Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

38
R.M. Oneal and R.J. Beil
artery. The dorsal nasal artery, which also can
have communications with the supratrochlear and
infraorbital arteries, forms an axial arterial net-
work for the dorsal skin as described by Marchak
and Toth [ 18 ] . Injection studies show the rich
anastomotic blood supply to the lateral skin of the
nose, allowing elevation of this entire soft tissue
envelope on a narrow vascular pedicle. Branches
of the superior labial artery supply the nostril sill
and the base of the columella. Consistently, a sub-
stantial branch ascends in the columella just
super fi cial to the medial crura (Fig. 4.5 ). The col-
umellar artery, which is often bifurcated, is cut
with a transcolumellar incision used in the open
rhinoplasty approach [ 19 ] . The branches of the
external nasal branch of the anterior ethmoidal
artery along with the angular artery in the ala also
contribute to the arterial supply to the nasal tip.
The level of these vessels should be consid-
ered in open rhinoplasty to minimize compromise
of the circulation to the nasal tip and columellar
skin. It is also important to maintain dissection
just super fi cial to the lateral crura of the alar car-
tilage to avoid injuring these lateral vessels. For
the same reason, when performing open rhino-
plasty, alar base excisions should always be lim-
ited to skin and super fi cial subcutaneous tissue
[ 20 ] . The venous drainage of the external nose
has the same-named veins, which accompany the
arteries. These veins drain via the facial vein and
the pterygoid plexus and through the ophthalmic
veins into the cavernous sinus.
Supraorbital n.
Supratrochlear n.
Infratrochlear n.
External nasal branch
of anterior ethmoidal n.
Infraorbital n.
Fig. 4.6 Sensory nerve supply of the external nose (Courtesy of Jaye Schlesinger, Ann Arbor, MI)

39
4 Surgical Anatomy of the Nose
4.4
External Sensory Nerve Supply
Sensibility to the external nose is mediated
through branches of the ophthalmic and maxil-
lary divisions of the fi fth cranial nerve (Fig. 4.6 ).
Sensibility to the skin of the nose at the radix, the
rhinion, and the cephalic portion of the nasal side
walls is supplied by twigs from the supratrochlear
and infratrochlear branches of the ophthalmic
nerve. The external nasal branch of the anterior
ethmoidal nerve, which emerges between the
nasal bone and the upper lateral cartilage, accom-
panying the same-named artery, supplies the skin
over the dorsum of the distal nose down to and
including the tip of the nose. Injury to this nerve
explains tip numbness commonly noted after rhi-
noplasty, as this branch is vulnerable during
intercartilage or cartilage-splitting incisions. To
minimize the chance of injury to this nerve, it is
best to avoid deep endonasal incisions. Instead,
the dissection should be maintained directly on
the surface of the cartilage (deep to the
fi bromuscular layer and extension of the perios-
teum (SMAS)) [ 11 ] . Sensibility to the soft tissues
on the side of the lower half of the nose is sup-
plied through the infraorbital branches of the
maxillary nerve, which also supplies portions of
the columella and the lateral vestibule. Thus, an
infraorbital block is important when relying on
local anesthesia during rhinoplasty.
4.5
Caudal Third of the Nose
The lower third, or base, of the nose is made up of
the lobule, columella, nostril fl oors, vestibules, alar
bases, and alar side walls. It contains the paired alar
cartilages and accessory cartilages and fi brous fatty
connective tissue (Figs. 4.1 , 4.2 , and 4.3 ).
4.5.1 Alar Cartilage Morphology
The traditional concept of alar cartilage morphol-
ogy was that of medial and lateral crura connected
by an anatomic domal segment. To clarify the
understanding of the surgical anatomy of the nasal
tip, Sheen and Sheen [ 4 ] introduced the concept of
a middle crus, with its inferior limit at the columel-
lar lobule junction and its superior limit at the junc-
tion of the medial extent of the lateral crus (Figs. 4.7 ,
4.8 , and 4.9 ). Daniel’s [ 21 ] observations place the
domal segment in the most superior aspect of the
middle crus. After Sheen’s original observation,
the middle crus has also been referred to as the
intermediate crus [ 20, 22 ] . The concept of a distinct
Medial crus:
Footplate segment
Columellar segment
Middle crus:
Domal segment
Lobular segment
Lateral crus:
Fig. 4.7 Paired alar cartilages –
frontal view (Courtesy of Jaye
Schlesinger, Ann Arbor, MI)

40
R.M. Oneal and R.J. Beil
and independent middle or intermediate crus has
been challenged by another study, in which the
term body or intercrural segment was applied [ 23 ] .
It is the authors’ opinion, however, that this struc-
ture is more than a connecting link between the
medial and lateral crura.
Its complex and variable structure is so important
to the con fi guration of the nasal lobule that it deserves
separate description and consideration. In this dis-
cussion, each alar cartilage is divided into three com-
ponents: the medial, middle, and lateral crura.
4.5.2 Medial Crus
The medial crus consists of two components: the
footplate segment and the columellar segment. In
most patients, angulation occurs in two planes:
the angle of cephalic rotation, as noted on lateral
view (Fig. 4.10 ), and the angle of footplate diver-
gence, as noted on base view (Fig. 4.9 ). The effect
of the con fi guration of the medial crus produced
by these angles greatly in fl uences the shape and
prominence of the fl ared portion of the base of
the columella (Fig. 4.3 ). The footplate segment
of the columella is in fl uenced not only by its
intrinsic shape but also by the posterior caudal
edge of the cartilaginous septum and by the
amount of soft tissue in the base of the columella.
The columellar segment begins at the upper limit
of the footplate segment and ends at the columel-
lar lobule junction (columellar breakpoint), where
it joins the middle crus. The length of the colu-
mellar segment varies. Elongated nostrils are due
in part to vertically long columellar segments.
Medial crus:
Columellar segment
Footplate segment
Middle crus:
Domal segment
Lobular segment
Lateral crus:
Fig. 4.8 Paired alar cartilages – lateral view (Courtesy of
Jaye Schlesinger, Ann Arbor, MI)
Medial crus:
Columellar segment
Footplate segment
Middle crus:
Domal segment
Lobular segment
Tip_defining point
Lateral genu
Medial genu
a
b
c
Lateral crus:
Fig. 4.9 Paired alar cartilages:
Angles of divergence and angle
of domal de fi nition. a – angle of
domal de fi nition; b – angle of
domal divergence; c – angle of
footplate divergence (Courtesy of
Jaye Schlesinger, Ann Arbor, MI)

41
4 Surgical Anatomy of the Nose
Natvig et al. described three common anatomic
variations of the medial crus in a cadaver study
that were con fi rmed by others (Fig. 4.11 ) [ 6 ] . The
most common type is an asymmetric parallel
(75%) (Fig. 4.12 ). The other two types, the fl ared
symmetric and the straight symmetric, occur
about equally (12.5%) [ 21 ] . Although the skin is
thin and the subcutaneous tissue is almost nonex-
istent laterally, the intervening soft tissue between
the columellar segments of the medial crus fre-
quently camou fl ages any asymmetries. In con-
trast, the absence of suf fi cient intervening soft
tissue creates a bi fi d appearance of the columella.
When performing an open rhinoplasty, it is
important to elevate with the columellar skin fl ap
at a depth to include all the intervening soft tissue.
If this is not done, the inadvertent postoperative
result could be an unplanned bi fi dity in the colu-
mella. When repositioning the columellar seg-
ments or resuturing them after separation to
expose the caudal septum in open rhinoplasty, it is
important to retain the natural fl are of the caudal
edges by placing any fi xation sutures only at the
cephalic borders. From the lateral view, the most
convex portion of the columellar lobular curve is
termed the columella breakpoint (Fig. 4.10 ). Its
con fi guration is determined intrinsically by the
shape of the junction of the columellar segment of
the medial crus and the lobular segment of the
middle crus. Acute angulations can produce an
unattractive protrusion. The amount of protrusion
of the columella (caudal projection) depends not
only on the horizontal width of the columellar
segment but also on the width of the membranous
septum and the amount of protrusion of the caudal
edge of the septal cartilage. Likewise, upward
retraction depends on a de fi ciency of the same
factors but most often is caused by retraction of
the caudal septum because of trauma or congeni-
tal deformity or iatrogenically because of over
resection of the edge of the caudal septum or fail-
ure to leave an adequate caudal septal strut during
submucous resection of the septum.
4.5.3 Middle (Intermediate) Crus
The middle crus is made up of the lobular segment
and the domal segment. The lobular segment of the
middle crus tends to be the most variable and has
Pronasale
Columellar breakpoint
b
a
c
Fig. 4.10 Alar cartilage: Angles of rotation. a – angle of
cephalic rotation; b – columellar lobular angle; c – angle of
tip rotation (Courtesy of Jaye Schlesinger, Ann Arbor, MI)
a
b
c
Fig. 4.11 Paired alar
cartilages: variations in shape
of the medial crus and lobular
segment of the middle crus.
( a ) Asymmetric parallel. ( b )
Flared symmetric. ( c )
Straight symmetric (Courtesy
of Jaye Schlesinger, Ann
Arbor, MI)

42
R.M. Oneal and R.J. Beil
the least correlation between the actual internal
structural con fi guration and the external appear-
ance. Its super fi cial expression is camou fl aged by
the thicker, overlying soft tissue envelope.
The lobular segment tends to have the same
variable con fi guration as described by Natvig et al.
for the medial crus. Their description did not
include the middle crus as a separate anatomic
unit. Daniel and Letourneau, in describing their
observations from open rhinoplasty, noted that in
almost all cases the cephalic edges of the lobular
segment were in close approximation but that the
caudal edges diverged (Fig. 4.13 ). Their length,
con fi guration, and angulation determine the shape,
height, and protrusion of the infratip lobule. The
domal segment is usually short and also frequently
the thinnest, delicate, and narrow portion of the
entire alar cartilage arch. In contrast to Sheen’s
earlier description, Daniel has described a medial
genu at its connection with the lobular segment
and a lateral genu at its junction with the lateral
crus [ 4, 6 ] . The domal segment can vary in
con fi guration (Fig. 4.14 ). It may be concave, which
is the least common. With the convex medial and
lateral genu, this con fi guration produces a double-
dome effect. It also can be smooth, which gives the
tip of the nose a wide, boxy con fi guration [ 6 ] .
Varying degrees of convexity of the domal seg-
ment produce a more esthetic tip [ 21, 24 ] . The
concave caudal edge of the domal segment fre-
quently has a notched con fi guration (the domal
notch), which is largely responsible for the facet of
the soft triangle. The soft triangle is at the apex of
the nostril, where dermis is in direct contact with
dermis containing no intervening subcutaneous
tissue [ 25 ] . Because the caudal edge of the domal
segment is so irregular and the cartilage itself is so
delicate, great care must be taken in making inf-
racartilaginous incisions to avoid injuring the car-
tilage edge or intruding into the soft triangle, where
postoperative scarring may produce deformity in
this delicate skin. The cephalic edges of the paired
Fig. 4.12 The medial and middle crura during open
rhinoplasty. Note the fl ared symmetric con fi guration,
the fl are of caudal borders, and the domal segment
Fig. 4.13 Fresh cadaver dissection: note the fl ared caudal
edges of the middle crura, the closed approximation of the
cephalic edge of the middle crus, and the domal segment
symmetry ( arrows )

43
4 Surgical Anatomy of the Nose
domal segments are frequently in close approxi-
mation or have minimal separation (Fig. 4.15 ) [ 20,
21 ] . The approximation of the domal segments
also may extend to include the adjacent cephalic
edge of the lateral crus. The cephalic edge usually
slopes posteriorly from the high point of the domal
segment in the normal esthetic nose to contribute
to the supratip breakpoint (Fig. 4.15 ). The paired
dome-de fi ning points characteristically decrease
at the most anterior projecting point along the
domal segments. These de fi ning points can be nar-
rowed using sutures [ 26 ] . The medial and middle
crura are also tightly bound together by transverse
fi brous connective tissue. The most anterior thick-
ening is termed the interdomal ligament (Fig. 4.16 ).
These fi bers fuse with the more cephalic transverse
fi bers between the cephalic edges of the lateral
crura and with vertically oriented fi bers connected
to the overlying dermis, termed the dermocarti-
laginous ligament by Pitanguy (Fig. 4.16 ) [ 27 ] .
There is strong evidence to support the idea that
the fi brous tissue connections between the full
length of the medial and middle crura create a
single function or unit of these paired structures (J
Tebbets, 1990, personal communication) [ 28 ] .
Thus, this paired structure can be considered one
leg of a tripod, with the lateral crura (and their
extensions) being the other two legs (Fig. 4.17 )
[ 29, 30 ] . The external expression of the domal seg-
ment depends on three factors: (1) its speci fi c
angulation, (2) its position relative to the opposite
domal segment as determined by the divergence of
the dome-de fi ning points, and (3) the thickness of
the overlying soft tissue (Fig. 4.17 ). The subcuta-
neous fat is thickest in the supratip area, and the
soft tissue thickness over the tip of the nose varies
considerably from patient to patient. A bi fi d tip is
caused by a de fi ciency of intervening soft tissue
between the domal segments and thin skin as much
as it is caused by the amount of divergence between
the dome-de fi ning points. The supratip breakpoint
is important esthetically because it de fi nes the
cephalic limit of the nasal tip and the inferior limit
of the nasal dorsum. It is created in part by the dif-
ference between the projection of the dome-
de fi ning points and the height of the anterior septal
angle (Fig. 4.18 ). Equally important is the degree
of posterior slope of the lateral crus immediately
adjacent to the convex domal segment of the mid-
dle crus [ 21, 24 ] . The most common relationship
between the anterior septal angle and the nasal tip
is where the distal portion of the caudal septum
does not have much in fl uence on the position of
the clinical domes; the domes are as much as
8–10 mm caudal to and 3–6 mm anterior to the
a
b
c
Fig. 4.14 Variations in
domal con fi gurations. ( a )
Convex domal segment
con fi guration. ( b ) Boxy broad
with minimal convexity. ( c )
Double-dome, concave dome
segment (Courtesy of Jaye
Schlesinger, Ann Arbor, MI)
Scroll area
Supratip slope
Supratip breakpoint
Columellar breakpoint
Supratip Lobule
Pronasalae
Infratip lobule
Lateral genu
Medial genu
Fig. 4.15 Note the supratip slope of the right alar carti-
lage and the scroll area of the lateral crus (Courtesy of
Jaye Schlesinger, Ann Arbor, MI)

44
R.M. Oneal and R.J. Beil
anterior septal angle. The latter differential consti-
tutes the supratip break. This distance may have to
be exaggerated to 10–12 mm in thick-skinned
noses to create an adequate supratip. Surgical tech-
niques to create a satisfactory supratip breakpoint
have been described including suturing of the
medialaspect of the lateral crura (to narrow and
elongate the tip of the nose), and lowering the dor-
sal surface of the caudal septal cartilage. This tech-
nique leaves an iatrogenic tissue void, which has a
propensity to fi ll in with scar tissue and can be one
of the causes leading to a supratip fullness or “pol-
lybeak deformity” [ 26 ] . An alternative is direct
suture sculpturing, thereby emphasizing the alar
cartilage projection to create an esthetically pleas-
ing supratip break with minimal cartilage excision
and potentially less “dead space” and possibly a
more predictable result (J Tebbets, 1990, personal
communication) [ 17, 31 ] .
4.5.4 Lateral Crus
The lateral crus is the largest component of the
nasal lobule and plays a major role in de fi ning the
shape of the anterior superior portion of the alar
a
b
Fig. 4.16 Fresh cadaver dissection. ( a ) The interdomal condensation of fi brous connective tissue between the medial
and middle crura. ( b ) The dermocartilaginous ligament (From the dermis to the domal segment of the middle crus)
Fig. 4.17 Tripod concept of nasal tip cartilages (Courtesy
of Jaye Schlesinger, Ann Arbor, MI)

45
4 Surgical Anatomy of the Nose
side wall. Medially, the lateral crus is directly
contiguous with the domal segment of the middle
crus, and laterally with the fi rst of a chain of
accessory cartilages that abut the pyriform pro-
cess [ 7, 32 ] .
Caudally, its free edge may be fl at or it may be
curved posteriorly to varying degrees. The caudal
edge parallels and provides support for only the
anterior one-half of the alar rim [ 8, 32 ] . Thus, any
excessive excision of the medial half of the lat-
eral crus can potentially contribute to weakening
of support of the anterior alar rim. As it pro-
gresses laterally, the caudal edge turns cephali-
cally away from the alar rim. Thus, a marginal
(infracartilaginous) incision does not follow the
rim of the ala, except medially, but ascends
cephalically following the edge of the cartilage
[ 24 ] . Usually the lateral crus is at its widest just
medial to where the caudal border takes its
cephalic turn (S Stahl, 1990, personal communi-
cation). The longitudinal axis of the lateral crus
(from dome point to lateral point) is more vertical
than indicated in classic texts and may be close to
45° [ 6, 15 ] . On frontal view this axis is directed
toward the pupil. A more exaggerated cephalic
positioning of the alar cartilage produces what
Sheen describes as a malpositioned or “parenthe-
sis” tip [ 1, 4, 33 ] . Zelnick and Gingrass [ 34 ]
a
b
Fig. 4.18 Fresh cadaver
dissection. ( a ) Domal
segment (right alar cartilage)
projects (3 mm) above the
anterior septal angle. ( b ) Soft
tissue and alar cartilage of the
right side of the alar base
(lower one-third of the nose)
have been removed. The
left-side medial and middle
crura are in anatomic
position. Note the relation-
ship of the medial crus to the
caudal septum and the
relationship of the domal
segment to the anterior septal
angle

46
R.M. Oneal and R.J. Beil
described several variations of shape of the lat-
eral crus in a report of preserved cadaver dissec-
tions (Fig. 4.19 ). In types C and D, the lateral
crus adjacent to the domal segment is concave.
This variation is favorable in achieving a more
convex dome, possibly requiring only minimal
modi fi cation of the lateral crus if combined with
the creation of a more acute angle of domal
de fi nition [ 21 ] . As noted by Zelnick and Gingrass,
however, because of the camou fl aging effect of
the overlying soft tissues, in many cases it would
be impossible to appreciate these variations with-
out direct exposure of the alar cartilages.
Dion et al. [ 32 ] observed side-to-side asym-
metry in lateral crus shape in more than half of
their 31 cadaver specimens. The junction of the
cephalic edge of the lateral crus and the caudal
edge of the upper lateral cartilage is known as the
scroll area. An early study on the con fi guration of
the caudal edge of the upper lateral cartilage
showed some degree of lateral (downward) curl-
ing. Conversely, the slope of the adjacent cephalic
edge of the lateral crus is usually a convex curve
downward (Fig. 4.20 ). In most people, there is
some degree of overlap of these cartilages, which
may enhance the function of the internal nasal
valve [ 11 ] . The degree of this curvature deter-
mines in part the fl are and fullness (bulbousness)
of the lateral lobule. If resection of either carti-
lage edge is contemplated, the underlying mucosa
should be preserved carefully and the cartilage
excision should be minimized to avoid unpredict-
able, undesirable late changes [ 35 ] .
More details of this junction were described
after microscopic study. The presence of a vari-
able number of small sesamoid cartilages was
noted. The cartilage pieces were interconnected
by a dense, fi brous connective tissue contiguous
with the super fi cial and deep perichondrium of
the upper lateral cartilage and the lateral crus. The
con fi guration of this junction was likened to rep-
tile skin or armor as it is characterized by closely
inherent multiple plates of cartilage with fl exibility
but little or no extensibility [ 7 ] . Because of the
b
c
a
d
e
Fig. 4.19 Variations of form
of the lateral crus of the alar
cartilage. ( a ) Smooth convex.
( b ) Convex medial, concave
lateral. ( c ) Concave medial,
convex lateral. ( d ) Concave
medial, convex central,
concave lateral. ( e ) Smooth
concave (Courtesy of Jaye
Schlesinger, Ann Arbor, MI)

47
4 Surgical Anatomy of the Nose
frequent overlap, the interspersed sesamoids, and
the nondistensibility, the intercartilaginous inci-
sion is rarely that but probably almost always an
intracartilaginous incision [ 7, 36, 37 ] .
The intrinsic shape and form of the alar carti-
laginous arch depend entirely on its inherent form
and resiliency. LePesteur and Firmin showed that
the paired alar arches are also a part of two carti-
laginous rings, one for each nostril (Fig. 4.21 ).
Each ring consists of the following components:
the medial crus embracing the caudal septum; the
septum fi rmly set on the anterior nasal spine; the
continuity of middle and lateral crus; and laterally
a chain of accessory cartilages. The most poste-
rior accessory cartilage is attached to the anterior
nasal spine through fi brous connections in the
nostril fl oor. These laterally placed cartilages con-
tained within a distinct structural formation are
accessory in contrast to the highly variable sesam-
oid cartilage found between the upper lateral car-
tilage and the lateral crus. The lateral accessory
cartilage con fi guration may vary, from multiple to
one or two larger pieces [ 8, 38 ] .
Scroll of cephalic
edge of lateral crus
of alar cartilages
Scroll of caudal edge of
upper lateral cartilages
Fig. 4.20 Nasal skeleton: note the cutaway section of the
right upper lateral cartilage and the lateral crus of the right
alar cartilage and the scroll junction of the upper lateral
cartilage and lateral crus (interlocked con fi guration)
(Courtesy of Jaye Schlesinger, Ann Arbor, MI)
Cartilaginous septum
Upper lateral cartilage
lateral crus of
alar cartilage
Accessory cartilage
Fibro-areolar tissue
Pyriform edge
Inferior turbinate
External lateral
triangle
10˚–15˚
a
b
Anterior nasal spine
Floor of nasal cavity
Fig. 4.21 ( a ) Note cartilage ring consisting of alar carti-
lage, accessory cartilages, caudal septal cartilage, and
their fi brous interconnections. The dotted line shows the
level of the cross sectioned view. ( b ) Nasal valve area
(Courtesy of Jaye Schlesinger, Ann Arbor, MI)

48
R.M. Oneal and R.J. Beil
In the non-Caucasian nose, the medial and lat-
eral crura are frequently shorter and the cartilage
structures comparatively weak, affording less
support [ 5 ] . Even in some Caucasian noses with
thick skin and soft tissue, the cartilages are thin,
providing less support than normal [ 2 ] .
4.5.5 The Nostril
The nostril is composed of the alar base and the
vestibule. There is wide variation in the shape
and size of the external naris.
4.5.6 Alar Bases
The shape and resiliency of the nostril and the
posterior half of the alar side walls depend on
dense fi brofatty connective tissue. Griesman [ 11 ]
reported on variations in con fi guration and
offered a classi fi cation of the junction of the alar
bases with the cheek, which forms the alar cheek
groove. The variations in con fi guration are the
following (Fig. 4.22 ):
1. Cheeked junction: the alar side wall is rela-
tively straight and the foot, or base, is only
slightly curved medially.
2. Labial junction: the foot (base) turns medially
and joins the columella in the middle of the
nostril fl oor.
3. Columellar junction: the alar base turns across
the nostril fl oor in a tubular con fi guration and
continues across the nostril fl oor in a broad
sweep. The size and shape of the tube vary
considerably in addition to the location of its
attachment to the skin of the base of the
columella.
The shape of the nasal base is considered the
most pleasing when it has the form of an equilat-
eral triangle with the ratio of the columellar
length to the height of the infratip lobule of
approximately 2:1 (Fig. 4.3 ). In Caucasians,
attractive nostrils normally have a teardrop shape.
Nostril con fi gurations vary considerably accord-
ing to racial and ethnic types, as described by
Farkas [ 38– 42 ] .
4.5.7 Vestibule
The vestibule of the lower third of the nose is the
cavity just inside the external nares bounded
medially by the mobile septum and columella
and laterally by the alar side wall with a protrud-
ing fold of skin with hair (vibrissae) under the
lateral crus. Inferiorly, it is bordered by the skin
overlying the alveolar process of the maxilla [ 43 ] .
Cephalic to that is the inferior edge of the pyri-
form ridge, which demarcates the junction of the
vestibule with the fl oor of the nasal cavity. The
vestibule forms part of a valve mechanism for
inspired air [ 44 ] . As described by Cottle [ 45– 47 ] ,
the vibrissae together with the vestibule provide a
series of baf fl es, or resistors, to the stream of air,
slowing down the currents of air and directing
them backward into the nasal cavity for warming
and moisturizing.
4.6
The Cartilaginous Vault
The upper (cephalic) cartilaginous vault is made
up of the paired upper lateral nasal cartilages and
the dorsal cartilaginous septum. Early studies
suggested that the cephalic one-third of the vault
a
b
c
Fig. 4.22 Variations in alar
base: nostril fl oor
con fi guration. ( a ) Cheek
type. ( b ) Labial type. ( c )
Tube type (Courtesy of Jaye
Schlesinger, Ann Arbor, MI)

49
4 Surgical Anatomy of the Nose
was a uni fi ed structure [ 48 ] . McKinney et al. [ 49 ]
showed that actually the entire cephalic two-thirds
of the vault is a single cartilaginous unit (Fig. 4.23 ).
Inferiorly, there is gradual separation of the upper
lateral cartilages from the septum to a level just
above the septal angle. Embryologically, a single
cartilaginous nasal capsule is present by 4 months
[ 48 ] . During development, as chondri fi cation pro-
ceeds, fi brous tissue ingrowth produces separa-
tion of the upper lateral cartilage from the pyriform
process laterally and from the caudal septum. The
amount of separation and fl are from the septum
varies, as does the amount of projection of the
caudal end of the septum, which can project 1 cm
beyond the caudal edge of the upper lateral carti-
lage (see Fig. 4.20 ) [ 50 ] . The lateral border of the
upper lateral cartilage frequently terminates at
the level of the nasal bone lateral suture line. The
fetal orientation of the cartilages extending
beneath the pyriform and the nasal bones, how-
ever, is maintained at birth, and this anatomic
variation needs to be respected when performing
nasal surgery in young children [ 51 ] . The lateral
con fi guration of the upper lateral cartilage tends
to be more rectangular than triangular and does
not, as is commonly believed, rest on the pyri-
form process (Fig. 4.21 ). This lateral space is
termed the external lateral triangle. It is bordered
by the lateral edge of the upper lateral cartilage,
lateral prolongation of the lateral crus, and the
edge of the pyriform fossa. It is lined by mucosa
and covered by the transverse portion of the
a
b
c
e
d
a
b
c
d
e
Fig. 4.23 Cross-sectional views of the nasal skeleton
showing the osseous and upper cartilaginous vault. ( a )
Bony vault caudal to nasofrontal suture (near radix). ( b )
Bony vault, just cephalic to intercanthal line. ( c ) Junction
of bony and cartilaginous vaults. Note the overlap of nasal
bones over the cephalic edge of the upper lateral cartilage
and the T con fi guration of the nasal septum continuous
structure with the paired upper lateral cartilages. ( d )
Middle third of upper cartilaginous vault. Note Y
con fi guration of the nasal septum and the persistent struc-
tural continuity of the nasal septum and the upper lateral
cartilage. ( e ) Caudal upper cartilaginous vault. Note that
the nasal septum and the upper lateral cartilages are sepa-
rate structures at this level (Courtesy of Jaye Schlesinger,
Ann Arbor, MI)

50
R.M. Oneal and R.J. Beil
nasalis muscle. It also may contain one or more
small sesamoid cartilages, and it functions as a
bellows during respiration [ 7, 46 ] . There is no
lateral skeletal support for the upper lateral carti-
lage; its support comes only from attachments to
the nasal bones and septum.
There is a common perichondrial lining on the
undersurface of the upper lateral cartilages and
the septum (Fig. 4.24 ). During traditional rhino-
plasty techniques, whenever the dorsum is low-
ered, the apex of the cartilaginous vault is often
interrupted depending on the amount of cartilage
removed [ 31, 52 ] . The upper lateral cartilages are
thus separated from the septum through their
length and totally depend on their connection
with nasal bones for their support [ 45, 50 ] . If the
mucoperichondrial lining between the septum
and the upper lateral cartilage is divided further,
instability is created. By creating submucosal
tunnels and performing an extra mucosal rhino-
plasty, the integrity of the mucoperichondrial
layer can be maintained beneath these structures
(see Fig. 4.24 ) [ 10, 50, 53 ] . Caudally, where the
upper lateral cartilage diverges from the septum,
the mucoperichondrium contains a fi brous
aponeurosis that lends support to this area of the
internal valve; it should be protected by gentle
and judicious dissection. As it approaches its
caudal end, the upper lateral cartilage ideally
forms an angle of 10–15° with the septum
(Fig. 4.21 ). This is the area of the internal nasal
valve, which requires fl exible patency for a nor-
mal airway [ 4, 35, 46, 54 ] . There are many varia-
tions in con fi guration and position of the anterior
septal angle because of development and racial
in fl uences [ 25, 50 ] . The high angular nose with a
prominent dorsum tends to have a more promi-
nent caudal septal cartilage than the nose with a
low fat dorsum [ 55 ] . Occasionally, the septal bor-
der of the distal septal cartilage may be de fi nitively
felt at the anterior septal angle and may present
almost subcutaneously between the caudal ends
of the upper lateral cartilages and medial lateral
crus. Most commonly, however, the closely
approximated medial aspects of the lateral crura
are superimposed [ 21, 56 ] . Lateral deviations of
the caudal dorsal septum can “arti fi cially” pro-
duce asymmetries in the position of the domal
segments similar to the secondary effect of cau-
dal de fl ections of the septal cartilage or the medial
crus. These external in fl uences on tip position
should be carefully documented preoperatively
by careful clinical examination.
4.7
The Bony Vault
The bony vault consists of the paired nasal bones
and the paired ascending processes of the maxilla
[ 57 ] . The vault is generally pyramidal in shape;
however, the cephalic portion of the bones fl ares
outwardly as they approach the nasofrontal suture
(Fig. 4.23 ). The narrowest part of the bony pyra-
mid is at the intercanthal line, which connects the
attachments of the medial canthal tendons at the
anterior crest of the lacrimal bone (Fig. 4.1 ) [ 11 ] .
The nasal bones are thicker and denser above the
level of the medial canthus [ 58 ] . The nasofrontal
suture line averages 10.7 mm cephalic to the inter-
canthal line [ 6 ] . The nasal bones average 25 mm
in length, although there may be considerable
variation. Thus, the bony vault is divided approxi-
mately in half at the intercanthal level (Fig. 4.25 ).
One variation described by Sheen is of short nasal
bones [ 4 ] . Preoperative recognition is important
Fig. 4.24 Caudal upper cartilaginous vault. The dark
black line on the left represents the continuous mucoper-
ichondrial layer in its normal con fi guration. The submu-
cosal tunnel on the right is the approach to the nasal
skeleton (Courtesy of Jaye Schlesinger, Ann Arbor, MI)

51
4 Surgical Anatomy of the Nose
because standard osteotomies in such patients
may lead to excessive postoperative collapse of
the bony and cartilaginous vault. Nasal bones also
tend to be shorter and smaller and the bony pyra-
mid is widened in the non- Caucasian nose [ 5 ] .
At the cephalic end of the nasal dorsum, the
soft tissue nasion, or sellion, is the deepest por-
tion of the curve between the glabella and the
nasal dorsum (nasofrontal groove or curve)
(Fig. 4.25 ) [ 11 ] . This is generally at a level
approximately between the supratarsal fold and
the upper lid margin with the eye open and
approximately 9–14 mm anterior to the corneal
projection [ 59 ] . This area is referred to as the
radix. The thin caudal edge of these two bones
and the adjacent thin anterior ridge of the pre-
maxilla, continuous with the anterior nasal spine,
make up the pyriform aperture.
Caudal to the intercanthal line, under the mid-
line of the fused nasal bones, there is an inward
curved bony spine that articulates with the superior
edge of the perpendicular plate of the ethmoid. This
spine is also just cephalic to where the dense fi brous
tissue connects the overlapped cephalic edges of
the upper lateral cartilages. These cartilages are, in
turn, fused to the cartilaginous nasal septum, which
articulates solidly with the perpendicular plate of
the ethmoids (Fig. 4.26 ). This con fl uent area of 4
solid structural elements is called the keystone area
(Fig. 4.27 ) [ 25, 36, 50 ] . This area provides critical
support for the nasal dorsum in the middle third of
the nose. If the bony and cartilaginous dorsum is
lowered and the side walls separated in the midline,
then the integrity of both the perpendicular plate of
the ethmoid and the dorsal cartilaginous septum is
essential to support the nasal dorsum once osteoto-
mies are performed.
To maintain this support, these midline bony
and cartilaginous structures must be preserved, or
if mobilization is required during reconstruction of
the septum, they must be reconstituted carefully.
4.8
Internal Anatomy of the Nose
4.8.1 Nasal Cavities
The normal spatial relationships of the nasal cavities
with surrounding structures in the skull are illus-
trated by a series of coronal computed tomography
(CT) scans (Fig. 4.26 ). The location of these sections
is depicted in relation to the sagittal view of the nasal
septum lateral wall and surrounding structures,
which also provide additional orientation for struc-
tures anterior and posterior to the CT scan cuts.
The nasal vestibule is lined with squamous epi-
thelium that contains numerous thick stiff vibris-
sae. The limen nasi is consistently at the junction
Caudal edge of
nasal bone
Intercanthal line
Sellion (nasion)
Nasofrontal suture
Fig. 4.25 Bony skeleton and
overlying soft tissue from the
right side. Note the relation-
ship of the sellion (nasion) to
the nasofrontal suture line
and the level of the intercan-
thal line. The intercanthal line
splits the dorsal (anterior)
length of the nasal bone
approximately in half
(Courtesy of Jaye
Schlesinger, Ann Arbor, MI)

52
R.M. Oneal and R.J. Beil

53
4 Surgical Anatomy of the Nose
of the skin with the nasal mucosa. This mucosa
has a highly specialized function in respiration
and should be preserved carefully when possible.
Superiorly, the lining consists of olfactory mucous
membrane, which has a yellowish hue.
4.8.2 Bony Septum
The perpendicular plate of the ethmoid forms the
upper third of the bony septum and is continuous
above with the frontal bone and the cribriform
plate. Anteriorly, it articulates with the inward
projection of the nasal bones in the midline, cau-
dally with the septal cartilage, and inferiorly with
the vomer (Figs. 4.26 and 4.27 ). The degree of
contact between ethmoid and vomer depends on
how much septal cartilage is interposed between
them. The level of the junction of the perpendicu-
lar plate with the septal cartilage at the dorsal key-
stone area varies with the amount of distal nasal
bone overlap of the upper lateral cartilage, but can
be 1 cm or more cephalic to the caudal end of the
nasal bone. Along its anterior junction with the
Fig. 4.26 ( a ) Location of coronal CT sections projected
on sagittal view of the cranium. ( b ) Level of the anterior
maxilla and frontal sinus. Note the groove in the premax-
illary crest and the groove in the perpendicular plate of the
ethmoid. ( c ) Level of the anterior aspect of the maxillary
sinus and posterior frontal sinus. Note the cephalic septal
cartilage extension between the vomer posteriorly and the
perpendicular plate of the ethmoid anteriorly. ( d ) Level
of the mid septum. Note the following: the crista galli
above the roof of the nasal cavity; the nasal crest of the
maxilla; the middle and inferior turbinates and meatuses;
and the ethmoid cells between the lateral wall of the nose
and the medial wall of the orbit. ( e ) Posterior septum.
Note the nasal crest of the palatine bone or fl oor of the
nose and the superior turbinate with the lateral ethmoid
interposed next to the medial orbital wall
Frontal sinus
Frontal bone
Nasal bone
Keystone area
Septal cartilage
Upper lateral cartilage
Medial crus of alar
cartilage
Anterior nasal spine
Premaxillary portion
of maxilla
incisive canal
Palatine process of maxilla
Nasal crest of maxilla
Palatine bone
Nasal crest of Palatine bone
Vomer
Sphenoid sinus
Perpendicular plate
of ethmoid bone
Cribriform plate
Crista galli
Fig. 4.27 The nasal septum. The left lateral wall of the nose has been removed (Courtesy of Jaye Schlesinger, Ann
Arbor, MI)

54
R.M. Oneal and R.J. Beil
septal cartilage, the ethmoid is sometimes grooved,
making its disarticulation from the septal cartilage
dif fi cult during septoplasty. In some patients, it
may be easier to incise through the cartilage
2–3 mm anterior to this junction to separate the
two structures. The vomer is shaped like the keel
of a boat and extends anteriorly and inferiorly
from the sphenoid superiorly to the nasal crest of
the palatine bones and maxilla, where it joins the
premaxillary wings of the maxilla (Figs. 4.26 , and
4.27 ). Anteriorly, the vomer and premaxillary
wings embryologically are paired bones that fuse
to form a groove for insertion of the inferior edge
of the quadrilateral septal cartilage. Caudally, the
most projecting part of the premaxilla is the ante-
rior nasal spine, which is the most caudal attach-
ment at the inferior edge of the septal cartilage. In
the non-Caucasian nose, the anterior nasal spine
may be undeveloped or even totally absent [ 5 ] .
The bony groove that supports the septal cartilage
is most prominent caudally in the premaxilla and
gradually becomes more fl attened as it progresses
posteriorly along the vomer.
4.8.3 Cartilaginous Septum
The septal cartilage is a fl at plate of cartilage of
irregular quadrilateral shape and varying size
(Fig. 4.27 ). Embryologically, it develops as a
single unit along with the cephalic two-thirds of
the upper lateral cartilages [ 48, 49 ] . It articulates
with the perpendicular plate of the ethmoid and
the fused portions of the vomer and premaxillary
wings. Its shape depends in part on the length and
angulation of the cephalic extension between the
vomer and the perpendicular plate of the ethmoid.
The quadrilateral cartilage provides support and
the form of the nasal dorsum from the cartilagi-
nous bony junction (rhinion) to just cephalic to
the lobule in the supratip area. The anterior septal
angle is at the junction of the dorsal and caudal
septum. The other two caudal angles are the inter-
mediate and posterior (Fig. 4.28 ). There are some
critical aspects about the tongue-and-groove
articulation between the quadrilateral septal car-
tilage and the premaxilla and vomer (Fig. 4.29 )
[ 36 ] . Although some periosteal fi bers are contin-
uous with the ipsilateral perichondrial fi bers,
many pass around the superior articulated edge of
the bone to become continuous with the opposite
periosteum or cross to become continuous with
the opposite perichondrial fi bers. The perichon-
drium has a similar crossed con fi guration around
the inferior edge of the quadrilateral cartilage.
There are fi brous connections within the groove
that allow mobility of the cartilaginous septum in
this bony groove, permitting slight rotation later-
ally when the cartilage is compressed, reducing
the danger of fracture. The sum effect is a joint
with intricate interweaving of periosteum and
Anterior septal angle
Intermediate
septal angle
Posterior
septal angle
a
b
Fig. 4.28 ( a ) The soft tissue has been removed. Note the
three angles of the caudal septum and the anterior nasal
spine. ( b ) Fresh cadaver dissection: right nasal wall removed.
Note the three angles of the caudal septum, the anterior nasal
spine, and the position of the left medial and middle crus
(Courtesy of Jaye Schlesinger, Ann Arbor, MI)

55
4 Surgical Anatomy of the Nose
perichondrium that makes a continuous muco-
perichondrial dissection dif fi cult.
4.8.4 Lateral Wall of the Nasal Cavity
The lateral wall of the nasal cavity is a special-
ized area (Fig. 4.30 ). It contains the three tur-
binates: superior, middle, and inferior. They are
scrolls of bone covered by mucosa containing a
plexus of large veins, which can become mark-
edly engorged. The turbinates can cause interfer-
ence with visualization and manipulation during
intranasal examination and usually require vaso-
constriction to allow adequate intranasal exami-
nation preoperatively. Vasoconstriction also
facilitates visualization of the posterior reaches
of the nasal cavities during surgical procedures.
The inferior turbinates often become compensa-
torily enlarged on the side opposite septal devia-
tions. There is crucial juxtaposition of the caudal
end of the inferior turbinate within the narrow
fl ow-limiting segment of the nasal valve area
(Fig. 4.21 ) [ 60 ] . Consequently, alterations of
their size and position are required frequently
during operations for nasal airway obstruction.
Inferior to each turbinate are the superior, mid-
dle, and inferior meatuses, respectively. Openings
from the various paranasal sinuses open into
these meatuses and the nasolacrimal duct,
which drains into the inferior meatus approxi-
mately 1 cm behind the pyriform opening.
There can be temporary interference with drain-
age of these adjacent structures because of
intranasal swelling, which may explain the
increase in tearing and sinus stuf fi ness seen
after rhinoplasty.
4.9
The Nerves, Blood Supply,
and Lymphatics of the Inside
of the Nose
Figures 4.31 , 4.32 , 4.33 , and 4.34 clearly depict
the nerves and arteries of the inner nose. They
should be studied carefully. Special mention of
only a few facts needs to be made. Little’s area on
the anterior septum is one of these (Fig. 4.34 ).
This is an area of vascular con fl uence of the
super fi cial terminal branches of the anterior eth-
moidal, sphenopalatine, and superior labial arter-
ies [ 13, 30, 61 ] . This is called Kesselbach’s plexus
(Fig. 4.34 ). Because of the rich supply of
super fi cial blood vessels in this concentrated
area, it is a common location for anterior nasal
bleeding and is easily accessible for cauterization
[ 13, 61 ] . It is particularly relevant with anterior
septal deviations.
Septal cartilages
Premaxilla
Periosteal layers
Fractured
premaxillary wing
Disposed
septal cartilage
forming spur
Perichondrial
layers
a
b
Crossed perichondrial and
periosteal fibers
Fig. 4.29 ( a ) Cross-sectional diagram depicting the joint between the septal cartilage and premaxilla. ( b ) Common
posttraumatic con fi guration of this junction (Courtesy of Jaye Schlesinger, Ann Arbor, MI)

56
R.M. Oneal and R.J. Beil
Superior concha
Middle concha
Inferior concha
Nasal bone
Upper lateral
cartilage
Alar cartilage
Torus tubris
Opening of
eustachian tupe
Fig. 4.30 Right lateral wall of the nasal cavity with left nasal wall and septum removed. The palate is sectioned in the
midline (Courtesy of Jaye Schlesinger, Ann Arbor, MI)
Lateral posterior
superior nasal n.
Lateral posterior
inferior nasal n.
Lesser palatine n.
Pterygopalatine nn.
Pterygopalatine
ganglion
Lateral internal
nasal branch of
anterior ethmoid n.
Exteranl nasal branch of
anterior ethmoidal n.
Greater palatine n.
Fig. 4.31 Nasal cavity showing the sensory nerve supply of the lateral nasal wall (Courtesy of Jaye Schlesinger, Ann
Arbor, MI)

57
4 Surgical Anatomy of the Nose
Medial internal
nasal branch of
anterior ethmoid n.
Medial posterior
nasal branch of
pterygopalatine
ganglion
Nasopalatine n.
Fig. 4.32 Nasal septum with left lateral wall of nose removed showing the sensory nerve supply to the nasal septum
(Courtesy of Jaye Schlesinger, Ann Arbor, MI)
Lateral nasal branch of
posterior ethmoidal a.
Posterior lateral
nasal branches of
sphenopalatine a.
Descending
palatine a.
Branch of angular a.
Lesser palatine n.
Posterior septal branch
of sphenopalatine a.
Lateral internal
nasal branch of
anterior ethmoid a.
Exteranl nasal branch of
anterior ethmoidal a.
Greater palatine n.
Sphenopalatine a.
Fig. 4.33 Nasal cavity showing the arterial blood supply to the right lateral nasal wall (Courtesy of Jaye Schlesinger,
Ann Arbor, MI)

58
R.M. Oneal and R.J. Beil
4.9.1 Veins
The submucosa of the interior of the nose is com-
posed of well-developed venous plexi, which are
particularly prominent on the inferior nasal con-
cha, the inferior meatus, and the posterior part of
the septum. They function like erectile tissue.
Batson [ 62 ] , in 1954, noted a rich venous plexus
on his injection studies, with interlacing veins of
diameters of 0.1–0.5 mm forming a widely inter-
mingled valveless network [ 62 ] . This rich venous
plexus forms essentially a cast of all the internal
nasal structures. This venous plexus also is pres-
ent in the tissues of the vestibule, but to a lesser
degree [ 62 ] . Dion et al. [ 32 ] noted microscopic
veins on the deep surface of the lateral crus and
the intercartilaginous area [ 32 ] . There is some
evidence from careful air fl ow studies that there
may be some mucosal congestion in the vestibular
mucosa. These various venous plexi converge into
de fi nitive veins that correspond to the arteries on
the lateral nasal wall and septum. They pass
through the pterygopalatine foramen into the pha-
ryngeal plexus and via the ethmoid branches into
the cavernous sinus. The external nasal vein drains
into the facial vein and jugular system. Thus,
injected materials or drainage from infection the-
oretically can spread rapidly into the cerebral,
ophthalmic, and central circulation [ 34 ] .
4.9.2 Lymphatics
Anteriorly, the nasal lymphatics drain through
the soft tissue nares and into the lymphatics of
the upper lip. Posteriorly, they are larger and
more prevalent, and some drain toward the deep
cervical lymph nodes. The majority, however,
pass into a plexus in front of the eustachian tube,
where they join the lymphatics from the upper
pharynx and middle ear to pass into the retropha-
ryngeal nodes [ 13, 63 ] .
Kiesselbach’s plexus
Septal branch of
superior labial a.
Posterior septal branch
of sphenopalatine a.
Medail internal
nasal branch of
anterior ethmoid a.
Septal branch of
posterior ethmoidal a.
Fig. 4.34 Nasal septum with the left lateral wall of the nose removed showing the arterial blood supply to the left side
of the nasal septum. Kesselbach’s plexus is shown in the dotted circle (Courtesy of Jaye Schlesinger, Ann Arbor, MI)

59
4 Surgical Anatomy of the Nose
Conclusions
Knowing the details of nasal anatomy is essen-
tial when undertaking rhinoplasty surgery.
Careful study of these details makes for a
more con fi dent, prepared practitioner.
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bone and the cartilaginous nasal septum. Plast
Reconstr Surg 8(6):443–455
49. McKinney P, Johnson P, Walloch J (1986) Anatomy
of the nasal hump. Plast Reconstr Surg 77(3):
404–405
50. Converse JM (1950) Corrective surgery of nasal devi-
ations. Arch Otolaryngol Head Neck Surg 52(55):
671–708
51. Poublon RM, Verwoerd CD, Verwoerd-Verhoef HL
(1990) Anatomy of the upper lateral cartilages in the
human newborn. Rhinology 28(1):41–45
52. Bernstein L (1975) Submucous operation on the nasal
septum. Otolaryngol Clin North Am 6:549
53. Robin JL (1979) Extra mucosal method in rhinoplasty.
Aesthetic Plast Surg 3:171
54. Kern EB (1977) Surgery of the valve. In: Sisson GA,
Tardy ME Jr (eds) Plastic and reconstructive surgery
of the face and neck: proceedings of the second inter-
national symposium, vol 2. Grune and Stratton, New
York, pp 501–554
55. Parell GJ, Becker GD (1984) The tension nose. Facial
Plast Surg 1:81
56. Daniel RK (1987) Rhinoplasty: creating an aesthetic
tip. Plast Reconstr Surg 80(6):775–783
57. Wright WK (1967) Study on hump removal in rhino-
plasty. Laryngoscope 77(4):508–517
58. Wright WK (1975) Surgery of the bony and cartilagi-
nous dorsum. Otolaryngol Clin North Am 8(3):
575–598
59. Byrd HS, Andochick S, Copit S, Walton KG (1997)
Septal extension grafts: a method of controlling tip
projection, rotation and shape. Plast Reconstr Surg
100(4):999–1010
60. Haight JS, Cole P (1983) The site and function of the
nasal valve. Laryngoscope 93(1):49–55
61. Ritter FN (1970) The vasculature of the nose. Ann
Otol Rhinol Laryngol 79(3):468–474
62. Batson OV (1954) The venous networks of the nasal
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63. Robison M (1944) Lymphangitis of the retro pharyn-
geal lymphatic system. Arch Otolaryngol Head Neck
Surg 105:333

Part II
Perspectives and Psychology

63
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_5, © Springer-Verlag Berlin Heidelberg 2013
5
5.1
Introduction
Man has always craved youthfulness and good
looks; indeed, the two terms have become almost
interchangeable. For some, the desire to stay
looking young drives them to seek aesthetic sur-
gery, and the nose is a common area of concern.
What follows is a discussion of the place of rhi-
noplasty in the ageing face: an examination of
how rhinoplasty relates to age in biological, psy-
chological, and social contexts and an analysis of
operative technique.
5.2
Ageing
It is necessary to start by trying to de fi ne ageing
in biological terms. The human aspects of advanc-
ing age are so familiar to us in our daily life that
this apparently simple task is surprisingly
dif fi cult. Although technically and chronologi-
cally we start to age from the moment we are
conceived, the word ageing implies a process of
irreversible deterioration following a peak in
function. However, this deterioration affects
different organ systems and tissues at different
rates in the same person: for example, gonadal
development fi nishes after puberty, while a
decline in musculoskeletal function does not start
until approximately the third decade. This pro-
gression also occurs at different rates between
individuals, and it can be examined at various
levels, from the body as a whole to its molecular
processes [ 1, 2 ] .
Since there are so many facets to biological
ageing, it is dif fi cult to de fi ne the moment at
which the developmental peak is reached and
ageing begins, with reference to the person as a
whole. In the face and nose, the effects become
apparent relatively early. It has been suggested
that changes start in the late teens, but do not
become obvious until the mid-twenties [ 3 ] , when
subtle alterations in structure of the skin and
underlying tissues start to be in fl uenced by extrin-
sic factors such as sun damage, smoking, and
alcohol. However, it tends not to be until midlife
that our appearance has altered to an extent that
prompts some to seek surgical assistance. It is
therefore less important to put a fi gure in years on
what constitutes ‘the ageing face’, more to recog-
nise the typical changes that occur.
Rhinoplasty in the Ageing Face
James W. Rainsbury and Darryl J. Hodgkinson
J. W. Rainsbury , M.D., BMBS, MRCS (*)
Department of ENT , Queen Elizabeth Hospital ,
Edgbaston , Birmingham B15 2BW , UK
e-mail: james.rainsbury@nhs.net
D. J. Hodgkinson , M.D., M.B.B.S.(Hons),
FRCS(C), FACS, FACCS, DIP
The Cosmetic and Restorative Surgery Clinic ,
20 Manning Road , Double Bay , NSW 2028 , Australia
e-mail: dr_hodgkinson@bigpond.com

64
J.W. Rainsbury and D.J. Hodgkinson
5.3
The Ageing Nose
The nose is a three-layered structure, consisting
of skin and subcutaneous tissues, bony and carti-
laginous support, and mucosa. Age-related
changes in the nose affect all three layers and are
predictable, although the extent to which they will
affect a particular individual is not (Table 5.1 ).
Microscopically, there is a reduction in dermal
collagen synthesis and an increase in the number
of disorganised elastic fi bres, resulting in thinner,
less elastic skin, particularly over the dorsum and
columella; meanwhile, despite an overall reduc-
tion in sebum production, the size of sebaceous
glands in the nasal tip increases, making it heavy
and bulbous. There is loss of support from the soft
tissues due to muscle atrophy and fatty in fi ltration
into the super fi cial musculo-aponeurotic system
(SMAS) layer. This causes sagging of the tip com-
plex, while the thinner areas of skin show up any
underlying structural irregularities. Combined with
reduced skin elasticity and resultant redundancy,
this means that wide undermining is required for
optimal redraping of the soft-tissue envelope for a
better fi nal result and that the thin skin is more
liable to be torn when raising this fl ap.
Cartilage either softens excessively or ossi fi es
[ 4, 5 ] . The macroscopic effect is downward migra-
tion of the lateral crura of the lower lateral carti-
lages and an unfurling of the scroll area, leading
to drooping of the nasal tip. In addition, maxillary
alveolar bone resorption causes posterior dis-
placement of the pyriform aperture and divergence
of the medial crura, reducing tip projection further
and exaggerating the already acute columellar
angle. Not only is the overall effect aesthetically
unacceptable to some patients, but the sagging tip
diverts air fl ow superiorly into the narrow vesti-
bule area, causing obstructive symptoms that may
be aggravated by internal or external valve col-
lapse (again, due to degenerative loss of cartilage
support) or a pre-existing septal deviation
(Fig. 5.1 ). The nasal bones themselves also
become brittle, and although this does not result in
any cosmetic alteration, it means that osteotomies
are less predictable and more prone to comminu-
tion and should, therefore, be avoided if possible.
Within the nose, the mucoperichondrium
becomes atrophic and fragile, which is easy to
tear. The number and activity of mucus-secreting
glands in the respiratory epithelium is reduced,
so these patients may complain of dryness or
excessive crusting post-operatively. Blood ves-
sels within the ageing mucosa and skin are thin
and sclerotic, which may lead to irritating intra-
operative bleeding and marked bruising, and
should alert the surgeon to the increased possibil-
ity of post-operative septal haematoma.
The end result of the changes is a long nose
with an under-projected, rotated tip; a dorsal
pseudo-hump; and functional internal and/or
external valve obstruction, some aspects of which
are nicely illustrated in Warhol’s iconic Before
and After (Fig. 5.2 ). These are the issues that
should be considered and addressed during rhi-
noplasty in the older patient (Table 5.2 ).
One critical anatomical concept to appreciate
in the ageing face is aesthetic balance. Part of our
perception of beauty depends on the presence of
proportion and speci fi c mathematical relation-
ships between the component parts. This idea is
not new: as far back as the Renaissance, Leonardo
da Vinci illustrated how facial proportions may
be represented by numerical ratios, and he dem-
onstrated how the vertical height of the aestheti-
cally pleasing face is divided into equal thirds
[ 6 ] . Age-related changes alter this balance: the
hairline recedes, and the nasal tip sags, and upper
two
thirds
lengthens,
creating
a
dorsal
pseudo-hump (Fig. 5.3 ). Meanwhile, the lower
third is shortened by maxillary and mandibular
bone resorption, most notably in the edentulous
Table 5.1 Age-related structural changes in the nose
Skin
Thinning of dorsum and
columella
Thickening of tip and alae
Subcutaneous tissue
Atrophy and fat in fi ltration of
SMAS layer
Cartilage
Softening or ossi fi cation
Downward migration of lateral
crura of lower lateral cartilages
Splaying of feet of medial crura
of lower lateral cartilages
Unfurling of scroll area
Bone
Maxillary alveolar resorption
Brittle nasal bones
Mucoperichondrium
Atrophic

65
5 Rhinoplasty in the Ageing Face
patient. So even if the ptotic nasal tip is corrected,
further attention may be required in the form of
restorative dentistry, mentoplasty or brow lift to
restore a harmonious sense of vertical proportion
[ 5 ] . At the same time, the overall effect of other
af fl ictions of facial ageing must be considered,
such as baggy eyes, jowls, wattle, and elongated
pinna [ 3, 7 ] . Patients will be variably affected by
these, so any change in nasal shape must be
assessed and corrected in context with the face as
Fig. 5.1 Age-related ptosis
of the nasal tip causes
diversion of air fl ow into
vestibule [ 5 ]
Table 5.2 Age-related aesthetic and functional changes
in the nose
Tip rotation
Tip under-projection
Increased nasal length
Dorsal pseudo-hump
Internal valve collapse
External valve collapse
Fig. 5.2 Andy Warhol
(1962), Before and After

66
J.W. Rainsbury and D.J. Hodgkinson
a whole [ 3 ] . Cosmetic change is often a by-prod-
uct of a functional rhinoplasty, so the surgeon
must be mindful that secondary changes in nasal
shape do not upset the aesthetic equilibrium. To
prevent an end result that is discordant with its
surroundings or exaggerate any shortcomings of
the rest of the face, the aim is conservative sur-
gery, not drastic change.
5.4
Preoperative Assessment
As with any other patient, assessment should be
performed in a systematic fashion: starting with a
relevant history, working through examination
and photography, and ending with counselling
the patient about what can realistically be
achieved and the potential risks and complica-
tions. In the older rhinoplasty patient, there are
several areas in the assessment that need particu-
lar attention.
5.5
History
The surgeon should establish whether the chief
presenting complaint is functional, cosmetic, or
a combination of the two. If obstruction is the
main problem, the nature of the obstruction
should be ascertained (unilateral or bilateral,
constant or variable), and enquiry should be
made about other nasal symptoms (rhinorrhea,
postnasal drip, facial pain, anosmia, itching,
sneezing, or bleeding). It is important to rule out
other causes for the patient’s blocked nose, such
as rhinitis, polyps, or neoplasm, before subject-
ing them to an inappropriate operation. Patients
with rhinitis should also be warned that their
condition may be exacerbated post-operatively,
possibly for weeks or months [ 8 ] . In patients
with a cosmetic complaint, it is important to
explore the patient’s expectations of what will be
achieved before embarking on surgery. In gen-
eral, it is accepted that correction of age-related
changes in the nose restores approximately
5 years to the ageing face [ 9 ] .
Other medical and surgical history should be
discussed. Previous nasal surgery or pinnaplasty
will in fl uence decisions about a donor site for
cartilage autografts. Coexisting medical com-
plaints are common in this group and may
increase the anaesthetic risk or affect the surgical
outcome. From a purely operative point of view,
hypertension should be controlled to reduce
bleeding, and diabetics should have good glyce-
mic control to optimise wound healing. Smokers
are more likely to have delayed wound healing
and wound breakdown. Drugs that inhibit plate-
let function (such as aspirin, dipyridamole, clopi-
dogrel, and non-steroidal anti-in fl ammatories)
and anticoagulants (such as warfarin) should be
stopped at an appropriate interval prior to surgery
if it is safe to do so. It should be noted that many
patients with the conditions or medications
1/3
1/3
1/3
>1/3
>1/3
<1/3
Pseudo-hump
Fig. 5.3 Change in facial
proportions with age,
demonstrating development
of dorsal pseudo-hump [ 5 ]

67
5 Rhinoplasty in the Ageing Face
described above will have ischemic cardio- or
cerebrovascular disease, and if there is any doubt
about the patient’s fi tness for surgery, the opinion
of the anaesthetist should be sought, or the opera-
tion should be postponed or cancelled. There are
also several herbal supplements that interfere
with clotting or platelet function, and these
should also be discontinued. They include garlic,
ginger, ginseng, feverfew, and Ginkgo biloba
[ 10 ] . Nevertheless, advanced age in itself is not a
contraindication for rhinoplasty, with some
authors reporting successful results in patients
aged 80 and above [ 11 ] .
5.6
Psychological Considerations
Psychologically, any change to the nose will
affect our self-image [ 12 ] . Certain nasal shapes
are identi fi able with ethnic groups, religions, or
cultures, and possessing a nose that is identi fi able
with a particular group helps the individual to ‘ fi t
in’. This concept is also deeply rooted in the way
in which we relate to our family: most of us
resemble our parents, and this shared similarity
plays a part in creating strong emotional bonds
within the family unit. The nose, our most promi-
nent facial attribute, is a major factor in forging
this bond, and is subconsciously interlinked with
our feelings towards our parents. Self-image is
ingrained in these ethnic, cultural, and family
foundations and is moulded with age by other
factors (e.g. strong positive or negative feelings
towards a parent) and events (for instance, derog-
atory or complimentary remarks about one’s
nose). An operation that alters facial appearance
either as a primary aim (cosmetic rhinoplasty) or
as a secondary effect (functional rhinoplasty) will
destabilise the patient’s self-image and alter their
way of relating to the world around them. This
disequilibrium appears more marked in older
patients undergoing rhinoplasty, who have had
many years to develop a crystallised self-image
and for whom their nose may be a strong, yet
unacknowledged link to loved ones [ 12, 13 ] .
Because of the nose’s profound psychological
signi fi cance, a good physical result may not
equate to a good emotional outcome, and the
older patient may even require a long period of
adjustment, akin to a period of grieving. Knorr
[ 13, 14 ] states that older patients who have not
disliked their nose since adolescence have the
greatest potential to be dissatis fi ed with the out-
come of rhinoplasty, the reason being that if their
reason for change is super fi cial (e.g. wanting to
look better for a wedding), the strong subcon-
scious associations with race and family will be
upset by surgical correction, leading to feelings
of disconnection from their social group.
Conversely, Rohrich and Hollier [ 5 ] feel that
those older patients with a long-standing dislike
towards their nose may not only have unrealistic
expectations about what surgery can achieve but
also may feel guilty, either about changing a fea-
ture that has strong family associations or for
seeming vain by electing to have a cosmetic pro-
cedure, and operating on them may cause
signi fi cant emotional upset. Either way, it is
imperative that any surgeon considering rhino-
plasty on patients in their middle age or older
should recognise the psychological impact that
the operation may cause and as a result err towards
subtle changes rather than radical surgery. It is
equally essential to recognise the emotionally
unstable patient and to think carefully before con-
sidering surgery; although Thomson [ 15 ] points
out that everyone has a degree of emotional vola-
tility, and we would not perform many operations
if equanimity was a strict condition for rhino-
plasty. It is vital to judge the patient’s level of
emotional reserve since it is this which will help
guard against post-operative dissatisfaction.
Indeed, some surgeons will ask for a psychologi-
cal assessment of these patients as a matter of
routine prior to embarking upon an operation.
Just as the importance of the patient’s psycho-
logical relationship with his nose should not be
underestimated, neither should their motivation
for rhinoplasty. This applies particularly in the
older patient. The aim of the operation is gener-
ally airway improvement, cosmetic, or a combi-
nation of the two. In those patients with a purely
functional problem, the motivation is usually
clear. However, in those with a cosmetic com-
plaint, the motivation may not be so obvious. In a
study of over 5,000 rhinoplasty patients of all
ages, Shulman et al. [ 16 ] found that for older
patients, the fi nal decision to proceed was usually

68
J.W. Rainsbury and D.J. Hodgkinson
triggered by positive factors, such as fi nancial
success or a new job. There was, however, a sub-
set of older patients whose motivation for rhino-
plasty was negative: the death of a spouse,
divorce, feeling ugly, or feelings of sexual inad-
equacy. The sexual symbolism of the nose is
interesting: it is widely accepted that a nose is
rarely just a nose in anyone’s subconscious mind,
and a patient’s desire for rhinoplasty may re fl ect
veiled feelings of sexual insecurity [ 12 ] . These
are feelings that many older people confront as
they fi nd themselves faced in the mirror with
bodies that are ageing in other ways. Yet fi xing
their nose will neither restore this lost feeling of
youth, nor bring back their departed spouse, nor
mend their broken marriage, however skilful the
surgeon. Although it is convenient to neatly cat-
egorise a patient’s motivation for rhinoplasty in
this way, real life is rarely so simple, and the real
driving forces for wanting an operation may be
vague, particularly in the older generation [ 4 ] .
Similarly, an older patient’s expectations may be
ill-de fi ned or unrealistic [ 5 ] , and the onus is on
the surgeon to clarify exactly what is being
requested, the reasons for it, and to be entirely
frank about what can realistically be achieved
within the limitations of ageing tissues and aes-
thetic balance.
5.7
Examination
Prior to functional and aesthetic nasal analysis, a
complete head and neck examination, including
fl exible nasolaryngoscopy, should be performed
since cutaneous and mucosal malignancies are
more common with advancing age, and their
treatment takes precedence [ 4 ] . Nasal examina-
tion focuses on inspection, palpation, and assess-
ment of function. Rather than repeat an in-depth
description of nasal examination, only the fea-
tures salient to the older patient are highlighted
here.
Inspection of the nose should be done in con-
junction with the rest of the face since other age-
related changes will have an effect on the
appearance of the nose, and some of these, for
example, malar fl attening, a ptotic chin, or laxity
of the upper or lower eyelids, may need to be
addressed simultaneously to optimise the end
aesthetic result. The surface anatomy of the nose
is directly related to the underlying structures,
so the examination in the outpatient setting will
be of considerable help in planning the proce-
dure. The skin changes associated with age will
have an effect on rhinoplasty outcome. Thin skin
over the dorsum will not hide minor bony irreg-
ularities, while rhinophyma affecting the tip
may have both functional and cosmetic conse-
quences. Most of the age-speci fi c changes in the
nose affect the lower third: tip bulbosity and pto-
sis leading to a relative dorsal hump and splay-
ing of the footplates of the medial crura leading
to reduced tip projection. Palpation will help to
con fi rm the thickness of the skin, the elasticity
and shape of the cartilages, and extent of tip sup-
port present. Functional evaluation is performed
on quiet and forced inspiration and may be com-
plemented by Cottle’s manoeuvre or manually
resupporting the tip. Of course, the older patient
is as likely as anyone else to have other coexist-
ing nasal cosmetic or functional problems,
which should be assessed and addressed as
necessary.
Six-view nasal photographs are taken (fron-
tal, basal, right and left lateral, right and left
oblique) for documentation purposes and to
allow a before and after comparison. Some sur-
geons use software to alter these images for the
patient, which may be a useful adjunct to a dis-
cussion of the results that may reasonably be
expected [ 8 ] .
5.8
Risks
In general, rhinoplasty is a safe operation, with
few complications in experienced hands, and the
potential complications are well documented [ 8 ] .
5.8.1 Bleeding
Older patients may be more prone to intra- or
post-operative haemorrhage due to underlying
hypertension and its associated atherosclerotic

69
5 Rhinoplasty in the Ageing Face
changes. Bleeding is usually self-limiting, and
adequate preoperative preparation and meticulous
haemostasis will minimise the risk. Occasionally,
a heavy bleed may occur due to sclerotic vessels
that do not constrict when cut, and this may
require packing, cautery, arterial ligation, or blood
transfusion.
5.8.2 Scar
Thinner skin over the dorsum generally heals
with minimal scarring, but the thicker, more seba-
ceous tip skin in the elderly may not, so close
attention should be paid to careful tissue handling
and skin closure. Subcutaneous scarring and con-
tracture may cause a poor cosmetic result that
does not declare itself until several months post-
operatively.
5.8.3 Bruising
Although unpredictable, post-operative bruising
tends to be more extensive and to last longer in
older patients [ 4 ] .
5.8.4 Poor Aesthetics or Function
Unsatisfactory cosmetic result may be visual or
tactile and may be exacerbated by thin dorsal
skin. It may also be due to an inadequate preop-
erative discussion of the patient’s expectations
and achievable results or due to a poor apprecia-
tion of the setting of the nose in the rest of the
ageing face. Nasal obstruction may be a result of
unpredictable behaviour of softened or ossi fi ed
cartilage autografts used for augmentation or due
to inadequate surgical planning, particularly with
respect to the internal valve area.
5.8.5 Anaesthetic Risk
In general, if a patient is fi t for other procedures
under a general anaesthetic, then they are fi t for a
rhinoplasty.
5.8.6 Wound Problems
Delayed healing and breakdown may be more
likely in the presence of smoking, diabetes,
decreased immunity, or atherosclerotic disease.
5.8.7 Septal Perforation
and Saddle Deformity
These are both rare, but the atrophic, fragile
mucosa inside the older nose, combined with cir-
culatory problems, may make them more likely.
Careful tissue handling, conservative septal carti-
lage graft harvesting, and use of septal quilting
sutures will help to reduce to incidence.
5.8.8 Other Risks
Other risks including infection, numbness, and
pain are no more likely in the older rhinoplasty
patient than in their younger counterparts.
5.9
Operative Technique
5.9.1 Anaesthesia and Preoperative
Preparation
In the authors’ opinion, general anaesthesia is
preferable to local with sedation, although the
latter is possible if the general health of the patient
requires it. However, this procedure is never an
essential one, so if medical co-morbidities pro-
hibit a general anaesthetic, the surgeon should
perhaps reconsider his choice of patient. Wherever
possible, hypotensive anaesthesia is preferable
for an optimal operative fi eld.
The patient is prepared and draped in the usual
manner. The author’s (JWR) preference for nasal
preparation is Moffat’s solution (2 mL 4%
cocaine, 1 mL 1:1,000 adrenaline, 1 mL 8.4%
sodium bicarbonate, 6 mL 0.9% saline), although
this should not be used in patients with ischemic
heart disease or hypertension due to the risk of
coronary artery vasospasm. Oxymetazoline spray
is a suitable alternative. Xylocaine 2% with
1:200,000 adrenaline is used for in fi ltration.

70
J.W. Rainsbury and D.J. Hodgkinson
5.9.2 Surgical Approach
Both closed and open approaches are suitable for
rhinoplasty in the ageing face, although the latter
is generally preferred, since most of the common
structural abnormalities affect the tip. A stepped
columellar incision is made with a trans fi xion
incision, which is continued as bilateral infracar-
tilaginous incisions. The soft-tissue envelope is
raised, taking particular care not to buttonhole
the thin dorsal skin. Wide soft-tissue undermin-
ing is required to allow optimum redraping of the
less elastic skin [ 5, 7 ] .
5.9.3 Augmentation Technique
The cosmetic and functional sequelae of age-
related changes in the nose have been previously
discussed (Table 5.2 ), and the operative strategy
should aim to address each of these in turn. The
armoury of techniques at the surgeon’s disposal
is shown in Table 5.3 .
5.9.4 Choice of Graft Material
In many cases, septal cartilage is the ideal choice
of graft material due to its thickness and ease of
accessibility, but in older patients, it may be
de fi cient (e.g. due to previous submucosal resec-
tion) or suboptimal. Conchal cartilage is an alter-
native, but it is often calci fi ed or too soft to provide
adequate support, particularly in the external
valve area. Both septal and conchal cartilages are
prone to buckling under the forces of scar con-
tracture [ 17 ] . Costal cartilage is a good source of
autograft, but is liable to warp, becomes calci fi ed
with advancing age, and requires a separate chest
wall incision which may be quite uncomfortable
[ 7 ] . This should probably be avoided altogether in
older patients with respiratory disease, in whom
the discomfort of breathing may precipitate
hypoventilation and post-operative chest infec-
tion. The use of bone from the calvarium, eth-
moid, and vomer has all been described, but these
are prone to resorption according to Romo et al.
[ 17 ] . The authors advocate the use of preformed
porous polyethylene implants (Medpor, Porex
Surgical), which biointegrate into native tissue
and have the advantage of strength and malleabil-
ity; however, they are associated with a 3–4% rate
of infection or extrusion.
5.9.5 Hump Reduction
Only when the tip work is complete should any
hump reduction be contemplated since the tip
changes may create the illusion of a dorsal hump
when none exists (Fig. 5.4 ). As a rule, the nasal
bones of any patient over 60 should be consid-
ered to be more fragile than in younger patients
[ 18 ] . Conservative dehumping avoids an ‘open
book’ deformity of the dorsum, necessitating cor-
rection with lateral osteotomies, which may com-
promise the internal valve. In this older age
group, osteotomies are prone to cause comminu-
tion, destabilising the dorsum. Therefore, some
authors recommend the use of complete fractures
(rather than greenstick), as well as following a
‘low to low’ osteotomy path to give more control
[ 5, 9 ] . Preservation of the periosteum is widely
Table 5.3 Augmentation and suture techniques employed
in the ageing nose
Aim
Surgical technique
Tip derotation and
projection
Medial crural-septal spanning
suture
Transdomal sutures
Tongue-in-groove [24 ]
Cephalic trim
Infratip lobular graft
Intercrural columellar strut graft
Premaxillary augmentation graft
Internal valve
support
Spreader graft [25]
Butter fl y spreader graft [26]
External valve
support
Alar batten graft ± lateral crural
resection [ 17 ]
Lateral crural strut graft
Length reduction
Trimming of caudal septum
Tongue-in-groove [24]
Rhinolift [27]
Adjunctive
techniques
Dorsal onlay dermal contour
graft
Interdomal suture
Rhinophyma reduction

71
5 Rhinoplasty in the Ageing Face
recommended, and some suggest that greenstick
fractures are less likely to disrupt this layer and
create a fl ail segment of nasal bone [ 19 ] . Rasping
is considered by some to be a suitable alternative
to formal dehumping, provided that care is taken
to reduce any cartilaginous component by sharp
dissection, since this will not be effectively
addressed by this method. Either way, caution
and a conservative hand are required.
Due to the thinner skin over the dorsum, a
camou fl age onlay graft may be utilised, such as
temporalis fascia, morselised cartilage, or a syn-
thetic equivalent.
5.9.6 Closure
After redraping the soft-tissue envelope, the colu-
mellar and infracartilaginous incisions are closed
with suitable sutures. Nasal packing is avoided
wherever possible, and an external splint is applied.
5.9.7 Post-operative Care
In this group of patients, unplanned overnight stays
are more common than in younger groups [ 20 ] .
Medications discontinued preoperatively should
a
b
Fig. 5.4 ( a ) Preoperative country and western singer with typical appearance of an ageing nose. Note the dorsal
pseudo-hump and ptotic tip. ( b ) Post-operative following rhinoplasty

72
J.W. Rainsbury and D.J. Hodgkinson
be recommenced as soon as it is safely possible.
As mentioned above, bruising may be marked, and
warning patients of this beforehand may help to
allay any distress caused by this. Since the nasal
mucosa is already atrophic, patients may fi nd that
moisturisation with saline drops or a water-based
lubricant (such as K-Y jelly) is bene fi cial [ 4 ] .
Figure 5.4 shows pre- and post-operative
appearances of a country and western singer who
had the typical changes of age affecting his nose.
Rhinoplasty rejuvenated his appearance and made
him feel more con fi dent as a stage performer.
5.9.8 Facelift Combined
with Rhinoplasty
Facial rejuvenation surgery, including facelift
and blepharoplasty with rhinoplasty, is occasion-
ally performed. Some technical challenges exist
when these procedures are performed in one
operative session.
The challenges include, not least, the time nec-
essary to perform these procedures. Extending an
elective cosmetic surgical procedure under gen-
eral anaesthesia over 4–5 h might not be consid-
ered appropriate, due to the prolongation of the
anaesthesia time. The effect of adrenaline, vaso-
constriction, lessens also with time, and this may
cause increased painful stimulation when the rhi-
noplasty is performed, raising blood pressure
increasing the possibility of haematoma occur-
ring during the facelift procedure. If blepharo-
plasty is performed with rhinoplasty, the additional
periorbital bruising and swelling and prolonga-
tion of ecchymosis have to be considered.
Positioning of an endotracheal tube orally, or
a tube change between performing the lower and
upper procedures, requires anaesthetic to insert a
fl exible rotational tube or change the tube after
the submental area has been approached and
repaired. Head manipulation is inadvisable after
facelift, and changing the position of the tube can
be time- consuming or cause tracheal irritation
and coughing.
A patient’s discomfort has to be considered,
especially if nasal packing or internal septal
splinting is anticipated. In the post-operative
period, distress from bandage discomfort, inci-
sional pain, swelling and headache and nasal
stuf fi ness may be a problem. Should also be eval-
uated as well as just how much the patient can
tolerate. Prolonged chemosis and ecchymosis
from a blepharoplasty combined with rhinoplasty
can also be very distressing for the surgeon and
the patient and require extraocular medication.
Patients, however, are keen to have combined
surgeries as they only perceive a one-time recu-
perative period and not anxious for two-stage
procedures, adding expense and extra time off
regular work or social activities.
Taking all these factors into account, there are
some patients whose ageing or pre-existing nasal
concerns must be addressed at the same time as
rejuvenation surgery if an optimal result is to be
achieved.
Careful planning with preoperative digital imag-
ing assists in performing the procedures sequen-
tially and with alacrity. The sequence used for
combined procedures is to inject the blepharoplasty
incisions and the facelift incisions with 1%
Xylocaine in 1:100,000 adrenaline. Approximately
30 mL is injected. With the oral endotracheal tube
rotated over the submental area, the upper and
lower lid blepharoplasties are performed, and these
should take approximately 1 h. After the hour, the
tube is rotated over the brow area, and the facelift
fi eld is injected with approximately 100 mL of
0.25% Xylocaine and 1:400,000 adrenaline, and
the nose is injected with approximately 10–20 mL
of 1% Xylocaine in 1:100,000 adrenaline, and the
nasal passages are packed with 1/2″ gauze soaked
in 1% Xylocaine in 1:100,000 adrenaline. After the
facelift, the oral endotracheal tube is then swung
inferiorly so that the nose can be approached.
The facelift proceeds in 2 h. The rhinoplasty
proceeds over 1 h. The patient is then extubated
and returns to the recovery room with head elevated
and ice-soaked gauze continuously applied to the
periorbital region, and these are continued over the
next 24 h by a dedicated one-on-one nurse.
An example of facelift combining with rhino-
plasty is shown with the effect being of a panfa-
cial rejuvenation (Fig. 5.5 ).
A special case is skin malignancies, which
occur commonly in the nose. These may require

73
5 Rhinoplasty in the Ageing Face
reconstruction, which can provide an ideal
opportunity to improve the appearance of the
nose simultaneously if the patient wishes to
have facial rejuvenation. Combining these pro-
cedures. The patient then receives a secondary
bene fi t of not only removal of the tumour under
histological control and nasal reconstruction, but
also facial rejuvenation (Fig. 5.6 ).
5.10
Discussion
Each patient should be individually assessed and
the surgical technique tailored to their anatomical
requirements, but a typical sequence might run as
follows [ 5 ] :
1. General anaesthetic
2. Appropriate
intranasal
preparation
and
in fi ltration of local anaesthetic
3. Open approach
4. Submucosal resection of septum and harvest-
ing of cartilage grafts
5. Columellar stabilisation and tip correction
6. Dehumping if required ± dorsal onlay
graft
7. Percutaneous osteotomies if required
8. Closure and splinting
9. Appropriate post-operative care
a
b
Fig. 5.5 ( a ) Preoperative female with appearances of an ageing nose and other age-related facial changes. ( b ) Post-
operative following simultaneous facelift, rhinoplasty, and cheek implants

74
J.W. Rainsbury and D.J. Hodgkinson
5.11
Quality of Life Outcomes
In the UK, health care is publicly funded and
delivered through the National Health Service
(NHS), where treatment is free at the point of
service, and based on clinical need rather than the
ability to pay. This results in rationing of non-
essential services, whose appropriateness is ques-
tionable in an overstretched system. Cosmetic
rhinoplasty is therefore rarely offered on the NHS,
regardless of age, although the operation is rou-
tinely performed for airway obstruction or follow-
ing nasal trauma. Both nasal obstruction and poor
aesthetics are distressing, and a number of papers
have tried to quantify improvements in quality
of life (QOL) following rhinoplasty [ 21– 23 ] .
McKiernan’s group used the Glasgow Bene fi t
Inventory (GBI), a validated questionnaire with a
range of outcomes between −100 (maximum
harm) to +100 (maximum bene fi t), to show that
rhinoplasty improves health-related QOL [ 21 ] .
Interestingly, they found that when the indication
was function alone, the improvement was +27.7,
while when aesthetics was the main complaint,
the score was +52.7. When aesthetics and func-
tion were addressed together, the score was +58.3
(tonsillectomy scored +49.9 in their original
paper) [ 22 ] . In a different paper, Litner et al. [ 23 ]
used another questionnaire to assess periopera-
tive QOL in patients undergoing various cosmetic
procedures and found not only that cosmetic rhi-
noplasty improved QOL signi fi cantly more than
other procedures for the ageing face but that the
a
b
Fig. 5.6 ( a ) Preoperative female with typical age-related
changes of the nose, face, and neck, who also had a basal
cell carcinoma (BCC) on her nasal tip. ( b ) Post-operative
following excision of BCC, bilobed fl ap reconstruction,
rhinoplasty, and simultaneous facelift

75
5 Rhinoplasty in the Ageing Face
greatest improvement in QOL was seen in patients
over 50. Although it is hard to put a cost-bene fi t
value on rhinoplasty, patient satisfaction is being
increasingly regarded as a key indicator of per-
formance. It is dif fi cult to say whether older
patients get satisfaction from rhinoplasty simply
because of the surgical changes or because they
feel better about themselves following their oper-
ation and take more care over their appearance in
general; nevertheless, there seems to be evidence
that rhinoplasty improves QOL and that older
patients derive the greatest bene fi t from it. Maybe
we can surmise from this that rhinoplasty in the
ageing face is a worthwhile operation in terms of
patient satisfaction and would have a place on the
NHS in an ideal world.
Conclusions
Rhinoplasty has a de fi nite place in the ageing
face and has the potential to give bene fi cial
results. However, as discussed above, a good
sense of aesthetic balance is fundamental in
creating a nose that is in harmony with the rest
of the face. Furthermore, exploring patient
motivation and expectation is critical, possibly
even more so than in younger patients.
References
1. Pathy M, Sinclair AJ, Morely AJ (1998) Principles
and practice of geriatric medicine, 3rd edn, Aging.
Wiley, Chichester, pp 9–34
2. Bond J, Briggs R, Coleman PG (1993) The study of
aging. In: Bond J, Coleman PG, Peace S (eds) Ageing
in society: an introduction to social gerontology, 2nd
edn. Sage, London, pp 19–52
3. Patterson CN (1980) The aging nose: characteristics
and correction. Otolaryngol Clin North Am 13(2):
275–288
4. Moody M, Ross AT (2006) Rhinoplasty in the aging
patient. Facial Plast Surg 22(2):112–119
5. Rohrich RJ, Hollier LH (1999) Rhinoplasty with
advancing age: characteristics and management.
Otolaryngol Clin North Am 32(4):755–773
6. Richter I (1998) The notebooks of Leonardo da Vinci.
Oxford University Press, Oxford
7. Cochran CS, Ducic Y, DeFatta RJ (2007) Restorative
rhinoplasty in the aging patient. Laryngoscope 117(5):
803–807
8. Rohrich RJ, Muzaffar AR (2006) Primary rhinoplasty.
In: Mathes SJ, Hentz VR (eds) Plastic surgery.
Saunders Elsevier, Philadelphia, pp 427–471
9. Guyuron B (1997) The aging nose. Dermatol Clin
15(4):659–664
10. Wynn RL, Bergman SA (2002) Drugs and herbal rem-
edies that affect blood clotting. Gen Dent 50(6):484–
488, 490
11. Shumrick KA, Campbell A, Becker F (1999) Nasal
reconstruction in the elderly patient. The case for not
letting age determine method. Arch Facial Plast Surg
1(4):297–301
12. Goin MK (1977) Psychological understanding and
management of rhinoplasty patients. Clin Plast Surg
4(1):3–7
13. Thomson JA Jr, Knorr NJ, Edgerton MT Jr (1978)
Cosmetic surgery: the psychiatric perspective.
Psychosomatics 19(1):7–15
14. Knorr NJ (1972) Feminine loss of identity in rhino-
plasty. Arch Otolaryngol 96(1):11–15
15. Thomson HS (1972) Preoperative selection and coun-
selling of patients for rhinoplasty. Plast Reconstr Surg
50(2):174–177
16. Shulman O, Westreich M, Shulman J (1998)
Motivation for rhinoplasty: changes in 5970 cases, in
three groups, 1964 to 1997. Aesthetic Plast Surg
22(6):420–424
17. Romo T 3rd, Soliemanzadeh P, Litner JA, Sclafani AP
(2003) Rhinoplasty in the aging nose. Facial Plast
Surg 19(4):309–315
18. Winkler AA, Downs BW (2008) Aging male rhino-
plasty. Facial Plast Surg Clin North Am 16(3):
329–335
19. Toriumi DM (1996) Surgical correction of the aging
nose. Facial Plast Surg 12(2):205–214
20. Mandal A, Imran D, McKinnell T, Rao GS (2005)
Unplanned admissions following ambulatory plastic
surgery–a retrospective study. Ann R Coll Surg Engl
87(6):466–468
21. McKiernan DC, Ban fi eld G, Kumar R, Hinton AE
(2001) Patient bene fi t from functional and cosmetic
rhinoplasty. Clin Otolaryngol Allied Sci 26(1):50–52
22. Robinson K, Gatehouse S, Browning GG (1996)
Measuring patient bene fi t from otorhinolaryngologi-
cal surgery and therapy. Ann Otol Rhinol Laryngol
105(6):415–422
23. Litner JA, Rotenberg BW, Dennis M, Adamson PA
(2008) Impact of cosmetic facial surgery on satisfac-
tion with appearance and quality of life. Arch Facial
Plast Surg 10(2):79–83

77
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_6, © Springer-Verlag Berlin Heidelberg 2013
6
6.1
Introduction
In the last years, there has been a marked expan-
sion of possibilities for aesthetic surgery, usually
requested by patients who are emotionally or
psychosocially motivated. A more than 500%
increase in the number of cosmetic surgery inter-
ventions has been reported from 1997 to 2007 by
the American Society for Aesthetic and Plastic
Surgery. The importance of beauty is enhanced in
modern society and culture, the ideal of beauty
being de fi ned by the media through magazines,
television, and music. Both men and women are
becoming increasingly concerned about their
physical appearance and are seeking cosmetic
interventions. Socioeconomic status and self-
esteem seem to depend on having body features
matching those proposed/imposed by media, and
thus beauty gains a meaning which goes beyond
the purely aesthetic aspects. Recognizing the rea-
sons behind the choice of cosmetic surgery is
becoming more and more important, as the
request for these interventions continues to rise
[ 1 ] , and among these patients, up to the 47.7%
meet criteria for a mental disorder [ 2 ] .
Psychiatrists see the interface of beauty with
mental health, self-esteem, and mental illness;
plastic and cosmetic surgeons may encounter a
broad spectrum of patients including those whose
pursuit of enhanced cosmetic appearance is
extremely maladaptive [ 3 ] .
In cosmetic and plastic surgery, the operative
competence is not focused on the correction of
pathological disorders, but on the amendment of
some morphologic traits not accepted by the
patient, or not adherent with the aesthetic canons
of the time, although they are absolutely compat-
ible with the norm. This may represent a problem
for subjects – as patients with body dysmorphic
disorder or narcissistic and histrionic personality
disorders – whose judgment is impaired because
of their psychiatric illnesses [ 3 ] . These patients
may live a dualism between body image and
inner self-image [ 4 ] . Their motivations when
seeking cosmetic surgery may be based on sub-
jective impairments of appearance, feelings of
inferiority, low self-esteem, and social phobias.
They may deny possible risks, side effects, and
complications, or can have unrealistic expecta-
tions of the procedure, and since cosmetic sur-
gery recognizes subjective indications, these
patients are at risk of making poor choices when
considering cosmetic interventions.
Researchers in this fi eld agree that clinicians
should acquire a basic understanding of these
psychiatric conditions, which often remain undis-
covered, in order to properly screen their patients
and understand their expectations and goals,
whether realistic or not. A more focused assess-
ment of patients could allow to avoid performing
inappropriate procedures which would frustrate
Self-Esteem and Personality
in Patients with Body Dysmorphic
Disorder Undergoing Cosmetic
Rhinoplasty
Carla Gramaglia and Enrica Marzola
C. Gramaglia , M.D., Ph.D. () • E. Marzola , M.D.
Psychiatry Section, Department of Neuroscience,
University of Turin, Via Cherasco 11, 10126
Torino, Turin, Italy
e-mail: carla.gramaglia@gmail.com;
enrica.marzola@gmail.com

78
C. Gramaglia and E. Marzola
both the clinician and the patient. Patients with
unrealistic expectations are more likely to be
dissatis fi ed with cosmetic procedures, and some
patients, as those with body dysmorphic disorder,
are often dissatis fi ed despite good procedural
outcomes of the cosmetic intervention [ 5, 6 ] .
A basic competence both in the surgical and
the psychological level, or referral to psychologi-
cal or psychiatric counseling, is recommended
even more when extensive (“type change”) pro-
cedures as rhinoplasty are performed, since such
procedures appear to require greater psychologi-
cal adjustment by the patient than “restorative”
procedures (e.g., face-lift) [ 7 ] .
6.2
Body Dysmorphic Disorder
6.2.1
Classi fi cation
Body dysmorphic disorder (BDD) is a relatively
common and often severe psychiatric illness that is
likely to be underrecognized and underreported. It
was historically known as dysmorphophobia and
was fi rst included parenthetically as an example of
an atypical somatoform disorder in the Diagnostic
and Statistical Manual of Mental Disorders-III
(DSM-III) (1980) [ 8 ] ; it appeared with diagnostic
criteria and was renamed as body dysmorphic dis-
order in the DSM-III-R (1987) [ 9 ] .
In DSM-IV-TR [ 10 ] , BDD is currently
classi fi ed as a somatoform disorder character-
ized by the patient’s excessive concern with an
imagined or minor defect in physical appearance
which causes signi fi cant distress and/or impair-
ment. The work group of the American Psychiatry
Association for DSM-V suggests that it should be
reclassi fi ed to anxiety and obsessive-compulsive
spectrum disorders, likely re fl ecting its similari-
ties in features, pathophysiology, and treatment
to obsessive-compulsive disorder. Moreover, even
if currently psychotic and nonpsychotic variants
of BDD are classi fi ed as separate disorders in
DSM-IV-TR (subtype of delusional disorder and
a somatoform disorder), available evidence indi-
cates that they may actually be the same disorder,
characterized by a spectrum of insight and a wide
range of severity [ 6, 11 ] . Patients with delusional
and nondelusional variants of BDD are similar in
demographic features, family history, BDD char-
acteristic, functional impairment, quality of life,
comorbidity, probability of remission at 1-year
follow-up [ 12 ] , and overall course of the disorder
[ 13 ] . Anyway, some differences emerged between
the two variants, being delusional BDD patients
more likely to have attempted suicide, to have drug
abuse or dependence and poorer social functioning.
They were also less likely to be currently receiving
mental health treatment and had more severe BDD
symptoms [ 14 ] , consistently with data from another
study reporting a signi fi cant positive correlation
between poorer insight and more severe symptoms
of the disorder [ 15 ] . However, most of these differ-
ences seem to be accounted for by BDD symptom
severity [ 14 ] . Furthermore, since contrary to expec-
tations BDD delusional form seems to respond to
serotonin reuptake inhibitors alone, a dimensional
approach to delusions/psychosis in these disorders
is supported and may be more accurate than the
current categorical view [ 6, 11, 14 ] .
Some preliminary recommendations con-
cerning changes in diagnostic criteria have been
suggested [ 6 ] commissioned by the DSM-V
Anxiety, Obsessive-Compulsive Spectrum, Post-
Traumatic, and Dissociative Disorders Work
Group, as a rewording of criterion A, the advan-
tages and disadvantages to adding a new criterion
to re fl ect compulsive BDD behaviors, the addi-
tion of a clinical signi fi cance criterion to differ-
entiate BDD from normal appearance concerns.
Table 6.1 shows the current DSM-IV-TR diag-
nostic criteria for BDD and those suggested for
DSM-V by Phillips et al. [ 6 ] .
6.2.2
Clinical Features
The main feature of BDD is a preoccupation with
an imagined defect in appearance or markedly
excessive concern with a slight physical anomaly,
which may be due to distorted perception [ 16 ] .
The preoccupation causes signi fi cant distress or
impairment in social, occupational, or other
important areas of functioning and is not better
accounted for by other mental disorders. BDD
preoccupations may include any body part and

79
6 Self-Esteem and Personality in Patients with Body Dysmorphic Disorder Undergoing Cosmetic Rhinoplasty
the concern may simultaneously focus on several
body parts, and usually involve facial features as
nose, ears, face, hair, or features related to sexu-
ality. Most common are concerns with the skin,
hair, and nose.
BDD subjects obsess about their perceived
defect and this can be time-consuming (several
hours each day), as their consequent behaviors:
they may seek reassurance from others, repeat-
edly mirror check their defect and try, for exam-
ple, to conceal it with clothing, makeup, and hats.
Almost all BDD patients have markedly
impaired quality of life because of their symptoms
as indicated both by cross-sectional/retrospective
and prospective studies [ 17 ] . Being ashamed of
their imagined ugliness, they feel anxious around
other people and fear being rejected because of
their appearance. As a consequence, they may
be socially isolated and show avoidant behav-
iors toward dating and social interactions [ 18 ] .
The impairment may involve social as well
as academic or occupational functioning of
BDD individuals. The assessment of psycho-
social functioning with the Global Assessment
of Functioning scale (GAF) [ 10 ] , Social and
Occupational Functioning Scale (SOFAS) [ 10 ] ,
and Longitudinal Interval Follow-up Evaluation
Range of Impaired Functioning Tool (LIFE-
RIFT) [ 19 ] in a prospective study of the course
of BDD revealed a poor psychosocial function-
ing during the 1–3 years follow-up period, with
BDD severity signi fi cantly predicting poorer
functioning on all three scales. Functioning was
not predicted by age, gender, BDD duration, or
personality disorders [ 18 ] .
The prevalence of BDD reported by published
studies in the general population (most frequently
United States general population) is 0.7–2.3%
[ 11 ] , but since the disorder is underdiagnosed
due to intense patients’ shame, these data may be
an underestimate. Moreover, because of frequent
comorbidity with other conditions, the diagnosis
of BDD is often overlooked.
The prevalence rate found in the general pop-
ulation is 6–16-fold higher in patients seeking
plastic surgery interventions. In aesthetic sur-
gery settings, a prevalence of 7–15% has been
reported in those undergoing cosmetic surgery
[ 1, 11, 20– 23 ] .
BDD usually appears in adolescence and
young adulthood, with an average age of onset of
16–17 years. Body image is crucial during ado-
lescence since global self-esteem is also deter-
mined by psychological and interpersonal
development, and it is likely to play a role in
BDD typical onset during this phase [ 24 ] . The
disorder affects men and women with near equal
frequency and often turns chronic when not
receiving treatment [ 18, 25 ] , with remission rates
lower than reported for mood disorders, most
anxiety disorders, and personality disorders in
follow-up studies [ 12 ] .
Table 6.1 Current DSM-IV-TR diagnostic criteria for
BDD and those suggested for DSM-V by Phillips et al.
DSM-IV-TR criteria for body dysmorphic disorder
(a) Preoccupation with an imagined defect in
appearance. If a slight physical anomaly is present,
the person’s concern is markedly excessive
(b) The preoccupation causes clinically signi fi cant
distress or impairment in social, occupational, or
other important areas of functioning
(c) The preoccupation is not better accounted for by
another mental disorder (e.g., dissatisfaction with
body shape and size in anorexia nervosa)
DSM-V suggested criteria for body dysmorphic
disorder (Phillips et al. [ 6 ] )
(a) Preoccupation with a perceived defect(s) or
fl aw(s) in physical appearance that is not
observable or appears slight to others
(b) The preoccupation causes clinically signi fi cant
distress (e.g., depressed mood, anxiety, shame) or
impairment in social, occupational, or other
important areas of functioning (e.g., school,
relationships, household)
(c) The appearance preoccupations are not restricted
to concerns with body fat or weight in an eating
disorder
Specify whether BDD beliefs are currently
characterized by:
Good or fair insight: Recognizes that BDD beliefs
are de fi nitely or probably not true, or that they may
or may not be true
Poor insight: Thinks BDD beliefs are probably true
Delusional beliefs about appearance: Completely
convinced BDD beliefs are true
Specify if:
Muscle dysmorphia form of body dysmorphic
disorder (the belief that one’s body build is too small
or is insuf fi ciently muscular)

80
C. Gramaglia and E. Marzola
Rates of full and partial remission reported by
a follow-up study of the course of BDD [ 12 ] were
respectively only 0.09 and 0.21, although the
84.2% of the subjects received mental health
treatment during the 12-month follow-up period.
A lower likelihood of partial or full remission
from BDD was predicted by more severe BDD at
intake, longer BDD duration, and the presence of
a comorbid personality disorder. Gender, race/
ethnicity, socioeconomic status, being an adult
versus an adolescent, age of BDD onset, delu-
sionality of BDD symptoms, comorbid major
depression, substance use disorder, social pho-
bia, obsessive-compulsive disorder, or eating dis-
order at intake did not predict remission from
BDD [ 13 ] . Receipt of mental health treatment or
nonmental health treatment (e.g., surgery, derma-
tologic treatment) during the follow-up year also
did not predict remission from BDD [ 13 ] .
Cosmetic surgery does not seem to have signi-
fi cant effects on BDD diagnosis, handicap, or
psychiatric comorbidity in BDD patients at the
5-year follow-up, despite declared patient satis-
faction [ 26 ] .
Hospitalization rates are high (48%) like those
of lifetime suicidal ideation and suicide attempts:
a history of suicidal ideation attributed primarily
to BDD is reported in 45–70% of those with
BDD, and past suicide attempts are reported in
22–24% [ 27, 28 ] . Both suicidal ideation and sui-
cide attempts are associated with lifetime and
current functional impairment due to BDD, and
with comorbid personality disorders [ 27 ] .
BDD individuals have commonly comorbid
conditions such as obsessive-compulsive disor-
der (OCD), major depression, delusions, or social
phobia. Of those with a primary diagnosis of
BDD, 30% meet criteria for OCD and the rela-
tionship between BDD and OCD is being
addressed with suggestions for DSM-V to include
BDD among the OCD spectrum disorders.
Major depression is the most frequent comor-
bid condition in BDD [ 29, 30 ] , being found in
60% of patients, often as a result of BDD itself.
BDD subjects with comorbid major depressive
disorder have more severe BDD and are more
likely to have an anxiety or personality disorder
as well as a family history of major depression.
Furthermore, they also have greater social anxi-
ety, suicidality, and poorer functioning and qual-
ity of life [ 30 ] .
As regards social phobia, the literature con-
cerning its relation with BDD is poor, which is
surprising considering their similarities [ 31 ] , high
comorbidity rates, and conceptualizations, sug-
gesting that BDD is a form of social phobia [ 32 ] .
Additional research is warranted to clarify this
issue.
6.2.3
Pathophysiology
Despite BDD being a severe and disabling condi-
tion, the understanding of its pathophysiology is
limited. Genetic factors are suspected to play a
causal role in the development of BDD, given its
prevalence rate in family members of a subject
diagnosed with this disorder.
6.3
Neurobiological Issues
Current research has focused on the possible
neurobiological substrates and abnormalities in
information processing that might explain BDD
patients’ characteristic symptoms, neurocogni-
tive de fi cits, increased self-focused attention,
and body image disorder [ 33 ] . Recent studies
highlighted a variety of plausible etiological
mechanisms hypothesizing that abnormal visual
processing [ 34 ] and de fi cient signal transduction
by the N -methyl- d -aspartate receptor (NMDAR)
[ 35 ] could play a role in vulnerability to BDD.
There is likely a complex interplay of dysfunc-
tions in frontal-subcortical circuits and temporal,
parietal, and limbic structures, with the involve-
ment of hemispheric imbalances in information
processing [ 33 ] .
The role of serotonergic transmission has
been investigated, mainly based on evidence about
the effectiveness of Selective Serotonin Reuptake
Inhibitors (SSRIs) in the treatment of BDD [ 33 ] .
Feusner and coworkers [ 36 ] found greater left
hemisphere activity in BDD subjects compared
to controls and overall fundamental differences
from controls in visually processing others’ faces.

81
6 Self-Esteem and Personality in Patients with Body Dysmorphic Disorder Undergoing Cosmetic Rhinoplasty
The main abnormality associated with apparent
perceptual distortions in patients with BDD
seems to be detail encoding and analysis rather
than holistic processing, i.e., BDD subjects might
have a bias for local, or detail-oriented, process-
ing of faces over global processing. This supports
the clinical observation that patients with BDD
focus on details of their appearance at the expense
of con fi gural elements. Data from a more recent
study [ 34 ] suggest that BDD patients could have
fundamental abnormalities in visual information
processing that are more pronounced for emo-
tional expressions in general, and may be related
to their perceptual disturbances.
6.4
Body Image and Cognitive
Behavioral Models
Although in literature the multidimensional nature
of body image functioning and disturbance has
not yet received a clear de fi nition, it can be
described as the personal notion of one’s physical
appearance based on self-observation, emotions,
physical sensations, and others’ reaction to one’s
body [ 37 ] . Body image is considered a core char-
acteristic of BDD, as it is in eating disorders.
BDD subjects are signi fi cantly less satis fi ed with
their appearance and body image than the general
population, and less satisfaction is associated with
more severe BDD and greater delusionality [ 38 ] .
Moreover, patients with BDD report more body
image impairment than those with eating disor-
ders on omnibus indices of body image distur-
bance and body image quality of life [ 39 ] . Soest
et al. [ 40 ] , according to the high correlations
found between body image and self-esteem, sug-
gest that a close connection exists between one’s
own appearance and overall self-esteem.
Cognitive-behavioral models are based on the
belief that these individuals use maladaptive cog-
nitive processes that overemphasize the impor-
tance of perceived attractiveness. Individuals
with BDD exhibit maladaptive attractiveness
beliefs and perceive their own attractiveness as
signi fi cantly lower than independent evaluators
do [ 41 ] . They are characterized by more perfec-
tionistic thinking than controls [ 41 ] , and since
they consider physical attractiveness excessively
important, BDD individuals experience low self-
esteem, anxiety, shame, and sadness and view
themselves negatively. To cope with these feel-
ings and cognitions, individuals use maladaptive
methods such as mirror gazing or avoidance [ 42 ] .
Compulsive mirror checking or mirror gazing to
con fi rm the perceived defect or avoid its recogni-
tion by others may itself play a role as maintain-
ing factor for BDD, leading to a loss of sense of
proportions [ 43 ] .
A recent study examining narrative accounts
of the self across different lifetime periods [ 44 ]
suggested that the majority of BDD subjects per-
ceived their past self as excessively attractive and
indicated that a return to their former infantile
and pure self would provide comfort, rather than
believing that the alteration of their current
appearance would rid them of BDD. These
fi ndings suggest that the dif fi culties associated
with appearance in BDD may be likely associ-
ated with narratives of loss, aging, decline, and
death.
6.5
Request for Cosmetic
Rhinoplasty in Subjects with
Body Dysmorphic Disorder
The number of people requesting cosmetic sur-
gery has been increasing in the last years, and
among these subjects the prevalence of BDD may
be as high as 7–15% [ 1, 11, 20– 23 ] . Due to the
nature of the symptoms and the poor or absent
insight, most BDD patients do not consider the
possibility that their defect is perception based
and that they suffer of a psychiatric disorder.
BDD patients may be convinced that the elimina-
tion of their real or imagined defect in appear-
ance is the best solution for their suffering, and
therefore they typically do not seek a psychiatric
consultation but instead a plastic or cosmetic
intervention.
Not only rhinoplasty remains one of the most
challenging aesthetic procedures to master [ 45 ]
because of the continually evolving societal per-
ception of beauty and patients’ and surgeons’
own sense of aesthetic proportion, but it is also

82
C. Gramaglia and E. Marzola
the most frequently sought among cosmetic
surgery intervention required by BDD patients
[ 46, 47 ] . This is not surprising since the face is
considered the personi fi cation of one’s soul and
identity; moreover, it is the most important physi-
cal representative of emotions. Even if every
component contributes to facial harmony, the
nose seems to be particularly relevant, maybe
because of its centrality and prominence in the
face. Furthermore, the nose has psychological,
cultural, ethnic, and symbolic meanings. It is not
infrequent that subconscious/unconscious per-
sonality factors or confused inadequacy feelings,
which may be often intimately involved in the
individual’s identity and sexuality, are equated
with some real or imaginary anatomical defect of
the nose or face [ 47 ] .
The relation among rhinoplasty, psychology,
and social environment has been discussed by
many authors, and all of them, independently of
their fi eld of study (cosmetic or plastic surgery,
psychiatry, psychology), have underscored that it
is critical for surgeons to be aware of their respon-
sibility regarding both the physical and emotional
levels of this issue [ 6, 11, 47 ] .
In a study designed speci fi cally to assess cos-
metic rhinoplasty in BDD patients, Veale et al.
[ 48 ] found the 20.7% of patients requesting rhi-
noplasty to have a possible diagnosis of BDD
according to the Body Dysmorphic Disorder
Questionnaire (BDDQ) [ 49 ] which was used as
screening instrument. Although this study was
not performed in a psychiatric setting, differently
from most of the existing literature, the authors
argue that there may have been as well a selection
bias in the recruitment of surgeons who may be
more aware of the problems in BDD. The fi ndings
by Veale et al. [ 48 ] revealed that BDD patients
requesting cosmetic rhinoplasty show several dif-
ferences compared to patients who normally
obtain this cosmetic intervention. BDD patients
are younger, more depressed, more anxious, and
display more preoccupations and compulsive
behaviors related to their nose. Furthermore, they
are more impaired in their relationship and occu-
pation and are more likely to have unrealistic
expectations of dramatic changes in their lives
after surgery [ 48 ] .
Elective cosmetic surgery is often performed
to improve psychosocial function in BDD
patients, although in the absence of physical indi-
cations [ 50 ] and without considering that retro-
spective outcome studies suggest that BDD
patients do not usually bene fi t from surgical treat-
ment and that their symptoms are the same, or
worse, after surgery [ 11, 26, 46, 48 ] . Moreover,
BDD subjects are generally unsatis fi ed with the
results of plastic surgery and later often become
concerned with another body part. In contrast,
SSRIs and cognitive-behavior therapy appear
to be good practice in addressing the disorder
[ 11, 18 ] .
Factors associated with poor psychosocial
outcome after cosmetic rhinoplasty include
young age, male gender, unrealistic expectations
of the procedure, previous unsatisfactory cos-
metic surgery, minimal deformity, motivation
based on relationship issues, and history of
depression, anxiety, or personality disorder [ 51 ] .
Therefore, patients’ evaluation and selection
for aesthetic facial surgery and rhinoplasty in par-
ticular need to go beyond assessment of anatomi-
cal indications. Surgeons could need to explain to
their patients the importance of a psychiatric eval-
uation or may try to screen BDD individuals in
cosmetic surgery settings [ 51 ] . Regrettably, an
of fi cial preoperative interview or procedure inclu-
ding measures for the assessment of BDD is lack-
ing. Further research is still required in the
development of a screening questionnaire or inter-
view for identifying patients with BDD seeking
cosmetic surgery.
6.6
Self-Esteem and Personality
in BDD Subjects
6.6.1
Self-Esteem
Self-esteem is an abstract concept with a compos-
ite and controversial nature, which is an important
component of psychological health. Although it
still lacks a clear consensus de fi nition in the area
of research, there is general agreement that low-
ered self-esteem frequently accompanies psychi-
atric disorders, including also major depressive

83
6 Self-Esteem and Personality in Patients with Body Dysmorphic Disorder Undergoing Cosmetic Rhinoplasty
disorder, eating disorders, anxiety disorders, and
alcohol and drug abuse. Moreover, self-esteem
also plays some role in the quality of life of psy-
chiatric patients [ 52 ] .
Although it may require measuring instru-
ments that capture the concept more effectively
than those currently available [ 53 ] , the most
widely used self-esteem test among psychologists
and sociologists is the Rosenberg Self-Esteem
Scale, developed by Morris Rosenberg [ 54 ] . It is
a ten-item Likert scale with items answered on a
four-point scale (from strongly agree to strongly
disagree), easy and quick to administer, and tries
to capture primarily the global entity of self-
esteem.
Self-esteem, together with issues related to
body image and teasing history, has been found
in association with motivational factors in patients
who seek cosmetic surgery [ 1, 40 ] . A correlation
has been suggested between individuals’ self-
esteem and demand for and use of cosmetic sur-
gery [ 55 ] . BDD, education, and culture also
predict the decision of undergoing cosmetic sur-
gery interventions [ 1 ] . Soest et al. [ 40 ] , according
to the high correlations found between body
image and self-esteem, suggest that a close con-
nection exists between one’s own appearance and
overall self-esteem, consistently with Phillips
et al. [ 56 ] .
Despite studies documenting the association
of poor body image with poor self-esteem, the
literature concerning self-esteem and BDD is still
scant and it is unclear whether poor self-esteem is
a cause or a consequence of BDD [ 56 ] .
Phillips and coworkers [ 56 ] found poorer self-
esteem being associated with more severe BDD
and depression, as well as greater delusionality.
Although the relationship between self-esteem
and BDD severity was largely mediated by depres-
sive symptoms, self-esteem did not improve
signi fi cantly more with fl uoxetine than placebo,
although it improved signi fi cantly more in
fl uoxetine responders than in nonresponders.
A study on self-esteem and attractiveness
beliefs in BDD [ 42 ] con fi rmed that BDD patients
had signi fi cantly lower implicit self-esteem com-
pared to controls, with subclinical BDD individu-
als being intermediate between these groups.
Furthermore, BDD subjects showed implicit cog-
nitions consonant with the stereotypes about
physical attractiveness, having a stronger implicit
association between attractive and competent
than the other groups.
Lower self-esteem in BDD subjects was also
found by other authors [ 57 ] , together with higher
fantasy proneness, higher self-ambivalence,
higher depression and anxiety [ 58 ] , and speci fi c
personality traits [ 57 ] .
6.6.2
Personality
Carl Gustav Jung, 1934, stated that personality is
the supreme realization of the innate idiosyncrasy
of a living being. It is an act of high courage fl ung
in the face of life, the absolute af fi rmation of all
that constitutes the individual, the most success-
ful adaptation to the universal condition of exis-
tence coupled with the greatest possible freedom
for self-determination.
Personality is not easily de fi ned; it concerns
the most important, most noticeable parts of an
individual’s psychological life. Personality con-
sists of enduring patterns of perceiving, relating
to feeling, and thinking about the environment
and oneself, which are exhibited in a wide range
of important social and personal contexts.
Personality can be described as the individual’s
usual model of inner experience and behavior,
which expresses itself in characteristic cogni-
tive, emotional, behavioral, and interpersonal
styles; speci fi c attachment patterns; self-view
and worldview; and adaptive and/or maladap-
tive schemas.
The personality features of subjects seeking
cosmetic surgery have been investigated in the
last years. In 1984, Marcus [ 59 ] studied patients’
narcissism in a cosmetic surgery setting, arguing
that this personality feature had been underem-
phasized despite being one important dimension
of the psychological experience of the typical
cosmetic rhinoplasty patient. Patients’ narcissism
was noticeable in their self-absorption, inade-
quate self-esteem, and fantasies of ideal beauty.
A recent review [ 60 ] investigating the psycho-
logical outcomes, background, and personality

84
C. Gramaglia and E. Marzola
types of patients seeking speci fi c plastic surgery
procedures found narcissistic and histrionic
personality disorders and BDD as the three most
common psychiatric conditions encountered in
patients seeking cosmetic surgery.
The Minnesota Multiphasic Personality Inven-
tory (MMPI) was used by Babuccu et al. [ 61 ] ,
who compared the personality features of rhino-
plasty patients and age-matched control subjects.
They found results out of the normal ranges in
one or more scales of the inventory in 45% of the
rhinoplasty patients group versus 28% of the
control group and described the personality fea-
tures of female and male patients. Females were
egocentric, childish, highly active, impulsive,
competitive, reactive, perfectionistic about them-
selves, talkative, and emotionally super fi cial, while
males were rigid, stubborn, oversensitive, suspi-
cious, perfectionistic, pessimistic, overreactive,
tense, anxious, and having feelings of inferiority
and somatizations.
Zojaji et al. [ 62 ] used the MMPI to assess the
effect of the patients’ personality on their satis-
faction with rhinoplasty. The most frequently
noted personality trait was obsessiveness; the
least one, antisociality. Satisfaction with rhino-
plasty was declared by the 55.1% of patients, and
a statistically signi fi cant relation emerged between
personality type and level of satisfaction with the
intervention.
Patient’s personality can therefore be a major
factor in fl uencing satisfaction results after rhino-
plasty [ 62 ] , and the same is for BDD. Although
the screening for BDD features and the assess-
ment of personality are recognized as crucial for
clinicians to suggest patients the best possible
treatment, data about personality of patients with
BDD who seek cosmetic surgery, and speci fi cally
rhinoplasty, are still limited.
Not only is there a dearth of studies address-
ing the issue of personality in cosmetic surgery
patients, but the research about personality in
BDD patients is even poorer [ 31, 57, 63– 65 ] .
This is surprising, given that diagnostic criteria
for Axis II diagnoses are met by the 53–87% of
BDD individuals for one or more personality
disorders [ 31, 64, 65 ] . The most common per-
sonality disorders are Cluster C (anxious); the
less common are Cluster B (dramatic) disorders.
Table 6.2 shows the current classi fi cation of per-
sonality disorders according to DSM-IV.
BDD individuals have been postulated to have
schizoid, narcissistic, and obsessional personal-
ity traits [ 66– 69 ] , as well as avoidant personality
disorder [ 70 ] . The description of their premorbid
features have included being sensitive, shy and
Table 6.2 Classi fi cation of personality disorders according to DSM-IV
Cluster A (odd or eccentric disorders)
1. Paranoid personality disorder: characterized by irrational suspicions and mistrust of others
2. Schizoid personality disorder: lack of interest in social relationships, seeing no point in sharing time with
others, anhedonia, introspection
3. Schizotypal personality disorder: characterized by odd behavior or thinking
Cluster B (dramatic, emotional, or erratic disorders)
1. Antisocial personality disorder: a pervasive disregard for the law and the rights of others
2. Borderline personality disorder: extreme “black-and-white” thinking; instability in relationships, self-image,
identity, and behavior often leading to self-harm and impulsivity. Borderline personality disorder occurs in
three times as many females as males
3. Histrionic personality disorder: pervasive attention-seeking behavior including inappropriate sexual seductive-
ness and shallow or exaggerated emotions
4. Narcissistic personality disorder: a pervasive pattern of grandiosity, need for admiration, and a lack of empathy
Cluster C (anxious or fearful disorders)
1. Avoidant personality disorder: social inhibition, feelings of inadequacy, extreme sensitivity to negative
evaluation and avoidance of social interaction
2. Dependent personality disorder: pervasive psychological dependence on other people
3. Obsessive-compulsive personality disorder: characterized by rigid conformity to rules, moral codes, and
excessive orderliness

85
6 Self-Esteem and Personality in Patients with Body Dysmorphic Disorder Undergoing Cosmetic Rhinoplasty
reserved, introverted, socially avoidant, insecure,
self-critical, perfectionistic, rejection-sensitive,
self-conscious, neurotic, hostile, insecure and
asthenic [ 31, 66, 68– 73 ] .
The relation between BDD and personality
disorders is not clear, although the personality
disorder or the personality features described
above have been suggested to represent a diathe-
sis predisposing for the onset of BDD symptoms
[ 31, 63, 74 ] . However, some questions are still
unanswered; for example, it is not clear whether
personality characteristics are modi fi ed or tem-
porarily distorted by BDD, or they simply coexist
with BDD without a causal relationship.
Only few studies have investigated personality
disorders in BDD subjects using the DSM
classi fi cation system; both categorical and dimen-
sional methods have been used for personality
assessment in patients seeking rhinoplasty. Other
studies [ 75, 76 ] are limited either because of the
small case series or the lack of standard assess-
ment instruments.
Veale et al. [ 64 ] found the 72% of BDD
patients having a DSM-III-R personality disor-
der using the Structured Clinical Interview for
DSM-III-R Personality Disorders (SCID-II)
[ 77 ] . The most common diagnoses were avoidant
and paranoid personality disorder (38% each),
followed by obsessive-compulsive personality
disorder (28%).
Phillips and McElroy [ 31 ] assessed BDD
patients’ personality with the SCID-II [ 77 ] and
the NEO-Five Factor Inventory (NEO-FFI) [ 78 ]
and found more than half (57%) of patients hav-
ing one or more personality disorders, most com-
monly Cluster C (avoidant) ones. The most
common diagnoses were avoidant (43%), depen-
dent (15%), obsessive-compulsive (14%), and
paranoid
(14%)
personality
disorders.
Consistently with the SCID-II fi ndings, the NEO-
FFI mean scores were in the very high range for
neuroticism, the low range for extraversion and
conscientiousness, the low-average range for
agreeableness, and the average range for open-
ness to experience. Fluvoxamine proved effective
in decreasing the number of personality disorders
between the study baseline and endpoint, in those
responding to treatment. The authors therefore
raise the question whether personality assessment
was confounded by BDD symptoms or some per-
sonality disorders are the sequelae of BDD.
Moreover, Phillips and McElroy [ 31 ] suggest
that, given the modest rate of obsessive-compul-
sive personality disorders, the obsessional traits
such as perfectionism observed in BDD subjects
are more likely to be due to BDD symptoms
rather than to obsessive-compulsive personality
traits.
Similar results were found by Cohen et al.
[ 65 ] , who used both categorical (SCID-II) [ 77 ]
and dimensional (Dimensional Assessment of
Personality Impairment, DAPI) [ 65 ] methods for
the assessment of personality in BDD patients
participating in a treatment study (clomipramine
versus desipramine). A high rate (87%) of BDD
patients met criteria for at least one diagnosis and
more than half (53%) had at least two diagnoses
of personality disorders. The most common per-
sonality disorders were cluster C ones (avoidant,
obsessive-compulsive, dependent). DAPI average
mean scores revealed a moderate impairment.
Consistently with Phillips and McElroy [ 31 ] ,
responders to pharmacologic treatment showed
less personality impairment than nonresponders.
Cohen et al. [ 65 ] consider personality disorder
having a distinct and dissociable nature in BDD
subjects, since they did not fi nd any signi fi cant
correlation among personality measures and other
clinical variables. Anyway, personality impair-
ment plays a relevant role in BDD, also as regards
treatment response.
Another study using the Structured Clinical
Interview for DSM-IV [ 63 ] found the following
rates of personality disorders in BDD subjects:
16.7% narcissistic, 16.7% borderline, 12.1%
avoidant, 9.1% paranoid, 7.6% schizotypal, and
7.6% obsessive-compulsive. Dependent, schizoid,
and histrionic personality disorders were less fre-
quent diagnoses. The authors also found that the
severity of dysmorphic symptoms BDD-Yale-
Brown Obsessive Compulsive Scale (BDD-
YBOCS) score was signi fi cantly related to the
severity of schizotypal and paranoid personality
disorders (cluster A).
The Temperament and Character Inventory
[ 79 ] has been used to investigate the personality

86
C. Gramaglia and E. Marzola
features of subjects with BDD traits undergoing
cosmetic rhinoplasty [ 57 ] . Subjects with BDD
traits were identi fi ed using the questions from the
BDDQ (patients with/without worry about their
appearance; patients spending <1 h/1–3 h/>3 h
per day thinking about the way they look; patients
with/without interference with their social life
depending on their worry about appearance).
Subjects worried about how they look, those with
interference in their social life due to this worry,
and those who spend more than 3 h per day think-
ing about the way they look showed lower self-
esteem, higher harm avoidance (HA), and lower
self-directedness (SD). In other words, consis-
tently with previous reports [ 31 ] describing BDD
patients as sensitive, introverted, and insecure,
patients with BDD traits in this study are pessi-
mistic, shy, insecure subjects with fragile and
immature personality and poor self-esteem.
6.7
Clinical Implications
and Conclusions
The process of surgery begins when the fi rst
meeting between patient and surgeon takes place.
Practitioners in the fi elds of plastic and cosmetic
surgery should be aware of the likelihood of
receiving for consultation patients suffering from
psychiatric disorders. The motivation for seeking
cosmetic surgery includes a combination of psy-
chological and emotional factors, but also a psy-
chiatric disorder can lead people to require such
interventions. Individuals with personality disor-
ders – mainly narcissistic and histrionic – and
BDD are more likely to seek cosmetic surgeons’
interventions [ 60 ] . Moreover, research has
revealed that the most common motivating fac-
tors for deciding to have cosmetic surgery include
BDD, body image, self-esteem, and teasing his-
tory [ 1 ] .
Since some individuals seeking cosmetic sur-
gery could be BDD patients and given the lack of
checklists to assess psychological features of
those seeking cosmetic interventions, clinicians
should accurately evaluate patients’ motivations
and provide them both information and psychoe-
ducation [ 7, 80, 81 ] .
Even if cosmetic surgery can improve patients’
psychological well-being, self-con fi dence, and
self-esteem, and reduce social anxiety in healthy
subjects, most of the existing literature supports
the fact that this is not true for BDD subjects
whose symptoms are unchanged or even worse
after surgery [ 51, 60, 82, 83 ] . Furthermore, satis-
faction with appearance change after intervention
and psychological/social status are different,
albeit related, issues. On one hand, patients can be
satis fi ed with the outcome of the intervention; but
on the other hand, they may as well experience no
change in their psychosocial features [ 51 ] .
Predictors of poor outcome of cosmetic inter-
ventions can be grouped in six main catego-
ries [ 51 ] : (1) demographic factors (being male,
younger age), (2) psychological/psychiatric
factors (history of depression or anxiety, dys-
morphophobia/BDD, personality disorders – nar-
cissistic and borderline), (3) relationship issues,
(4) unrealistic expectations regarding the out-
come of the procedure, (5) dissatisfaction with
previous surgical procedure, and (6) minimal
deformity.
Several pro fi les of patients with a high risk of
postoperative dissatisfaction have been described,
and the important role of BDD and its treatment
has been highlighted. Patients at high risk have
been found to be obsessive, perfectionist, com-
pulsive, impolite, and fl attering. They are more
likely to be single, immature, males, overex-
pectant or obsessive, and narcissistic (SIMON
acronym) [ 83 ] .
Rhinoplasty patients have been long consid-
ered an at-risk group for surgery and psycho-
logically challenging [ 82 ] . The psychological
aspects of rhinoplasty are a relevant issue, and
some plastic and cosmetic surgeons consider it
a mine fi eld [ 84 ] because of technical challenges
and the unpredictability of patients’ reaction
even to a technically successful intervention.
Moreover, rhinoplasty is the most frequently
sought cosmetic intervention by BDD patients
[ 46, 47 ] .
Therefore, this psychiatric disorder should be
the object of a careful screening procedure by cos-
metic and plastic surgeons, since these patients –
as other psychologically unstable ones – may

87
6 Self-Esteem and Personality in Patients with Body Dysmorphic Disorder Undergoing Cosmetic Rhinoplasty
never be satis fi ed and consequently request fur-
ther interventions, or have psychopathological
consequences.
Despite the growing interest and attention
paid to the issue of BDD in cosmetic surgery set-
tings, and albeit BDD is improved by surgery in
only 3.6% of cases, it is estimated that the
26–40% of BDD patients receive the requested
procedure [ 46 ] .
Recently, Crerand et al. [ 84 ] reported about
the comparison between BDD subjects who
received cosmetic surgical or minimally invasive
treatments and those who did not. The latter had
more severe BDD and delusionality. Anyway,
also in treatment receivers, overall BDD severity
improved with only 2.3% of cases. After cosmetic
interventions, BDD patients are usually unsatis fi ed
despite the good objective outcome and are likely
to begin to worry about another body area.
Switching is not unexpected, since BDD patients
have a distorted body image and a tendency to
obsess about minor fl aws [ 84 ] , as suggested also
by neuroimaging studies which found BDD sub-
jects showing a bias for detail processing over
holistic processing when exposed to facial stimuli
[ 36 ] . The surface change that is the consequence
of cosmetic surgery is not likely to affect the
underlying disorder and its psychopathological
core, and therefore surgery is not a cure for BDD
patients [ 85 ] .
Given these fi ndings, and considering the
reports of lawsuits and violence perpetrated by
BDD patients toward their surgeons [ 7, 37, 86,
87 ] , it is no wonder that some consider BDD a
contraindication for cosmetic surgery interven-
tions [ 51, 88 ] .
Despite the availability of these data and the
general agreement about the little ef fi cacy of cos-
metic surgery in BDD patients, practitioners in
the fi eld of cosmetic surgery may still tend to
underestimate the frequency of the disorder in
patients requesting their intervention [ 37, 84 ] .
The “2001 Body Image Survey” was performed
e-mailing the survey to the active members of the
American Society for Aesthetic Plastic Surgery
(ASAPS) to investigate their awareness of and
experiences with BDD. The fi ndings from the
survey revealed that respondents believed that
the 2% of patients seen in cosmetic surgery set-
tings for an initial consultation had BDD, which
is consistent with the prevalence of BDD in the
general population, but is signi fi cantly lower
than the BDD rates reported in cosmetic surgery
settings [ 1, 11, 20– 23 ] . This suggests that
despite their awareness of BDD, surgeons tend
to underestimate its frequency [ 37, 84 ] . Eighty-
four percent indicated that they refused the
intervention to BDD patients; 84% reported to
have treated a patient supposed to be appropri-
ate for surgery, but thereafter realized that the
patient had BDD. Although 82% of respondents
believed that BDD patients had a poor outcome
after cosmetic surgery, only 30% considered
BDD to be always a contraindication to cos-
metic surgery [ 37, 84 ] . This may depend on the
temporary improvements which can be seen in
BDD patients and to the surgeons being unaware
of patients’ preoccupations switching to another
body part [ 84 ] .
To understand the importance of rhinoplasty
psychological implications and, even more impor-
tantly for surgeons, to recognize those patients
who may have an unfavorable postoperative course
regardless of the objective outcome, the selection
of patients should include an evaluation of medi-
cal, sociocultural, psychological, and environmen-
tal factors. Clinicians need to develop a thorough
understanding of the patient’s motivations for the
procedure, expectations for the surgical outcome,
and ego strength for tolerating the stress of opera-
tive intervention.
Recommendations to help clinicians detect
the psychological issues underlying the request
of cosmetic surgery include: allowing patients
to speak and explain their reasons for seeking
cosmetic surgery; assessing the extent of the
preoccupation for the perceived defect; enquir-
ing the amount of time per day spent worrying
about the defect and the consequent emotional
distress and impairment in functioning; inter-
viewing patients in order to obtain a thorough
medical, social, and psychiatric history; and
asking for history of previous satisfactory/
unsatisfactory procedures, doctor shopping,
and history of lawsuits toward previous physi-
cians [ 84 ] .

88
C. Gramaglia and E. Marzola
It may be also useful to investigate patients’
expectations of the outcome of the intervention,
both in cosmetic and other terms [ 7, 51, 89 ] .
A distinction has been suggested between expec-
tations regarding the self (e.g., improvement of
body image) and expectations in terms of exter-
nal parameters (e.g., enhancement of one’s social
network, getting a job), the latter being more con-
cerning for the surgeon.
Since extreme body dissatisfaction is the most
relevant feature of BDD, a careful investigation
for the preoccupation with an imagined or slight
defect in appearance seems to be the quickest,
albeit not always easy, screening test that a cos-
metic surgeon can perform [ 60 ] . The use of brief
and widely used tools as the Body Dysmorphic
Questionnaire (Tables 6.3 and 6.4 ) should also be
considered [ 3 ] , together with the assessment of
subjects’ self-esteem.
Still, all these recommendations can be
insuf fi cient and since reliable screening instru-
ments for clinical practice are not currently
available, the decision about surgery can be
controversial. Anyway, although de fi nitive data
on the treatment outcome of cosmetic treat-
ments for BDD are lacking and it is not possible
to predict the response to treatment, data from
literature suggest that cosmetic procedures are
Table 6.3 Questions that may help the screening for
body dysmorphic disorder, based on DSM-IV criteria
1. Are you very worried about your appearance in any
way?
If yes: What is your concern? Do you think (body
part) is especially unattractive?
If yes: What about the appearance of your face, skin,
hair, nose, or the shape or size or other aspect of any
other part of your body?
2. Does this concern preoccupy you? That is, do you
think about it a lot and wish you could worry about it
less?
3. What effect has this preoccupation with your
appearance had on your life? Does it cause you
distress or interference with your functioning in any
way?
Table 6.4 Assessments of body dysmorphic disorder
Multidimensional Body-Self Relations Questionnaire a
Self-reported measure of body image. It assesses satisfaction with appearance and preoccupation with perceived
defects. This is used in clinical trials and may not be practical in routine of fi ce settings. A study of 92 patients
with body dysmorphic disorder who took the questionnaire revealed that patients with this condition differ from
population norms in numerous aspects of body image, including perception of illness
Body Dysmorphic Disorder Examination Self-Report b
Measures body image dissatisfaction; with more detail, the dissatisfaction the patient has related to the perceived
defect. This is another tool used in clinical trials and may not be practical in routine of fi ce settings
Yale-Brown Obsessive Compulsive Scale Modi fi ed for Body Dysmorphic Disorder (BDD-YBOCS) c
A 12-item semistructured clinician-administered tool that has consistently been shown to be a reliable and valid
measure of BDD severity. It assesses the severity of obsessions (time occupied, interference with functioning,
distress, resistance against the obsession, and control over the obsession) and compulsions (time occupied,
interference with functioning, distress if the compulsion is prevented, resistance against the behavior, and control
over the behavior). Summary scores can be calculated for the obsessions items, compulsions items, and a total
score (total score = 0–40). Higher scores indicate more severe symptoms
Body Dysmorphic Disorder Questionnaire (BDDQ) d
Screening tool for BDD; allows the selection of patients with possible BDD. The BDDQ has been validated in a
psychiatric population with a sensitivity of 100% and speci fi city of 89%
Dysmorphic Concerns Questionnaire (DCQ) e
Oosthuizen and coworkers developed the seven-item Dysmorphic Concern Questionnaire (DCQ) to assess
dysmorphic concern as a symptom without seeking to establish a diagnosis of BDD
Respondents rate their concern about their physical appearance relative to others on a four-point scale
a Cash [ 90 ]
b Rosen et al. [ 91 ]
c Phillips et al. [ 49 ]
d Phillips et al. [ 92 ]
e Oosthuizen et al. [ 93 ]