated twenty strokes three times a day.
2. Further follow-up
- The next visit after cast removal will be after three weeks in order to watch for any mild deviation or any infection or intranasal adhesions or to remove obvious sutures. If mild deviation is noticed at this stage, the patient is instructed to perform unilateral index finger massage by placing the index finger along the deviated side and pushing gently to the opposite side for ten minutes / four times a day.
- Next follow-up will be in two months time to watch for any mild deviation, notching, pinching or any nasal asymmetry. If any of the other mentioned problems are obvious and concerning the patient, correct without any delay.
- The next visits will be in six months, then, one year. If any problems arise, correct without any delay and don’t leave your patient waiting even with a minor problem.