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

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DOI 10.1007/978-3-642-28053-5_7, © Springer-Verlag Berlin Heidelberg 2013
7
7.1
Introduction
The history of the 18-year-old Afghan Aisha has
recently moved and shocked the world. This
young woman decided to fl ee her home to avoid
beatings and abuse of her husband and in-laws.
She was then ordered the mutilation of the nose.
Her picture was published in the Western press,
and later plastic surgery has reconstructed her
features. This dramatic story reveals the central-
ity of the nose in the body image and also empha-
sizes the symbolic value of the nose in the context
of both physical and sexual identity of the person.
Violence on the face and especially on the nose is
violence against the person, sexual identity, and
ultimately against the dignity and freedom.
The word person, individual, derives from the
Latin word persona that means mask. Person, the
mask, in the face of Western culture is the whole
individual in terms of somatic and psychological.
The face, with its changes, communicates mood
and emotions. Indeed, it is well known that the
facial expressions of emotion are recognized
worldwide from individuals belonging to differ-
ent cultures.
The nose is literally the center of the face and
seems to have a central role in the harmony of the
face. Artists, anatomists, surgeons, and even
criminologists have always been occupied by the
con fi guration of the nose. The nose can cause
serious problems with the facial image and then
the entire social body image and the image of an
individual. In 2006, the American Society of
Plastic Surgery had in fact revealed that rhino-
plasty is the most popular plastic surgery for
patients from many ethnic groups (African-
Americans, Asians, and Hispanics). This alone
makes it clear that it is commonly believed that
changes to the nose have psychological and social
impact that, in turn, has an impact on the person.
The concept of identity has several de fi nitions,
but equality, continuity, and difference are the
three that emerged as fundamental aspects, which
de fi ne this concept. In 1956, Erikson [ 1 ] stated
that the term identity expresses such a mutual
relation in both that it connotes a persistent same-
ness within oneself (self-sameness) and a persis-
tent sharing of some kind of essential character
with others, “a sense of individual identity, a con-
tinuity of personal character maintaining an inner
group in solidarity with ideals and identity.”
There is a strong association between nose
morphology and personal identity, and we must
bear in mind that in many patients, the most
Psychological Aspects
of Rhinoplasty
Mauro Ercolani and Alessandro Agostini
M. Ercolani , M.D. ()
Department of Psychology and Specialistic,
Diagnostic and Experimental Medicine ,
Università di Bologna ,
Viale Carlo Berti Pichat 5 , Bologna 40127 , Italy
Scuola di Specializzazione in Psicologia Clinica ,
dell’Università di Bologna , Bologna , Italy
e-mail: mauro.ercolani@unibo.it
A. Agostini , M.D.
Department of Psychology , University of Bologna ,
via Berti Pichat 5 , Bologna , Italy
Department of Clinical Medicine , S.Orsola Malpighi
University Hospital , via Massarenti 5 , Bologna , Italy
e-mail: alessandro.furey@tiscali.it

94
M. Ercolani and A. Agostini
important expectation from rhinoplasty is not
only an improved facial harmony but an existen-
tial change. Patients believe that, thanks to the
aesthetic change, they have the possibility to
change their behavior and their relationships with
the external world.
7.2
The Psychological Aspects
of Rhinoplasty: Expectations
and Motivations
The psychological implications of rhinoplasty,
plastic surgery of the nose, on patients are fre-
quently underlooked or not given enough attention
during surgeons’ training and residency programs.
In turn, ineffective preoperative screening has led
to high percentages of postoperative dissatisfac-
tion among patients and dangerous outcomes
for initially high-risk patients and their respec-
tive surgeons. Reports of worsening symptoms
of psychiatric disorders such as body dysmor-
phic disorder (BDD), postsurgical dissatisfaction
syndrome, and/or threats against the surgeons by
dissatis fi ed patients has increased discussion of
an urgent need for better screening methods of
patients’ psychological status before approving
surgical procedures.
The motivations, anxieties, and expectations
of patients requesting plastic surgery must be
evaluated thoroughly in order to identify why
these individuals are willing to confront the
fi nancial burden, associated risks of surgery, and
the variety of inconveniences resulting from sur-
gery. If rhinoplasty is expected to improve the
quality of life of the patient by boosting self-
esteem and reducing social anxiety, granted that a
patient is evaluated as a “good candidate” or a
“low-risk” patient, sometimes de fi ned or indi-
cated by the acronym SYLVIA (secure, young,
listens, verbal, intelligent, attractive), this proce-
dure should be considered a legitimate treatment
option by both physicians and their patients.
However, if patients do not exhibit these qualities
and instead tend to align more with another type
of patient group, for instance male patients
referred to by the acronym SIMON (single,
immature, male, overexpectant or obsessive,
narcissistic), this type of surgery should at the
very least be reconsidered, and most likely
avoided, if the patient is evaluated as a “high-
risk” surgical candidate.
Existing researches available on this topic reit-
erate the importance of evaluating all patients on
an individual level. Additionally, it stresses the
necessity of a thorough and in-depth assessment
of a patient’s psychological baseline, prior to sur-
gery, as a critical step in best treating the patient
as well as avoiding postsurgical dissatisfaction
and dangerous or violent actions taken against the
patients themselves or the surgeons who con-
ducted the surgery. Most importantly, medical
experts insist that more research must be dedi-
cated to the psychological aspects of rhinoplasty,
in addition to legislative and ethical components,
as there is a paucity of this type of research
whereas the majority seems to focus on other top-
ics such as methodology and instrumentation.
7.3
The Body Image Disorders
An increased incidence of individuals suffering
from disturbances of self-perception related to
their bodies, their bodies’ size, and other physical
defects, whether real or imagined, has pushed
this subject out of the more limited clinical
domain and into a broader community analysis.
The formation of “standards” of personal beauty
as publicized by the advertising industry has
exacerbated this problem further by emphasizing
and exaggerating particular features of the body
and inevitably encouraging the public to take cor-
rective action.
A closer look at nonclinical populations
gives an interesting perspective on the issue of
body image disorders. Dissatisfaction of per-
sonal appearance has also been referred to as
“normative discontent.” The prevalence of dis-
satisfaction of one’s body image in the Western
world is clearly evident as the topic of “dieting”
is publicized in all forms of media in these
countries. It has been noted that there is a heavy
cultural in fl uence regarding this issue, as
Westerners tend to value a slimmer female form
and de fi ne it as the ideal for feminine beauty.

95
7 Psychological Aspects of Rhinoplasty
Conversely, individuals living in Third World
countries such as India and Africa tend to prefer
a larger and fuller female fi gure. A self-rated
questionnaire assessing the proportion of vari-
ous parts of the body was used as part of a study
conducted in Birmingham, England. Results col-
lected from male and female subjects from three
allotted age groups, ranging from 11- to 18-year-
olds, reported that in general females described
their bodies as “much too big” much more fre-
quently than their male counterparts in each of
the three age groups. Peer pressure and exposure
to the media, usually beginning around the time
of adolescence, seems to be a key factor in elicit-
ing behaviors such as dieting and other actions in
which individuals strive to take control of their
body in order to alter and modify their physical
appearance in different manners. Discontent with
body image may be attributed to underlying low
self-esteem and depression; the DSM glossary
states that the critical factor which de fi nes a body
dysmorphic disorder is the preoccupation with
some imagined fl aw in an individual who appears
normal to others. The most frequent complaints
stem from facial features such as excessive facial
hair, wrinkles, shape of the nose, mouth, jaw, and
eyelids. The individual’s concern is typically
excessive, exaggerating a minor physical defect
that may actually exist but not appear as notice-
able to others as the person perceives it to be. This
disorder usually presents in patients between the
ages of adolescence and their 30s, and it gener-
ally persists over the course of several years. The
treatment of a patient who suffers from this disor-
der and seeks treatment for a bodily “abnormal-
ity” that may or may not be present and if present
may be minimal is challenging since there are no
absolute standards of physical “normality.” In
some cases, when the patient is particularly insis-
tent and is incapable of resolving his issues with
other forms of therapy, psychiatric consultation is
advisable.
In 1969 [ 2 ] , one of the largest studies to date
was conducted among patients referred to undergo
plastic surgery. Reich concluded that from a sur-
gical point of view, an operation is performed in
order to ameliorate a correctable deformity.
Choosing plastic surgery as a form of treatment
must be considered seriously from a mental
health perspective, with two speci fi c factors in
mind: “the realism of the patient’s expectations
and the likely ability of the patient to withstand
an imperfect result.” Psychiatric therapy is
required if either of these two criteria is not
deemed reasonable or satisfactory, possibly lead-
ing to the reinforcement of existing emotional
issues that might jeopardize the health and stabil-
ity of the patient.
7.4
The Minimal Defect
Hay has greatly enriched the knowledge about the
concept of the so-called minimal defect. He noted
that plastic surgeons refer two groups of patients
to the psychiatrist for the preoperative evaluation.
The two groups consisted in those with severe
psychiatric disturbance and those with minimal
defects. One could re fl ect: Why this emphasis on
minimal defects? In Hay’s opinion, one plausible
explanation is that the early psychiatric work on
cosmetic surgery was done in the USA at time
when psychoanalytic thought was dominant in
the fi eld of psychiatry. Psychoanalysts aimed to
understand the patients’ unconscious meaning of
concerns about the nose or physical defects and
furthermore to bring this understanding into
patients conscious awareness. In other words, an
intrapsychic con fl ict may be displaced into con-
cerns about the body parts. In this view, the sur-
gery treatment of a physical defect before the
underlying con fl ict is understood and resolved
may cause psychological decompensation. Given
that the psychic stability is maintained by means
of the symptoms, alterations of the symptoms
may act as a trigger and lead the patients to refo-
cus and resymbolize their con fl icts into concerns
about other parts of the body.
In this view, patients with minimal defect
were categorized as basic neurotic. Barsky
[ 3 ] introduced the classi fi cation of cosmetic
surgery patients into basic neurotic and situa-
tional neurotic. The basic neurotic patients use
the imaginary defect as a symptom to channel
their neurosis. Therefore, the cosmetic surgery
is destined to fail because patients will always

96
M. Ercolani and A. Agostini
fi nd other symptoms. In other words, cosmetic
surgery cannot be effective for a primitive
neurotic con fl ict. On the other hand, the situ-
ational neurotic patients suffer from anxiety
and psychological discomfort primarily caused
by the “deformity.” In this group of patients,
symptoms are more stable and the cosmetic
surgery can relieve the psychological suffering
of patients.
To date, the psychoanalytic terminology is
not widely used and the main problem of differ-
ential diagnosis is with dysmorphophobia. This
term is used in psychiatry and is considered an
early symptom of psychosis. Dysmorphophobia
refers to a situation in which a patient complains
of a physical deformity which he believes is
noticeable to others but which is objectively
within the normal limits. The term minimal
defect should be distinguished from dysmor-
phophobia because in the fi rst is present a defor-
mity although minimal.
Hay [ 4 ] investigated the minimal defect in
some controlled studies. He found no differences
between male and female in all psychological
evaluations. Furthermore, he found that, com-
pared to controls, the rhinoplasty patients were
more obsessive, self-punishing, neurotic, and
hostile. In particular, he found that there was no
correlation between the psychometric results
concerning psychological disturbances and the
degree of deformity.
Therefore, he rejected the two group’s hypoth-
esis and proposed to evaluate the issue of mini-
mal defect in terms of two main variables. These
were sensitive personality disorders and amount
of environmental berating. The fi rst variable con-
cerns personality factors. Patients may be
described into three groups along this variable:
(1) patients with sensitive personality disorders
in whom a single disparaging remark may trigger
abnormal psychogenic development; (2) less sen-
sitive patients, which require much more teasing
to reach the trigger point; and (3) patients which
are able to withstand teasing inde fi nitely.
On the other hand, patients are subjected to
the amount of environmental berating. This is not
directly related to the degree of deformity, but to
how patients deal with teasing.
Overall, Hay’s research and further researches
have shown no correlation between the magnitude
of the nasal deformity and the development out-
come in terms of psychological disturbances, psy-
chological improvement, and patients’ satisfaction.
As a result, on the basis of the minimal
defect alone, rhinoplasty should not be denied.
Psychiatric consultations are often frustrating,
while psychological evaluation should be encour-
aged for all patients and persons with very sensi-
tive personality. In these patients, the operation
will not conduct to psychological improvements.
On the other hand, in patients with minimal defect,
we may sometimes assist in overall adjustments
and improvement in interpersonal relationships.
7.5
Short-Term Outcome
of Rhinoplasty for Medical
or Cosmetic Indications
Psychological and psychiatric research has long
sought to investigate the psychological outcome
of patients who underwent rhinoplasty. Researches
with short- and long-term follow-up did not
con fi rm concerns about potential psychopatho-
logical imbalances after the operation, but empha-
sized that a majority of the patients improved
psychologically after the operation even though
previous psychopathological disturbances did not
change substantially [ 5– 8 ] . Some studies suggest
that the bene fi t is at least partly conditioned by
the motivation for having the operation and the
gender of the patient.
Connolly and Gipson [ 9 ] tested patients some
years after rhinoplasty and compared their results
to patients operated for traumas: In patients who
had requested the operation for aesthetic reasons,
they found signi fi cantly higher incidence of severe
psychological disturbance. As regards patient gen-
der, Thomson et al. [ 10 ] , in their exhaustive review
of the psychiatric problems of patients seeking
rhinoplasty, found that male patients are more
psychologically disturbed than female patients.
This conclusion was corroborated by Robin et al.
[ 8 ] , who also pointed out that male patients gain
fewer bene fi ts from rhinoplasty as shown by a
drop in the average score in psychometric testing.

97
7 Psychological Aspects of Rhinoplasty
Ercolani et al. [ 7 ] conducted a pre- and postop-
erative psychometric evaluation of male and
female patients with different motivations for sur-
gery. Pre- and postoperative psychometric evalua-
tion of male and female patients undergoing
rhinoplasty with aesthetic or functional motiva-
tion, at 6-months follow-up, highlighted an
improvement in the emotional health in the group
as a whole. This improvement involved all person-
ality factors assessed, with a signi fi cant decrease
in neuroticism and anxiety scores and an increase
in extroversion score. The psychological improve-
ment was greater for females than males in neu-
roticism. Although both groups achieved equal
bene fi ts from the surgical correction, patients
seeking rhinoplasty for aesthetic dissatisfaction
were more disturbed than patients with functional
motivation at both preoperative evaluation and at
6-months follow-up. Overall, consistently with
previous follow-up studies with patients undergo-
ing rhinoplasty [ 5– 8 ] , their fi ndings con fi rmed
that a majority of patients bene fi ts psychologically
from the operation.
The impact of variables such as the gender of
the patient and motivation for the operation is a
far more complex matter.
1. Patient Gender
On the postoperative situation, Ercolani et al.
[ 7 ] found that male patients experience fewer
psychological bene fi ts from rhinoplasty. These
fi ndings are consistent with previous studies
by Robin et al. [ 8 ] . Furthermore, the fewer
psychological effects of rhinoplasty in male
patients was probably not related to a more
severe psychopathology, rather to other vari-
ables such as lower social approval.
2. Motivation for Rhinoplasty
Regarding motivation for the operation, both
functional and cosmetic patients show postop-
erative psychometric improvement. However,
cosmetic patients con fi rmed a preoperatively
higher neuroticism score at follow-up, com-
pared to those who received surgery based on
a medical referral. In other words, as Wright
and Wright [ 6 ] or Ercolani et al. [ 7 ] pointed
out, although in a majority of cases it has a
positive effect on a number of psychometric
parameters, rhinoplasty cannot be regarded as
a surgical alternative for curing psychological
disturbances in patients, especially those suf-
fering from dysmorphophobia.
7.6
Long-Term Outcome
of Rhinoplasty for Medical
or Cosmetic Indication
A number of studies on the psychological effects
of cosmetic surgery have reported that patients
show short-term psychological improvement, but
little is known about the long-term persistence of
psychological changes. In a 5-year follow-up
study, Ercolani et al. [ 11 ] found in rhinoplasty
patients signi fi cant decrease of neuroticism and
anxiety mean scores at 6-months follow-up and
con fi rmed 5 years later. These fi ndings showed
that most rhinoplasty patients bene fi t from sur-
gery and their improvement persists over the long
term.
Moreover, a signi fi cant increase of extrover-
sion score was found at the 6-month follow-up
that did not persist 5 years later. These data are
consistent with the observations of Linn and
Goldman [ 12 ] who described euphoric reactions
with a general increase in social interactions aris-
ing in rhinoplasty patients during the fi rst months
following surgery.
Despite these results that showed that cos-
metic surgery for aesthetic reasons induces psy-
chological improvement in our patients as a
whole, rhinoplasty must not be considered a “sur-
gical solution” for psychological dif fi culties and
it cannot be expected to substantially modify pre-
operative severe psychological disturbance. Most
of the patients who had marked preoperative psy-
chological suffering, particularly moderate dys-
morphophobia, maintained high scores on the
neuroticism and anxiety scales 5 years later.
Therefore, the psychological improvement obtained
by rhinoplasty did not substantially modify the
pre-existing psychopathology, even though, in a
majority of cases, rhinoplasty had positive effects
on a number of psychometric parameters. It is,
therefore, probable that the high prevalence of
severe psychological disturbances many years
after the intervention in subjects who underwent

98
M. Ercolani and A. Agostini
cosmetic surgery for aesthetic reasons is the
development of a preoperative psychopathology,
which is not modi fi ed by surgical intervention.
The authors concluded that patients with “mini-
mum defect” and moderate dysmorphophobia
require greater psychological preparation aimed
at deepening the understanding of the psycho-
logical implications of their request.
7.7
Psychosocial Outcomes
for Patients Seeking
Cosmetic Surgery
Honigman et al. [ 13 ] investigated the existing
body of scienti fi c literature to address whether
elective cosmetic surgery improves a patient’s
psychological well-being (emotional state of the
person) and psychosocial functioning (parame-
ters related to normal functioning in social and
occupational domains of life). Computerized
research took into account the patients’ status in
both of these areas before and after the surgical
procedures. Poor psychosocial outcomes were
indicated by factors such as being young, male,
having unrealistic expectations on the surgery,
previous unsatisfactory results from similar types
of surgeries, complicated relationship issues, a
history of depression, anxiety, or personality dis-
orders, etc. Elective plastic surgery has yet to
ensure measurable and meaningful improvement
in psychological well-being and psychosocial
functioning, which leads researchers to push for
further study of these implications.
The general body of research seems to con fi rm
that in general there is a positive outcome for
patients’ psychological well-being and psycho-
social functioning after undergoing elective cos-
metic surgery; however, there are also multiple
indications of poor outcomes that cannot be
ignored. Further precautions must be taken by
surgeons prior to moving forward with their cor-
rective procedures with a focus on identifying
and fl agging patients that may be prone to poor
outcomes. A few pre-emptive recommendations
proposed to help improve the likelihood of
patients’ positive outcomes in psychosocial
terms, after undergoing elective cosmetic surgery,
are characterizing already existing psychiatric
conditions, clearly emphasizing the uncertainty
of surgical outcomes to patients, using standard-
ized and the most innovative techniques for
assessing patients, and requiring patients to com-
plete detailed questionnaires as part of the preop-
erative screening process.
References
1. Erikson EH (1956) The problem of ego identity. J Am
Psychoanal Assoc 4(1):56–121
2. Reich J (1969) The surgery of appearance: psycho-
logical and related aspects. Med J Aust 2(1):5–13
3. Barsky AJ (1944) Psychology of the patient undergo-
ing plastic surgery. Am J Surg 65:238–243
4. Hay GG (1970) Psychiatric aspects of cosmetic nasal
operations. Br J Psychiatry 116(530):85–97
5. Hay GG, Heather BB (1973) Changes in psychomet-
ric test results following cosmetic nasal operations. Br
J Psychiatry 122(566):89–90
6. Wright MR, Wright W (1975) A psychological study of
patients undergoing cosmetic surgery. Arch Otolaryngol
101(3):145–151
7. Ercolani M, Baldaro B, Rossi N, Trombini E, Trombini
G (1999) Short-term outcome of rhinoplasty for medi-
cal or cosmetic indication. J Psychosom Res 47(3):
277–281
8. Robin AA, Copas JB, Jack AB, Kaeser AC, Thomas
PJ (1988) Reshaping the psyche: the concurrent
improvement in appearance and mental state after rhi-
noplasty. Br J Psychiatry 152:539–543
9. Connolly FH, Gipson D (1978) Dysmorphophobia.
A long-term study. Br J Psychiatry 132:568–570
10. Thomson JA, Knorr NJ, Edgerton MT Jr (1978) Cosmetic
surgery: the psychiatric perspective. Psychosomatics
19(1):7–15
11. Ercolani M, Baldaro B, Rossi N, Trombini G (1999)
Five-year follow-up of cosmetic rhinoplasty. J Psychosom
Res 47(3):283–286
12. Linn L, Goldman JB (1949) Psychiatric observations
concerning rhinoplasty. Psychosom Med 11(5):307–314
13. Honigman RJ, Phillips KA, Castle DJ (2004) A review
of psychological outcomes for patients seeking cos-
metic
surgery.
Plast
Reconstr
Surg
113(4):
1229–1237

99
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_8, © Springer-Verlag Berlin Heidelberg 2013
8
8.1
The Nose and Its Psychological
Signi fi cance
Centrally located, the nose is the most prominent
facial feature. The unique anatomy of the nose is
re fl ected by the complex nomenclature used to
describe it as well as the efforts made to charac-
terize the geometric proportions of the “ideal”
nose. In his writings on the nose, Leonardo da
Vinci [ 1 ] describes ten types of “normal” noses,
but writes, “of abnormal faces I here say nothing,
for they are kept in the mind without dif fi culty.”
To paraphrase, it is challenging to accurately
describe a “normal” nose and very easy to iden-
tify an abnormal nose. Amodeo [ 2 ] describes the
nose as “the fulcrum of the face” and goes on to
describe its “cultural, ethnic, symbolic, and psy-
chological signi fi cance.” Authors have described
the nose as a symbol of one’s sexuality and have
even referred to the nose as “the scapegoat for
feelings of inadequacy” [ 2 ] . One can see how
psychology begins to enter into the equation.
When differentiating rhinoplasty patients from
other cosmetic patients, one must keep in mind
that rhinoplasty patients are seeking an alteration
in their natural appearance, as opposed to the
aging face patient who desires a return to a previ-
ously acceptable appearance. The rhinoplasty
patient desires a fundamental change in his face
and may in fact have never been happy with his
appearance. This highlights how closely self-
esteem and personality are tied to rhinoplasty. As
a result, the motivations for seeking rhinoplasty
can be complex.
This distinction between patients seeking aes-
thetic nasal surgery and patients seeking aging
face surgery is highlighted by Litner et al. [ 3 ]
who prospectively used a validated appearance-
related assessment questionnaire for patients
seeking these surgical procedures. The authors
reported that the nasal surgery group had
signi fi cantly greater levels of psychological dis-
tress due to concerns over facial appearance than
did those in the aging face group. The authors
believe this reinforces the concept that rhino-
plasty patients present a unique challenge for the
surgeon, particularly when compared to patients
seeking other cosmetic procedures of the face.
Anatomically speaking, there are many rea-
sons for a patient to seek rhinoplasty. Intertwined
with each of these anatomic reasons is a psycho-
logical motivation to have the anatomy altered.
Patients often seek an “existential change,
the possibility to change their behavior, their
Psychological Considerations
in Revision Rhinoplasty
Bryan T. Ambro and Richard J. Wright
B. T. Ambro , M.D., M.S. ()
Division of Facial Plastic and Reconstructive Surgery,
Department of Otorhinolaryngology – Head and Neck
Surgery , University of Maryland Medical Center ,
16 South Eutaw St., Suite 500 , Baltimore ,
MD 21201 , USA
e-mail: bryanambro@yahoo.com
R. J. Wright , M.D.
Department of Otorhinolaryngology – Head and Neck
Surgery , University of Maryland Medical Center ,
16 South Eutaw St., Suite 500 , Baltimore ,
MD 21201 , USA
e-mail: rwright@smail.umaryland.edu

100
B.T. Ambro and R.J. Wright
relationships with the external world, thanks to
the aesthetic change” [ 2 ] . For many, this is true,
as a positive change in physical appearance can
lead to heightened self-esteem. Following sur-
gery, some authors describe an increase in
patients’ capacity to enjoy life, reduced anxiety,
and feelings of being more positively treated by
others.
8.2
Patient Satisfaction After
Primary Rhinoplasty
With reported revision rates ranging between 8%
and 15% [ 4 ] , it can be inferred that the vast major-
ity of primary rhinoplasty patients are satis fi ed
with their outcomes – both physical and psycho-
logical. This inference is reinforced by Litner
et al. who demonstrated that rhinoplasty patients
as a group had signi fi cant postoperative improve-
ment in psychological well-being and quality of
life, as measured by a validated appearance-
related questionnaire. The authors believe that a
patient is more likely to be satis fi ed if he or she
has speci fi c, realistic expectations of the cosmetic
outcome of rhinoplasty and understands that a
change in appearance will not provide a “cure”
for other life problems.
Honigman et al. [ 5 ] published a review of psy-
chological and psychosocial outcomes for
patients seeking cosmetic surgery. They de fi ned
“psychological” as “the emotional state of the
person” and “psychosocial” as “pertaining to
functioning in social and work/study domains.”
Factors associated with poor psychological and
psychosocial outcomes included being young,
being male, having unrealistic expectations of the
procedure, previous unsatisfactory cosmetic sur-
gery, minimal deformity, motivation based on
relationship issues, and a history of depression,
anxiety, or personality disorder. A number of
other authors have investigated this topic and
have drawn similar conclusions [ 6– 10 ] .
Honigman further distinguishes between
patient satisfaction with the technical outcome
of procedures and satisfaction with changes in
psychosocial status. This is a very important dis-
tinction to appreciate when trying to understand
patient satisfaction and reasons for seeking revi-
sion rhinoplasty. The technical outcome may be
satisfying, but the life changes, or absence
thereof, may be ultimately what is unsatisfying
for the patient. These patients often mistakenly
believe that more change (i.e., more surgery)
will beget the changes that the primary surgery
did not.
Ercolani et al. [ 11 ] published a study on long-
term follow-up of cosmetic rhinoplasty that
quanti fi es the life changes following cosmetic
rhinoplasty. The authors used two validated
psychological questionnaires (the Maudsley
Personality Inventory and the Inventory for
Personality and Anxiety Testing) to pro fi le
patients preoperatively, 6 months postoperatively,
and again 5 years postoperatively. For compari-
son, the authors also used a control group of sub-
jects who did not undergo surgery. The results
showed that compared to the control group, pre-
operative cosmetic rhinoplasty candidates were
signi fi cantly more neurotic, more anxious, and
less extroverted. At both 6 months and 5 years
of follow-up, the authors observed a signi fi cant
decrease in anxiety and neuroticism among
patients who underwent cosmetic rhinoplasty.
Six months after surgery, rhinoplasty patients
had a signi fi cant increase in extroversion, which
the authors describe as an early euphoric reac-
tion leading to increased social interactions.
This early increase in extroversion, however, did
not persist at the 5 years follow-up. In addition,
rhinoplasty patients in the preoperative period
showed more evidence of dysmorphophobia
(body dysmorphic disorder), social phobia, sex-
ual and somatization disorders, and personality
disorders than did the control group. There was
no improvement observed in these pathologic
conditions at either 6 months or 5 years of fol-
low-up. From this study, one may conclude that a
cosmetic rhinoplasty candidate who is anxious or
self-conscious about her nose, but is otherwise in
good mental health, will have a lasting positive
psychological improvement. On the other hand,
those with signi fi cant psychopathology may ini-
tially believe that a change in their nose will lead
to a change in their life, but this is unlikely to be
the case.

101
8 Psychological Considerations in Revision Rhinoplasty
8.3
Reasons for Seeking Revision
Rhinoplasty
In a 2010 study by Yu et al. [ 12 ] , the authors
reported the three most common reasons for
patient dissatisfaction following rhinoplasty as
tip asymmetry, nasal obstruction, and a crooked
middle third. Numerous other studies report a
variety of patient concerns, both aesthetic and
functional, among those seeking revision surgery
[ 13, 14 ] . With this understanding, it is important
for the surgeon to keep in mind that dissatis fi ed
patients generally have legitimate concerns that
can be objectively evaluated by the surgeon and
should not be re fl exively thought of as “dif fi cult”
patients.
It is helpful when evaluating patients seeking
revision rhinoplasty to divide them into three
general categories: (1) those with poor technical
outcomes (in whom there is concordance between
the patient complaints and the surgeon’s assess-
ment), (2) those who are unsatis fi ed with a rea-
sonable but not perfect surgical outcome, and (3)
those who are unsatis fi ed with a technically very
good outcome. Within each of these three groups,
patients may be further subcategorized based on
psychological and psychosocial parameters.
For the fi rst and third groups, the decision to
operate is often rather easy to make. If there is a
poor technical result that the surgeon believes
he or she can improve upon, it may be reason-
able to operate given that the patient’s goals are
realistic and appropriate. Conversely, if the pri-
mary outcome appears technically very good,
the decision not to operate is also easy to make
and defend. It is the intermediate group, in
which there is signi fi cant dissatisfaction over a
reasonable outcome, that the surgeon must be
more cautious in patient selection and factor in
patient psychological motivations. In this group,
it is particularly important that there be concor-
dance between the patient’s stated reasons for
dissatisfaction and the surgeon’s assessment of
the technical shortcomings of the initial surgery.
If the surgeon believes that an improvement
cannot be accomplished, the decision not to
operate should be made, regardless of the pres-
ence or absence of patient psychopathology. If
the surgeon is “on the fence” and is considering
operating, an attempt should be made to identify
“problem patients” (i.e., those who are unlikely
to be satis fi ed by any result).
8.4
Psychological Pro fi les of Those
Seeking Revision Rhinoplasty
To understand the dif fi cult cosmetic patient, it is
helpful to fi rst understand the characteristics of
the ideal patient. Noted psychologist Mary Ruth
Wright [ 15 ] describes this patient as one who
“chooses surgery as a treatment, not a cure. He
knows what he wants and speaks in speci fi c rather
than vague terms. He is realistic, not idealistic,
and is able to separate his wishes and wants from
his expectations.” This patient has an accurate
mental image of what he will look like and what
his life will be like after surgery.
It cannot be overstated that the surgeon must
keep in mind the consistency between the level of
patient concern over a perceived imperfection
and the surgeon’s objective assessment of the
level of deformity. Fattahi [ 16 ] accurately writes,
“the clinician must see what the patient sees.”
This point is further emphasized by Gorney [ 17 ]
who proposed a “surgical eligibility guide.”
Using this guide, the level of patient concern is
plotted against the surgeon’s assessment of the
deformity. Those with high levels of concern over
minor deformities will fall onto the lower end of
the eligibility spectrum, and it may be best to
avoid operating on these patients.
In contrast to Wright’s ideal, many published
works on revision rhinoplasty and cosmetic sur-
gery in general identify different patient person-
ality types or patient characteristics that are
problematic. It has been said that all cosmetic
surgery patients are, in effect, psychiatric patients
[ 11 ] . While there may be some truth to this state-
ment, there are clearly some patients who stand
apart from the norm and warrant further discus-
sion. This list includes male patients, those with
questionable motives for pursuing surgery, and
those with psychiatric conditions including
depression, psychotic disorders, and personality
disorders.

102
B.T. Ambro and R.J. Wright
Much has been written about the increased
dif fi culty of dealing with male cosmetic surgery
patients [ 18, 19 ] . When compared to female
patients, male patients have been described as
more emotionally unstable, as having a less clear
body image, and having vague expectations of sur-
gery. These factors are more likely to contribute to
patient dissatisfaction following surgery. When
counseling the male patient who exhibits these
characteristics, the surgeon should encourage the
patient to speak in clear, well-de fi ned terms about
his perception of his imperfections and what
exactly he hopes to change.
Polysurgical syndrome is a described psychi-
atric condition that is essentially an “addiction”
to surgery. These patients may describe past sur-
gical failures and can often be identi fi ed simply
by reviewing their past surgical history. A patient
with polysurgical syndrome is best not operated
upon and should be referred for psychiatric
evaluation.
It has been reported that up to 20% of cos-
metic surgery patients will have a history of
depression, which is approximately fi ve times
higher than among the general population [ 20 ] .
Despite the prevalence of this mood disorder in
cosmetic patients, there is a lack of consensus in
the literature regarding outcomes data in this
patient population. A recent review of this topic
identi fi ed studies reporting higher rates of patient
dissatisfaction among those with depression, as
well as studies reporting similar rates of satisfac-
tion and dissatisfaction between depression
patients and “healthy” patients [ 20 ] . It is our
belief that the diagnosis of depression is not a
positive predictor for postoperative dissatisfac-
tion and depression is not a contraindication to
surgery. The authors feel strongly that patients
should be in a treatment regimen before undergo-
ing surgery. Lastly, patients should also be made
aware of the possibility of symptom exacerbation
when faced with a life stressor such as cosmetic
facial surgery.
Some patients may pursue cosmetic surgery
for questionable motives. A decisional con fl ict
arises when the request for surgery does not
re fl ect the patient’s actual desires, as when one
knowingly or unknowingly seeks surgery to
please someone else (e.g., a spouse/romantic
interest). Similarly, one may encounter patients
who truly desire surgery but have a signi fi cant
other or family member who opposes the idea. In
these instances, it is best for the surgeon to help
the patient to clarify his or her motivations.
A surgeon may not have dif fi culty identifying
a patient with psychotic behavior, but identifying
a patient with a personality disorder can be subtle.
Often, the surgeon or the of fi ce staff may get a
vague sense that there is something “off” about a
patient, even when that patient is displaying rea-
sonably appropriate behavior. In these instances,
it behooves the surgeon to be familiar with some
basic characteristics of common personality dis-
orders to help identify those who may be less than
ideal surgical candidates.
A personality disorder is de fi ned as a deeply
ingrained, nonpsychotic, in fl exible, maladaptive
pattern of behaving and relating to others. These
patients are particularly challenging in part due
to the fact that they may at times behave appro-
priately, which may result in the disorder being
unrecognized. Some of the more common per-
sonality disorders encountered by the cosmetic
surgeon include the borderline personality, the
narcissistic personality, the obsessive-compulsive
personality, the histrionic personality, and the
passive-aggressive personality. These are all
speci fi c psychiatric terms that have designated
diagnostic criteria [ 21 ] . While it is not the role of
the cosmetic surgeon to diagnose a patient with a
personality disorder, it is important to be familiar
with some of the traits associated with these dis-
orders so that a problem patient can be identi fi ed
and potential postoperative dissatisfaction can be
averted. In some cases, it may be appropriate to
request a referral to a mental health-care profes-
sional prior to further discussion of revision
surgery.
The borderline personality is characterized by
a sense of loneliness and emptiness, unpredict-
able mood swings, irritability, and fear of aban-
donment. Borderline patients tend to “split”
people into two groups: all good and all bad.
Initially, the surgeon may fall into the “good” cat-
egory and be idealized by the patient. If the
patient is disappointed, the surgeon may be

103
8 Psychological Considerations in Revision Rhinoplasty
switched to the “bad” category and be vili fi ed by
the patient. This rigid classi fi cation, without any
middle ground, may also be applied to nursing
and of fi ce staff, who may experience poor treat-
ment even while the patient behaves kindly
toward the surgeon. The borderline patient is best
identi fi ed preoperatively and avoided.
The narcissistic personality is characterized by
a feeling of superiority compared to others, regard-
less of actual life achievements. These patients
have a high opinion of themselves, expect others
to behave deferentially toward them, and have
little regard for the well-being of others. They
often expect special treatment from the surgeon
and his staff and disregard of fi ce rules and peri-
operative planning. They tend to pay very close
attention to clothing and makeup and behave in
a way that is designed to draw attention to them-
selves. A narcissistic personality often expects
special treatment regarding appointment times,
access to the surgeon over the telephone, or other
considerations that deviate from the service most
patients expect. Like the borderline patient, these
patients are poor operative candidates.
Patients with obsessive-compulsive personal-
ity disorder demonstrate rigid, controlling, and
perfectionistic behavior. They often rely on lists
and schedules and pay close attention to small
details. They do not tend to show emotion and
can display a constricted affect. When making a
decision, they will attempt to rationally weigh
both sides of an argument and may have great
dif fi culty coming to a decision. Once decisions
are made, they are pursued intensely. They may
have unrealistic goals for surgery and can fi xate
on minor deformities both preoperatively and
postoperatively. Obsessive-compulsive patients
are often stubborn and when surgical outcomes
are not what they expected may become de fi ant
and demand correction, even if the outcome is
technically good. In dealing with these types of
patients, it is imperative that a preoperative dia-
log is undertaken in order to set and agree upon
realistic expectations and the possibility of less
than ideal outcomes.
The histrionic personality is characterized by
dramatic, exaggerated, and colorful behavior.
These patients strive to be the center of attention
and attempt to involve others in their emotional
drama. They may dress provocatively and behave
seductively, and tend to create unjusti fi ed dra-
matic situations and crises. The surgeon is warned
to be mindful of maintaining appropriate bound-
aries and encouraged to have an assistant present
during all interactions.
Patients with passive-aggressive personality
disorder are resentful and feel unfairly burdened
or singled out by others. They will often appear
to be in compliance with the surgeon’s expecta-
tions, but this compliance can be super fi cial.
They will frequently complain to others about the
unjust demands placed upon them. These patients
may appear to follow postoperative guidelines
and of fi ce rules, but can act in subtle ways to
undermine or antagonize the surgeon. Although
these patients may not be optimal candidates,
revision surgery can be undertaken as long as the
behavior is deemed not to negatively in fl uence
the ultimate outcome.
8.5
Practical Considerations
and Recommendations in
Dealing with the Revision
Rhinoplasty Patient (Table 8.1 )
The counseling of the revision candidate is
undoubtedly a more involved and time-consuming
process than for the primary patient. One of the
principal goals of the initial consultation is to
maintain and establish communication and rap-
port. Patients must feel they have an open forum
to vent their frustrations and that they have a
compassionate listener. It behooves the surgeon
to remember that patient dissatisfaction is often
rooted in legitimate concerns and that most
revision patients are not potential “problem
patients.” However, a “red fl ag” should be raised
if signi fi cant discordance exists between the
patient’s concerns and the surgeon’s objection
assessment.
The surgeon who is considering revising
another surgeon’s patient must be empathetic
toward the patient’s anger that stems from the
additional time, emotional strain, and fi nancial
expenses that a revision surgery entails. It must

104
B.T. Ambro and R.J. Wright
be stressed, however, that validating a patient’s
frustration does not require passing judgment on
a previous surgeon’s result. Disparaging another
colleague’s work is ill advised and is unlikely to
bene fi t any of the involved parties. Instead, the
surgeon should encourage moving forward from
the past and to focus on the present. Moreover,
the young, less-experienced surgeon should not
make the mistake of assuming that he or she can
succeed where a colleague has failed. Major revi-
sions can prove to be quite challenging and should
be approached with caution and an honest appre-
ciation of one’s own skill set.
When dealing with a dissatis fi ed patient of
their own, the surgeon should consider several
important points. (1) Never re fl exively agree to a
revision surgery for the sole purpose of improv-
ing an awkward situation. A rash decision to
operate, even if marginally indicated, will more
times than not result in further dissatisfaction. (2)
Avoid reacting defensively to a patient’s unhap-
piness. Trying to convince a patient that their
concerns are unfounded will only serve to further
antagonize the situation. (3) Avoid the natural
inclination to minimize interactions with an
unhappy patient. As dif fi cult as it may be, these
patients should be treated with extra attention and
care, so as to avoid the appearance of apathy and
neglect, which is often the root of malpractice
lawsuits.
The surgeon who is contemplating revising
his or her own result should be truthful with his
Table 8.1 Patient characteristics and suggestions for the surgeon
Patient type
Patient characteristics
Suggestions for the surgeon
The male patient May be less emotionally stable than female
counterpart
Encourage to better de fi ne perceptions
of physical imperfections
Less clear body image
Establish realistic expectations for surgery
Vague expectations of surgery
The depressed
patient
Depressed mood
Patient should be treated for depression prior
to surgery
Symptoms may be exacerbated following surgery
The decisional
con fl ict
May seek surgery to please someone else
Encourage patient to discuss and clarify
motivations for surgery
May have spouse/romantic interest who opposes
surgery
Borderline
personality
May display mood swings and irritability
Patients with borderline personality disorder
are best avoided as surgical candidates
Splits people into all good and all bad categories
May idealize the surgeon while treating of fi ce
staff poorly
Narcissistic
personality
High opinion of him/herself
Patients with narcissistic personality disorder
are best avoided as surgical candidates
Expects special treatment and may disregard
of fi ce policy/perioperative instructions
Obsessive-
compulsive
personality
Rigid, controlling behavior
Clear, preoperative discussion of expectations
and possibility of less than ideal outcome
Perfectionist
Not necessarily a contraindication to surgery
May have dif fi culty making a decision
May have unrealistic goals or fi xation on minor
deformities
Histrionic
personality
Exaggerated, colorful behavior
Establish boundaries for appropriate behavior
Strive to be the center of attention
Have assistant present if necessary
Attempts to involve others in his/her personal
problems
Not necessarily a contraindication to surgery
May dress or behave in a provocative manner
Passive-
aggressive
personality
Often feel unfairly burdened or singled out
Clear preoperative discussion of patient
instructions
May only be super fi cially compliant with
perioperative instructions
Not necessarily a contraindication to surgery

105
8 Psychological Considerations in Revision Rhinoplasty
or herself despite the dif fi culty of acknowledging
one’s own shortcomings and imperfections. The
following questions should be asked: Do I under-
stand what went wrong with the initial surgery?
If so, do I have the knowledge and skills to cor-
rect or improve the result? If the answer to either
of these questions is no, the surgeon is encour-
aged to consider referring the patient to a col-
league for a second opinion.
The decision on whether or not to operate
should be made via a systematic approach that
factors in the physical, psychological, and psy-
chosocial issues at hand. All too often, the psy-
chological considerations of revision rhinoplasty
are regretfully underappreciated or overlooked.
All consultations should include routine open-
ended questions that give insight into the patient’s
true motivations for seeking revision surgery.
Moreover, it is the surgeon’s duty to inform the
patient of the potential limitations of secondary
surgery so that realistic expectations can be
agreed upon.
The wise surgeon chooses his or her revision
rhinoplasty patient carefully. A thorough under-
standing of the complex anatomical as well as the
psychological problems will undoubtedly maxi-
mize patient and surgeon satisfaction.
References
1. Richter JP (ed) (1970) The notebooks of Leonardo Da
Vinci. Dover Publications, New York
2. Andretto Amodeo C (2007) The central role of the
nose in the face and the psyche: review of the nose
and the psyche. Aesthetic Plast Surg 31(4):406–410
3. 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
4. Kamer FN, McQuown SA (1988) Revision rhino-
plasty. Arch Otolaryngol Head Neck Surg 114:257
5. Honigman RJ, Phillips KA, Castle DJ (2004) A review
of psychosocial outcomes for patients seeking cos-
metic surgery. Plast Reconstr Surg 113(4):1229–1237
6. Guyuron B, Bokhari F (1996) Patient satisfaction fol-
lowing rhinoplasty. Aesthetic Plast Surg 20(2):
153–157
7. Haraldsson P (1999) Psychosocial impact of cosmetic
rhinoplasty. Aesthetic Plast Surg 23(3):170–174
8. Meningaud JP, Benadiba L, Servant JM, Herve C,
Bertrand JC, Pelicier Y (2003) Depression, anxiety
and quality of life: outcome 9 months after facial cos-
metic surgery. J Craniomaxillofac Surg 31(1):46–50
9. Ozgur F, Tuncali D, Güler Gürsu K (1998) Life, satis-
faction, self-esteem, and body image: a psychosocial
evaluation of aesthetic and reconstructive surgery
candidates. Aesthetic Plast Surg 22(6):412–419
10. Zojaji R, Javanbakht M, Ghanadan A, Hosien H,
Sadeghi H (2007) High prevalence of personality
abnormalities
in
patients
seeking
rhinoplasty.
Otolaryngol Head Neck Surg 137(1):83–87
11. Ercolani M, Baldaro B, Rossi N, Trombini G (1999)
Five-year follow-up of cosmetic rhinoplasty. J Psychosom
Res 47(3):283–286
12. Yu K, Kim A, Pearlman SJ (2010) Functional and
aesthetic concerns of patients seeking revision
rhinoplasty. Arch Facial Plast Surg 12(5):291–297
13. Thomson C, Mendelsohn M (2007) Reducing the
incidence of revision rhinoplasty. J Otolaryngol
36(2):130–134
14. Ballert JA, Park SS (2008) Functional considerations
in revision rhinoplasty. Facial Plast Surg 24(3):
348–357
15. Wright MR (1984) How to recognize and control the
problem patient. J Dermatol Surg Oncol 10(5):
389–395
16. Fattahi T (2011) Considerations in revision rhino-
plasty: lessons learned. Oral Maxillofac Surg Clin
North Am 23(1):101–108
17. Gorney M (2010) Recognition and management of
the patient unsuitable for aesthetic surgery. Plast
Reconstr Surg 126(6):2268–2271
18. Rohrich RJ, Janis JE, Kenkel JM (2003) Male rhino-
plasty. Plast Reconstr Surg 112(4):1071–1085
19. Wright MR (1987) The male aesthetic patient. Arch
Otolaryngol Head Neck Surg 113(7):724–727
20. Ambro BT, Wright RJ (2010) Depression in the cos-
metic surgery patient. Facial Plast Surg 26(4):
333–338
21. Moore D, Jefferson J (2004) Handbook of medical
psychiatry, 2nd edn. Mosby, Philadelphia

Part III
Preoperative

109
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_9, © Springer-Verlag Berlin Heidelberg 2013
9
9.1
Introduction
Computers have moved from curiosity to com-
monplace within the practice of plastic surgery, a
fi eld ideally positioned to bene fi t from the facility
with which photographic records of patients can
be archived, stored, retrieved, and, in the focus of
this chapter, digitally manipulated.
Patient counseling, care, and follow-up in facial
plastic surgery are as dependent on the photo-
graphic documentation as the internal medicine
specialist who relies on an accurate recording of a
hypertensive patient’s blood pressure over time.
Digital imaging systems have been in use since the
mid-1980s but were cumbersome and expensive
and often required a degree of computer expertise
that was not common among physicians in active
practice during the early era of the personal com-
puting [ 1– 4 ] . Technological advances, over the
ensuing two decades, culminated in the ubiquity
with which digital photography and computer sim-
ulated imaging (CSI) are found in the consultation
rooms of surgeons who perform rhinoplasty.
As personal computer costs declined, the
fi nancial savings associated with digital storage
of patient photographs prompted many surgeons
to transfer older 35-mm slides to digital storage
media [ 4– 7 ] . Similarly, technical advances in
digital cameras improved image resolution and
allowed immediate viewing of photographs dur-
ing patient consultation and simple retrieval of
images for resident education, research, and pre-
sentations. These bene fi ts of digital photography
are further desirable, as they are delivered at a
decreased cost in comparison to 35-mm single-
lens re fl ex (SLR) camera systems [ 5 ] . Financial
savings aside, the perceived image quality of dig-
ital imaging provides a statistically signi fi cant
improvement over that offered by the former gold
standard, 35-mm slide fi lm, when appropriately
controlling for subject matter variation, lighting,
distance to subject, lens, and sensor size [ 8 ] . The
present state of digital camera technology offers
decreased costs, improved integration into clini-
cal practice, and better images than was possible
with standard 35-mm SLR cameras. Digital
imaging technology bypasses the often circuitous
route by which early adopters of computer simu-
lated imaging (CSI) managed to produce their
morphed photos [ 3, 4, 6 ] . CSI software now
offers to all surgeons the ability to sketch like an
artist in modifying patient photographs, and
therein lies both the power and danger of CSI in
rhinoplasty.
Computer Simulated Imaging
in Rhinoplasty
Robert T. Adelson
R. T. Adelson , M.D.
Division of Facial Plastic and Reconstructive Surgery,
Department of Otolaryngology , University of Florida
College of Medicine , 1600 SW Archer Road ,
Gainesville , FL 32610 , USA
e-mail: robert.adelson@ent.u fl .edu,
robertadelson@me.com

110
R.T. Adelson
9.2
Accuracy of Computer
Simulated Imaging
in Rhinoplasty
Before a surgeon adopts CSI into their rhino-
plasty practice, one should become familiar with
the body of knowledge surrounding two pertinent
issues: (1) the reliability with which surgical
results re fl ect preoperative computer imaging and
(2) the relationship between CSI and patient sat-
isfaction. The peer-reviewed literature spanning
20 years is available concerning CSI in rhino-
plasty, and while important trends are known,
gaps in the knowledge base are recognized.
The initial studies of CSI in rhinoplasty were
limited to small numbers of patients within the
practices of experienced surgeons, and while
even the earliest experiences with the technology
were perceived as accurate and helpful, a rigor-
ous method of analyzing the precision of CSI has
not emerged [ 1, 2 ] . Despite two decades of publi-
cation on this subject, there remains no standard
convention for evaluating the accuracy of preop-
erative CSI to the actual postoperative results,
making direct comparison between authors more
dif fi cult. Despite this, important trends are borne
out over time with regard to the proportion of
patients whose postoperative result will appear
identical, similar, or different from the CSI, no
matter the method of analysis.
The majority of accuracy studies employ
reviewers, both experts and laypersons, to assess
the degree of similarity between the preoperative
CSI and the postoperative photographs. While
this method does not quantify the speci fi c differ-
ences between the prognosticated image and the
eventual result, it is the most commonly utilized
research technique and may better answer a
patient’s primary concern of how close the post-
operative result will re fl ect the CSI in the overall
view, rather than in each speci fi c measurement.
Retrospective studies of patients who have
undergone CSI during their rhinoplasty consulta-
tion are useful in that both patient and surgeon
reviewers can critically assess the overall gestalt
of how closely their results re fl ect the preopera-
tive CSI. In nearly every study, surgeons were
more critical than laypersons in assessing the
comparison between CSI and postoperative
results [ 9– 12 ] . Vuyk et al. [ 13 ] demonstrated
nearly identical results between surgeon and
patient reviewers, with results that are “identical”
or “more aesthetic” than the CSI in 83% of cases
and results that were “less aesthetic” than the CSI
in 17%. Sharp’s [ 14 ] retrospective study found
68% of patients to appreciate their results as
either “identical” or “aesthetically superior” to
the CSI, while 32% found the results “less aes-
thetic” then the CSI. Similar results are revealed
by Muhlbauer and Holm [ 11 ] , who demonstrated
“identical or similar” results appreciated by 70%
of surgeons and 80% of patients, with “approxi-
mate or poor” results noted by 30% of surgeons
and 16.5% of patients. This method of evaluating
overall results was examined in detail by Agarwal
et al. [ 9 ] and Punthakee et al. [ 12 ] , who reviewed
both frontal and lateral images as opposed to the
previous studies that were limited to lateral views
alone. Among the expert reviewers in Agarwal’s
study, 32% of the preoperative CSI did not pre-
dict the postoperative result, and the least predic-
tive values were noted in African-American
patients, likely as a result of the thicker, skin-soft
tissue envelope [ 9 ] . Similarly, Punthakee et al.
[ 12 ] determined preoperative CSI to be predic-
tive of the postoperative result in about 75% of
cases, and the lateral views were somewhat supe-
rior to the frontal views in their accuracy. While
the technique is generally perceived as accurate,
in as many as one third of cases, the goal depicted
in CSI is not delivered postoperatively.
Finer degrees of distinction among qualitative
results have been sought to determine if CSI is
more predictive of postoperative results for differ-
ent features of the nose. Mehta et al. determined
accuracy to be moderate for both primary and
revision cases and that supratip edema remains a
limiting factor in assessing accuracy 6 months
following surgery [ 10 ] . Surprisingly, the frontal
CSI was found to be more accurate than the lat-
eral view in 76% of cases, calling into question
both the historic use of the lateral view in the
majority of studies and a generally accepted sur-
geon preference for demonstrating proposed sur-
gical changes on the patient’s lateral view [ 4, 10 ] .
Given the available research, surgeons should

111
9 Computer Simulated Imaging in Rhinoplasty
develop a level of comfort in morphing both the
pro fi le and frontal view to re fl ect potential surgical
changes.
Methods of objectively measuring the differ-
ences between preoperative CSI and postopera-
tive photographs have been proposed, in
contradistinction to the aforementioned qualita-
tive reviews, yet no one method of analysis has
been shared between authors and veri fi ed as a
standard for further study. Bronz [ 4 ] offered the
fi rst large study of CSI in rhinoplasty based upon
exact measurements of CSI and postoperative
photographs. This prospective study of 100 con-
secutive patients who underwent preoperative
CSI allowed comparisons to 1-year postoperative
lateral pro fi le photographs. A method of pro fi le
analysis in CSI was proposed using identical pro-
portions of the images, and drawing pro fi le lines
over each photographs allowed exact measure-
ments to be made and discrepancies to be
identi fi ed between the CSI and the postoperative
photograph. Sixty-two percent of cases were
found to be identical (<1 mm between pro fi le
lines), 26% similar (1 mm between pro fi le lines),
and 12% different (>1 and <2 mm between pro fi le
lines) [ 4 ] .
Similarly, the author [ 15 ] undertook an
objective study of the accuracy of CSI in rhino-
plasty by retrospectively measuring fi ve param-
eters of the right nasal pro fi le on CSI and on
6-month postoperative photographs and found
only the measurements at the columella-tip angle
to differ signi fi cantly. The persistence of nasal
tip edema and diminished accuracy at this loca-
tion in the fi rst 6 months following surgery has
been a limiting factor in other studies and is an
important consideration to review during preop-
erative counseling [ 10 ] . In addressing the appli-
cability of preoperative CSI in more challenging
revision rhinoplasty cases, decreased postopera-
tive
accuracy
was
reported,
though
not
signi fi cantly so [ 10 ] . Awareness of postoperative
tip edema and the decrement in accuracy of pre-
operative CSI that is expected in more dif fi cult
cases will allow surgeons to better educate their
patients regarding surgical outcomes and should
encourage conservatism in illustrating postoper-
ative results.
9.3
Computer Simulated Imaging
and Patient Satisfaction
Studies of both the qualitative and quantitative
measures of predictive accuracy are impor-
tant considerations for the rhinoplasty surgeon
employing CSI; however, the role that CSI plays in
patient satisfaction may be the ultimate marker of
success. Researchers have approached this ques-
tion from two vantage points: (1) patient percep-
tion of CSI during rhinoplasty consultation and
(2) relationship between accuracy of preoperative
CSI and postoperative patient satisfaction.
Early adopters of CSI expressed concern that
the incorporation of impersonal equipment like
computers into the doctor-patient relationship
would be received poorly by the average patient
[ 14, 16 ] . Quite the opposite was demonstrated in
multiple questionnaire studies. Reports from the
preliminary years of the personal computing era
found that only 2% of patients reported feeling
intimidated by the use of CSI, 90% were encour-
aged by the “high-tech” equipment, and none
reported a loss of the “personal touch” of the doc-
tor-patient relationship [ 16 ] . With the increased
penetration of computers into every facet of life,
the preservation of the doctor-patient relationship
has been upheld in more recent reviews of the
subject [ 13 ] . In fact, a vast majority of patients
across multiple studies expressed the belief that
CSI during consultation enhances the doctor-
patient relationship, improves con fi dence in the
surgeon’s judgement, and better enables the
patient to visualize proposed changes, and that
CSI should be a routine component of preopera-
tive counseling for rhinoplasty [ 11, 13, 14, 16 ] .
Within this generally positive questionnaire
data are some fi ndings with important implica-
tions for how surgeons use CSI in the preopera-
tive process. There is no question that CSI is a
powerful method of demonstrating potential sur-
gical changes to a patient [ 13, 16 ] and that this
method depicts changes more realistically than
primitive techniques using simple sketching,
transparencies, or verbal description alone.
A highlight of these studies of CSI in preopera-
tive counseling is the recognition by both patient
and surgeon that CSI fostered the introduction of

112
R.T. Adelson
surgical changes that had not previously been
considered in a large number of cases. Vuyk et al.
[ 13 ] found 62% of rhinoplasty patients counseled
with CSI were presented with changes to their
nose that they had not previously considered, and
38% altered the wishes and expectations for sur-
gery that they held prior to CSI. Thomas et al.
[ 16 ] also found large proportions of his rhino-
plasty patients undergoing preoperative counsel-
ing with CSI to appreciate rhinoplasty changes
not previously considered prior to CSI (28%) as
well as to modify their preconceived surgical
changes (30%). Sharp et al. [ 14 ] noted 32% of
study patients to report being presented with rhi-
noplasty options not previously considered, and
fully 20% of these patients adopted the suggested
changes. This superior ability to educate patients
visually regarding the possible results of rhino-
plasty is an important communication tool and
perhaps the most effective method in my own
practice by which the patient and I come to an
understanding of the goals for surgery.
The second component of understanding the
relationship of CSI accuracy to the ultimate
marker of success, patient satisfaction, is decid-
edly more dif fi cult to elucidate and is the subject
of far less research. Sharp demonstrated that the
incorporation of preoperative CSI into preopera-
tive counseling increased patient satisfaction in
patients undergoing cosmetic rhinoplasty when
compared to those patients who did not receive
similar counseling sessions [ 14 ] . Similarly, the
preoperative use of a three-dimensional radio-
logic viewer for CSI signi fi cantly improved the
functional results of rhinoplasty, decreased the
revision rate, and improved postoperative satis-
faction over a patient group that did not have
access to CSI in their preoperative counseling
[ 17 ] . While both of the above studies support the
notion that CSI improves patient satisfaction with
both cosmetic and functional rhinoplasty proce-
dures, neither speci fi cally addresses the role of
the accuracy of CSI in patient satisfaction.
Muhlbauer and Holm [ 11 ] reported that patients
satis fi ed with their rhinoplasty results were
not critical of the accuracy of the preoperative
CSI and that not all patients with poor matches
between the preoperative CSI and their eventual
result sought revision surgery. When patients
are divided into “happy” and “unhappy” catego-
ries based upon the results of a questionnaire,
Mehta et al. [ 10 ] found the accuracy scores to be
signi fi cantly higher for the “happy” group, while
lower accuracy scores were reported for those
patients whose responses to surveys placed them
in the “unhappy” group. There are multiple vari-
ables in the production of a satis fi ed rhinoplasty
patient, and accuracy of the preoperative CSI is
only one of those features. While improved accu-
racy seems to correlate with greater patient satis-
faction, further research is needed. Nevertheless,
it is an admirable and tacitly understood goal of
all rhinoplasty surgeons who use CSI that mea-
sures should be taken to improve one’s accuracy
with the technology while striving to deliver both
ethical patient counseling and excellent surgical
results.
9.4
Ethical Issues in Computer
Simulated Imaging
Incumbent upon those surgeons who utilize the
great power of CSI for patient education and pre-
operative counseling is the responsibility to use
this technology carefully and as an adjunctive
method of enhancing patient communication.
Multiple reviews of patient reactions to CSI dem-
onstrate increased comfort with the idea of cos-
metic surgery and a greater ease in committing to
undergoing such operations when CSI is a compo-
nent of their preoperative counseling [ 14, 16 ] .
While surgeons traditionally use various tools to
enhance a patient’s con fi dence in their abilities,
several reviews of this topic suggest that CSI alone
greatly increases patient con fi dence in the sur-
geon’s judgement [ 13, 14, 16 ] . Improved
con fi dence in surgeon abilities is reported by
42–84% of respondents as a result of CSI in the
counseling process [ 13, 14, 16 ] . In unethical hands,
CSI risks become a marketing tool, with 84% of
patients across multiple studies reporting it is eas-
ier to commit to undergoing surgery after counsel-
ing with CSI [ 13, 14, 16 ] . Surgeons should be

113
9 Computer Simulated Imaging in Rhinoplasty
aware of the persuasive impact of CSI revealed by
these studies and avoid using CSI as a method of
“pitching,” selling, or unduly in fl uencing patients
to undergo rhinoplasty operations [ 17, 18 ] .
Time-honored methods of improving patients’
con fi dence in their surgeon are important adjuncts
that should not be forgotten in the computer era.
The author routinely utilizes case studies of pre-
vious patients with similar anatomic problems
and aesthetic goals to counsel new rhinoplasty
patients, thereby demonstrating a surgical track
record for the new patient instead of a virtual one
alone. Additionally, previous case studies are
supplemented with the preoperative CSI where
applicable, so new patients can understand the
use of this technology as an aesthetic goal to
strive for instead of an exact forecast of the
eventual result.
CSI is most useful and perhaps employed most
ethically when the technology is presented sim-
ply as a tool for communication that places the
surgeon and the layperson on more equal footing.
Reconciling differences in opinion regarding that
which is aesthetically desirable while technically
possible assists both parties in reaching a greater
understanding of the proposed operation.
Ethically, the surgeon is reminded that the
ability to demonstrate a result in pixels does not
directly translate to the ability to deliver a similar
result in fl esh and bone. The surgeon should dem-
onstrate morphed images within the boundaries
of one’s surgical ability, refrain from providing
fl awless results, and should temper their surgical
aspirations with the knowledge of their previous
rhinoplasty results [ 9, 14, 19 ] .
9.5
Legal Issues in Computer
Simulated Imaging
At the dawn of the age of computer imaging in
plastic surgery, experienced surgeons worried,
and rightfully so, that the temptation to depict
faultless results might result in gimmicks and
marketing ploys at best and malpractice litiga-
tion at worst [ 20 ] . While the deluge of litigation
predicted in 1997 never arrived, the reluctance
of surgeons to employ CSI due to perceptions
of increased medicolegal liability, a failure to
meet patient expectations, concerns regarding
establishment of a contract or warranty to
deliver a depicted result, and general uneasi-
ness with the legal and ethical implications of
this new technology represent a summary of the
most commonly cited reasons for refraining
from or restricting one’s use of CSI (Cohen
GM, February 26, 2011, personal communica-
tion) [ 7, 9, 13, 21 ] . In fact, a search of scholarly
journals and discussion with experienced law-
yers fi nds the subject of litigation stemming
directly from CSI to be exceedingly rare (Cohen
GM, February 26, 2011, personal communica-
tion) [ 7, 21 ] . The rarity of such litigation may
instead illustrate the strength of CSI as a tool to
improve communication rather than a contract
to provide a speci fi ed outcome, which is neither
implied nor stated in the consent to provide
medical care [ 21 ] .
Miscommunication between the physician and
the patient is among the most commonly cited
etiologies of malpractice litigation [ 22 ] . Similarly,
dissatisfaction with rhinoplasty results (in the
absence of obvious complications) is largely
attributed to inability of the surgeon to de fi ne the
limitations of surgery in conjunction with the
failure of a patient to convey their concerns and
expectations for surgery [ 18 ] . The arena of CSI
provides a level playing fi eld for changes to be
proposed, demonstrated, and tested for realism
against a surgeon’s technical ability and previous
experience. This narrowing of the gap between
patient expectations and the surgical feasibility
should decrease anxiety and allay surgeon con-
cerns regarding their ability to deliver a desired
result as long as several legal and ethical guide-
lines are followed. These guidelines represent a
collection of recommendations from peer-
reviewed literature and are applied within the
author’s rhinoplasty practice, but do not consti-
tute the advice of an attorney.
Morphing of the expected results should be
conservative and take into consideration the sur-
geon’s abilities both with CSI as well as the
proposed rhinoplasty operation for a speci fi c

114
R.T. Adelson
patient’s anatomy. A general consensus of the
peer-reviewed literature as well as among prac-
ticing rhinoplasty surgeons emphasizes the tenet
of “under promise and over deliver.” It is advis-
able to demonstrate outcomes that are somewhat
less favorable than what the surgeon believes can
be achieved, as this practice reigns in patient
expectations and assures the surgeon that reason-
able goals are attainable prior to surgery [ 9 ] .
Demonstrating the potential adverse aesthetic
outcomes of rhinoplasty covered in the informed
consent process may improve the degree of
knowledge with which the patient enters into an
operation, and this can supplement the informed
consent process [ 7, 9, 21 ] . Preoperative CSI
should be retained as a routine part of the medical
record [ 21 ] . Surgeons are advised to provide a
copy of the CSI to patients and include a dis-
claimer indicating that CSI constitutes a simula-
tion for the purposes of illustration and discussion
and does not guarantee the actual surgical results
[ 7, 9, 11, 14, 20, 21 , Cohen GM, February 26,
2011, personal communication]. Resist the temp-
tation to depict exceptional results and instead
provide for patients either an average result or a
range of results slightly better or worse than the
target goal. Above all else, conservative use of
CSI technology is encouraged so that patients are
informed and not swayed by images that may be
more perfect than what one can deliver in the
operating room [ 17, 21 ] .
One fi nal bene fi t of CSI with medicolegal
implications has been the early identi fi cation and
exclusion from surgery of patients who cannot be
satis fi ed during the preoperative consultation
[ 13 ] . CSI affords patients the chance to visualize
the changes they desire in realistic rhinoplasty in
a manner. When the surgeon cannot morph a nose
to the satisfaction of a patient or when a patient’s
aesthetic goals are evaluated with CSI and not
felt to be achievable or desirable, surgery is
deferred. The realistic depiction of surgical
results with CSI allows rhinoplasty surgeons to
be more secure in the patient’s understanding of
the surgical goals. This facilitates intervention or
exclusion when such goals are not compatible
with either the surgeon’s aesthetic sense or tech-
nical abilities.
9.6
Future Developments
in Computer Simulated
Imaging in Rhinoplasty
As computing power increases, so do the available
options for CSI in rhinoplasty. Three-dimensional
imaging platforms are in the earliest stages of
adoption but are desirable as they offer details of
the face and nose that are not obtainable with stan-
dard two-dimensional imaging [ 23 ] . Three-
dimensional imaging may offer new cephalometric
measurements for better understanding the com-
plex surface anatomy of the nose [ 24 ] . Similarly,
morphing of a three-dimensional model of the
nose to patient speci fi cations and the associated
quantitative measurements may allow custom fab-
rication of alloplastic materials for dorsal augmen-
tation, perhaps allowing very exacting preoperative
planning [ 25 ] . Incorporation of three-dimensional
reconstructions of computed tomography (CT)
scans of the face represents a new and more holis-
tic approach to understanding the skeletal sub-
structure of the nose and its relationship to both
functional and aesthetic changes in the postopera-
tive state. The use of three-dimensional CSI for
preoperative planning has been shown to decrease
revision rates and surgical times while increasing
patient satisfaction when compared to patient
groups counseled with representative photographs
or with conventional CSI [ 17 ] . The expense, radia-
tion exposure, and limitations posed by metal arti-
facts pose signi fi cant barriers to wider acceptance
of three-dimensional CT systems [ 17, 25 ] .
Finally, CSI appears poised to play a role in
the education of both practicing surgeons and
residents and fellows in training programs. The
rhinoplasty learning curve is steep, and opportu-
nities to explore the structure of the nose and the
results of surgical interventions are never
suf fi cient to meet the demands of the voracious
learner. A three-dimensional model of the nose
has been produced in a true virtual reality envi-
ronment, allowing surgeons to better understand
the anatomic relationships of the nasal structures
[ 26 ] . This prototype represents a fi rst step in pro-
viding a realistic example patient upon which rhi-
noplasty maneuvers can be demonstrated and
assessed prior to surgery.

115
9 Computer Simulated Imaging in Rhinoplasty
9.7
Practical Guidelines
for Computer Simulated
Imaging in Rhinoplasty
There are likely as many valid approaches to per-
forming CSI in rhinoplasty as there are surgeons
employing this technology in their practices. In
the absence of a generally accepted technique for
CSI in rhinoplasty, this section seeks to provide
guidelines for providing useful preoperative coun-
seling based on many of the aforementioned stud-
ies as well as pearls that have been gleaned from
extensive utilization of this technology within my
own practice. Knowledge of other surgeons’
experience is helpful but only through careful and
honest self-examination of one’s results, aesthetic
sense, surgical proclivities, and their strengths
and weaknesses both as a surgeon and as a com-
puter imager will the tool of CSI become accu-
rately incorporated into patient counseling.
Historically, surgeons utilized facial casts,
transparencies, free-hand sketches, life-size pho-
tographs, complicated cephalometric measure-
ments, and myriad other measures in the attempt
to analyze patient anatomy and explain the goals
of rhinoplasty maneuvers [ 4, 19, 27 ] . CSI is intro-
duced to patients as a method of facilitating com-
munication about a medical subject in which
there is a disparity between the knowledge base
of the two parties involved in the discussion. The
visual impact and clarity provided by CSI is far
superior to the historical measures described
above, yet in my practice, it is emphasized that
CSI is a communication tool that is superior to
sketches and drawings, not a forecasting tool.
The use of this communication tool should pro-
vide a visual representation of a mutually agree-
able aesthetic goal that is easier to understand
than the historically acceptable lines and angles
drawn across a photograph that was of little
meaning to the average patient.
Patients routinely express a greater under-
standing of what is possible during surgery as
they observe the requested changes in their nasal
appearance, modi fi ed in real time, in response to
their opinions regarding their nose.
Morphed images should be prepared by the
operating surgeon, as this offers yet another
opportunity to conceptualize the rhinoplasty
operation and assess areas of correction that are
most important to the patient [ 11– 13, 17, 19 ] .
Patients are included as active participants in the
process of CSI so that they are given greater
degrees of control over changes in the appearance
of the nose than if several possible surgical
options were morphed and then presented to them
in consultation [ 6, 11 ] . A greater understanding
of the patient’s goals for rhinoplasty can be
attained through the instant feedback of responses
to various degrees of tip rotation, dorsal height,
and alar positioning. Discrepancies between
patient and physician perceptions both of desir-
able and achievable results are readily addressed
when presented preoperatively. Several of the
author’s guidelines for using CSI in rhinoplasty
are reviewed below, in addition to two case studies
that highlight key issues in the use of CSI:
1. CSI is limited to a communication tool by
which patient desires can be easily translated
into realistic depictions of potential surgical
results. Patients are instructed that one third of
all postoperative rhinoplasty results will not
re fl ect the preoperative CSI [ 9, 11, 13, 14 ] and
that this tool is most helpful in assisting con-
versations regarding what is aesthetically
desirable within the bounds of surgical reality.
Patients are reminded that research suggests
that their own aesthetic result will most likely
be, on average, somewhat better or somewhat
worse than the preoperative CSI.
2. All CSI for preoperative consultation is per-
formed by the operating surgeon [ 10– 12, 18 ] .
The nose is morphed with the patient present so
that patients can provide instant feedback
regarding proposed changes as opposed to a
counseling scenario in which several options
are prepared and then presented to the patient
as discrete entities. When patients can offer
opinions regarding the scale of change in an
interactive process, fi ner degrees of alterations
are appreciated and the patient’s desires may be
better understood. Photographs are printed for
the patient and copied to their medical record.
While disclaimers are not printed on the photo-
graphs, patients are counseled regarding the use
of CSI as both an educational instrument and a
surgical goal to strive for and not as a promise
or guarantee of a surgical result [ 9, 11, 14 ] .

116
R.T. Adelson
3. Changes in the nose are demonstrated such
that a range of acceptable results is understood.
For example, in a patient with a routine dorsal
hump, the pro fi le can be modi fi ed from slight
convexity through a straight pro fi le as well as a
mildly retruse dorsal line to enable discussion
of the range of acceptable/preferable results.
4. Expected changes are tempered both in revision
cases and in those patients with thick skin-soft
tissue envelopes as a lesser degree of predict-
ability in the accuracy of CSI is known [ 9, 10 ] .
5. The “soft compare” or shadow function of
many imaging programs allows the surgeon to
overlay the preoperative pro fi le with that of
the surgical goal on a single photograph. This
allows the patient to review a visual “summary
statement” of the surgical plan.
6. Target the CSI to re fl ect planned rhinoplasty
maneuvers and grafts to better re fl ect the expected
result. I am always cognizant of the principle of
“under promise and over deliver,” and refrain
from using computer tools to draw perfect noses.
Case 1 (Fig. 9.1 )
A 39-year-old Caucasian female presented for cosmetic rhinoplasty to address a dorsal hump.
While a low radix is recognized on the preoperative image, the need for radix augmentation to
deliver an improved dorsal line is not inherently obvious to the patient. Resection of the dorsal
hump alone in a CSI demonstrates an unacceptably low nasion. Through the use of CSI, the
patient’s concerns regarding her dorsal hump and columellar show are better understood by the
surgeon, and a balanced approach in building up the radix while smoothing the dorsal convexity
is recommended. The patient’s dissatisfaction with her nostrils was discussed using computer
morphings of her images and addressed in the CSI that predicts the possible result of both tongue-
in-groove setback of the medial crura and alar-rim grafting (Fig. 9.1.c). Seven months postopera-
tively reveals a dorsal line, tip projection and tip rotation that are very similar to the CSI in
addition to an alar-columellar relationship that is more pleasing than the preoperative prediction.
a
c
d
b
Fig. 9.1 ( a ) Preoperative photograph of female patient
presenting with concerns regarding dorsal hump.
( b ) CSI demonstrating radix augmentation in conjunc-
tion with modest dorsal resection to yield a balanced
result. The alar-columellar relationship is morphed
to demonstrate a more favorable result with planned
tongue-in-groove setback of the medial crura as well
as alar-rim grafting. ( c ) CSI demonstrates that removal
of the dorsal hump alone would result in a low nasion
with a straight, yet weak and shallow, nasal pro fi le.
( d ) Seven-month postoperative result depicts a natu-
ral appearing result with a straight pro fi le and more
aesthetically pleasing alar-columellar relationship

117
9 Computer Simulated Imaging in Rhinoplasty
Conclusions
CSI has been a part of the practice of rhino-
plasty since the mid-1980s, yet there is a rela-
tive paucity of peer-reviewed literature to
provide surgeons with evidence-based deci-
sions regarding its use. With the decreasing
cost of computer technology, these morphing
systems have proliferated and are in wide use;
however, there is a disparity between the fre-
quency with which CSI is used and the regu-
larity with which its accuracy is put to scienti fi c
study. While important trends have emerged
from the extant literature, surgeons are
reminded of the two essential variables in the
Case 2 (Fig. 9.2 )
A 41-year-old Caucasian female presents with nasal airway obstruction in addition to concerns
regarding dorsal hump, long appearing nose, and large nostrils. The preoperative CSI focuses
on the above concerns by increasing tip rotation, providing a more retruse dorsal line, and treat-
ing the alar retraction. Using the preoperative CSI as a guide for surgery, the patient underwent
dorsal hump removal with lateral osteotomies, lateral crural overlay technique with lateral cru-
ral strut grafts and alar-rim grafts. While the patient’s 2-year postoperative photographs do not
identically re fl ect the preoperative CSI, the result is natural in appearance and the patient’s chief
aesthetic motivations for surgery have been addressed in a manner alluded to the morphed prog-
nostication. The alar retraction has been corrected, and the tip rotation is very close to the pre-
operative CSI. While the dorsal pro fi le is retruse, it is less so than depicted in the preoperative
CSI. Despite this, the patient feels that her aesthetic goals were understood and addressed to her
satisfaction.
a
b
c
Fig. 9.2 ( a ) Preoperative photograph of female
patient presenting with alar retraction, a long appear-
ing nose, and a dorsal hump. ( b ) CSI demonstrates a
straight, retruse dorsal line with correction of alar
retraction and increased tip rotation. ( c ) Two-year
postoperative photograph. While the dorsal line is
retruse, it is less so than what is depicted in the preop-
erative CSI. The tip rotation is improved, and the alar
retraction has been corrected in a manner that closely
re fl ects the preoperative CSI

118
R.T. Adelson
correlation between preoperative CSI and
postoperative result: the skill of the surgeon as
an imager/illustrator and the technical
pro fi ciency with which the operation is per-
formed. The commonly used phrase “Quid
bene diagnoscit bene curat” (make a good
diagnosis and you’ll make a good cure) evokes
many of the bene fi ts of using CSI in rhino-
plasty. Mophing technology allows surgeons
to trial and assess rhinoplasty maneuvers, pro-
viding a better understanding of the anatomic
changes and the ensuing aesthetic result.
Surgeons are advised to practice morphing
patient photographs to enhance their imaging
skills and re fl ect upon the accuracy of their
CSI results just as they make a habit of study-
ing their postoperative photographs as part of
routine critical self-assessment.
References
1. Schoenrock LD (1990) Five-year facial plastic experience
with computer imaging. Facial Plast Surg 7(1):18–24
2. Papel ID (1990) Quantitative facial aesthetic evalua-
tion with computer imaging. Facial Plast Surg
7(1):35–44
3. Mattison RC (1992) Facial video image processing:
standard facial image capturing, software modi fi cation,
development of a surgical plan, and comparison of pre-
surgical and postsurgical results. Ann Plast Surg
29(5):385–389
4. Bronz G (1994) Predictability of the computer imaging
system in primary rhinoplasty. Aesthetic Plast Surg
18(2):175–181
5. DeLange GS, Diana M (1999) 35 mm fi lm vs digital
photography for patient documentation: is it time to
change? Ann Plast Surg 42(1):15–19
6. Bronz G (1999) The role of the computer imaging sys-
tem in modern aesthetic plastic surgery. Aesth Plast
Surg 23(3):159–163
7. Koch RJ, Chavez RJ, Dagum P, Newman JP (1998)
Advantages and disadvantages of computer imaging in
cosmetic surgery. Dermatol Surg 24(2):195–198
8. Hamilton GS (2009) An objective comparison of
35-mm fi lm and digital camera image quality: a new
gold standard. Arch Facial Plast Surg 11:205–209
9. Agarwal A, Gracely E, Silver W (2007) Realistic
expectations: to morph or not to morph. Plast Reconstr
Surg 119(4):1343–1351
10. Mehta U, Mazhar K, Frankel AS (2010) Accuracy of
preoperative computer imaging in rhinoplasty. Arch
Facial Plast Surg 12(6):394–398
11. Muhlbauer W, Holm C (2005) Computer imaging and
surgical reality in aesthetic rhinoplasty. Plast Reconstr
Surg 115(7):2098–2104
12. Punthakee X, Rival R, Soloman P (2009) Digital
imaging in rhinoplasty. Aesthetic Plast Surg 33:
635–638
13. Vuyk HD, Stroomer J, Vinayak B (1998) The role of
computer imaging in facial plastic surgery: a clinical
study. Clin Otolaryngol 23:235–243
14. Sharp HR, Tingay RS, Coman S, Mills V, Roberts
DN (2002) Computer imaging and patient satisfac-
tion in rhinoplasty surgery. J Laryngol Otol 116:
1009–1013
15. Adelson RT, DeFatta RJ, Bassichis BA (2008)
Objective assessment of the accuracy of computer-
simulated imaging in rhinoplasty. Am J Otolaryngol
29:151–155
16. Thomas JR, Freeman MS, Remmler DJ, Ehlert TK
(1989) Analysis of patient response to preoperative
computerized video imaging. Arch Otolaryngol Head
Neck Surg 115:793
17. Moscatiello F, Jover JH, Ballester MAG, Hernandez
EC, Piombino P, Califano L (2010) Preoperative digi-
tal three-dimensional planning for rhinoplasty.
Aesthetic Plast Surg 34:232–238
18. Ewart CJ, Leonard CJ, Harper JG, Yu J (2006) A sim-
ple and inexpensive method of preoperative computer
imaging for rhinoplasty. Ann Plast Surg 56(1):46–49
19. Hamilton GS (2010) Morphing images to demonstrate
potential surgical outcomes. Facial Plast Surg Clin
North Am 18:267–282
20. Gorney M (1986) Preoperative computerized video
imaging. Plast Reconstr Surg 78(2):268
21. Chavez AE, Dagum P, Koch RJ, Newman JP (1997)
Legal issues of computer imaging in plastic surgery: a
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22. Avery JK (1985) Lawyers tell what turns some patients
litigious. Med Malpractice Rev 2:35–37
23. Lin SJ, Patel N, O’Shaughnessy K, Fine NA (2008)
Three-dimensional imaging in measuring facial aes-
thetic outcomes. Laryngoscope 118:1733–1738
24. Honrado CP, Larrabee WF (2004) Update in three-
dimensional imaging in facial plastic surgery. Curr
Opin Otolaryngol Head Neck Surg 12:327–331
25. Lee TY, Lin CH, Lin HY (2001) Computer-aided pro-
totype system for nose surgery. IEEE Trans Inf
Technol Biomed 5(4):271–278
26. Vartanian AJ, Holcomb J, Ai Z, Rasmussen M, Tardy
ME, Thomas JR (2004) The virtual nose: a 3-dimen-
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Facial Plast Surg 6:328–333
27. Pham AM, Tollefson TT (2010) Objective facial pho-
tograph analysis using imaging software. Facial Plast
Surg Clin North Am 18:341–349

119
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_10, © Springer-Verlag Berlin Heidelberg 2013
10
10.1
Introduction
Rhinoplasty is done to make the nose aestheti-
cally pleasing while preserving or improving
nasal function [ 1 ] . Aesthetic surgeons should
have an idea of nasal aesthetics. Standard rela-
tionships between various areas of the head and
face were formulated by scholars and artists of
the Renaissance based on clinical Greek canons
[ 2 ] . These relationships were formulated based
on the reference to an artistic ideal of beauty [ 3 ] .
Neoclassical canons are well known to plastic
surgeons, but their use has been limited to the
role of working guides [ 2 ] . The average propor-
tions in the population differ from the widely
used aesthetic standards [ 3 ] . Ideal aesthetic pro-
portions, angles, and geometric relationships are
not exactly seen in beautiful faces and cannot be
obtained surgically in the general population [ 4 ] .
Everybody has an inborn sense of beauty, and
this perception is, or is becoming, consistent
across races and cultures [ 5 ] . Some patients seek
a beautiful nose, but rhinoplasty is very often per-
formed to improve shape changes caused by
trauma, to correct abnormalities and asymme-
tries, and to obtain a normal-looking nose.
Therefore, it may be false to assume that all
patients necessarily prefer beauty to correction of
speci fi c shape changes [ 6 ] . Patients seeking rhi-
noplasty frequently have dimensional abnormali-
ties, including excessive or inadequate nasal
length or tip projection [ 7 ] . Many patients seek
reduction in dimensions, but most do not realize
that a simple nasal reduction may not create what
they want [ 8 ] . In rhinoplasty, the difference
between a good result and a poor result can be
measured in millimeters [ 9 ] . Most often, patients,
and sometimes surgeons, do not have an idea of
the real changes that occur following rhinoplasty.
A nose, for example, may appear short due to the
high position of the cephalic edges of the alar
cartilages and the wide intercrural space. Their
correction makes the nose appear longer when it
actually has become shorter [ 10 ] .
Preoperative planning for rhinoplasty is
mainly based on photographic measurements.
Outcome assessment, on the other hand, is
mostly done subjectively by asking about patient
satisfaction [ 11, 12 ] . Generally, for aesthetic
surgeries, many studies have recommended
assessing the outcome subjectively by measur-
ing the quality of life or the patient’s opinion
via questionnaires [ 13– 16 ] . Outcomes instru-
ments are being tested regarding their reliability
and validity in the clinical settings [ 17, 18 ] .
Rhinometry: Clinical Index
for Evaluation of the Nose
Abdoljalil Kalantar-Hormozi
and Arash Beiraghi-Toosi
A. Kalantar-hormozi , M.D. ()
Department of Plastic Surgery , Shahid Beheshti Medical
University (SBMU) , 15 Khordad Hospital, Aban Street,
Karim Khan Avenue , Tehran , Iran
e-mail: kalantarj@yahoo.com
A. Beiraghi-Toosi , M.D.
Department of Plastic Surgery ,
Ghaem Hospital, Faculty of Medical Sciences ,
Mashhad University of Medical Sciences ,
Mashhad , Iran
e-mail: arash_beiraghi@yahoo.com

120
A. Kalantar-Hormozi and A Beiraghi-Toosi
Objective quanti fi cation of the outcome for
plastic surgery is important, but measures still
are elusive [ 19 ] . Photographic evaluation, using
varied parameters, has been applied for outcome
assessment [ 20 ] .
Photographs, as two-dimensional views, do
not assess the detailed depressions, projections,
and asymmetries shown by other views. For
example, if a nose is deviated to the right side, a
right-angled triangle can be imagined in the fron-
tal view so that its longer side is the nose, another
side is the vertical midline, and the last side is a
horizontal line drawn at the nasal tip level. The
vertical side is measured during photography
analysis, but that is less than the real nasal length.
If the nose is straightened during the operation
without any change in nasal length, the nose will
seem elongated in the postoperative photographic
analysis. Similarly, such a triangle can simply be
drawn for almost all patients in the sagittal plane
because the radix is almost always posterior to
the tip. The vertical side of the triangle is mea-
sured during photographic analysis, whereas the
real nasal length is longer. Change in tip projec-
tion may affect nasal length in postoperative pho-
tographic analysis and vice versa.
Actual preoperative dimensions and postop-
erative changes can be obtained only by physical,
three-dimensional measurements. “Rhinometry”
is the real, clinical measurements of the nose
[ 21 ] . It is an important adjunct to the preoperative
physical examination and postoperative judg-
ment. Description of its parameters and our clini-
cal study is presented here.
10.2
Rhinometric Parameters
The measurement of the “rhinometric parame-
ters” is done with slide calipers and is expressed
in millimeters. They are as the following:
1. Nasal length (L): de fi ned as the maximum dis-
tance from radix to nasal tip (any part above
columella) (Fig. 10.1 ).
2. Tip projection (P): de fi ned as the distance
from alar-cheek junction to the most project-
ing point of the tip (Fig. 10.2 ).
3. Bony base width (BB): de fi ned as the widest
distance between bases of the nasal bones at
the junction of the nasal bone and the maxilla
(Fig. 10.3 ).
4. Alar base width (AB): de fi ned as the distance
between the outermost points of alar bases at the
junction of the alar base and the lip (Fig. 10.4 ).
5. Alar base width during a smile (AS): de fi ned
as the alar base width during a full smile
(Fig. 10.5 ).
6. Right alar base to columellar base distance
(RA) and
7. Left alar base to columellar base distance
(LA): measured with a horizontal ruler at the
level of the columellar base in one hand, while
the vertical distance of the alar base to this
ruler is measured on each side with the other
hand (Fig. 10.6 ).
Two other measurements are performed for the
evaluation of the face:
8. Upper facial third (UF): de fi ned as the dis-
tance from the trichion to the radix
(Fig. 10.7 ).
Fig. 10.1 Measurement of nasal length

121
10 Rhinometry: Clinical Index for Evaluation of the Nose
Fig. 10.2 Measurement of tip projection
Fig. 10.3 Measurement of bony base width
Fig. 10.4 Measurement of alar base width
Fig. 10.5 Measurement of alar base width during a smile

122
A. Kalantar-Hormozi and A Beiraghi-Toosi
9. Lower facial third (LF): de fi ned as the dis-
tance from the columellar base to the most
inferior point of the chin (Fig. 10.8 ).
10.3
Clinical Study
The “rhinometric parameters” were measured
before the operation and many times after the
operation during all the visits for all patients.
Among the patients, 300 patients without any
history of nasal fracture or previous surgery or
any gross facial or nasal deformity were studied
for the changes of the parameters following
rhinoplasty.
In the authors series, the length of the nose
and tip projection were more than ideal in most
patients before rhinoplasty and they were
signi fi cantly greater in men. The nasal length, tip
projection, bony base width, alar base width, and
alar base width during a smile were signi fi cantly
reduced after the operation. The mean reduction
of nasal length in the men was greater, and the
Fig. 10.7 Measurement of upper facial third
Fig. 10.8 Measurement of lower facial third
Fig. 10.6 Measurement of left alar base to columellar
distance

123
10 Rhinometry: Clinical Index for Evaluation of the Nose
mean reduction of tip projection was less than in
the women, although not statistically signi fi cant.
The patients who underwent surgery with the
closed approach had signi fi cantly greater reduc-
tion in nasal length than those who had surgery
by open procedure. On the other hand, the patients
who underwent surgery with the open approach
had a signi fi cantly greater reduction in tip projec-
tion than those who had surgery by closed proce-
dure [ 21 ] .
All the patients expressed satisfaction with
these pre- and postoperative data when they were
simply asked about it (Figs. 10.9 , 10.10 , and
10.11 ).
10.4
Discussion
Preoperative assessment of nasal aesthetics is an
integral part of preoperative planning. What
occurs after the operation is not exactly what
patients and surgeons see and feel. Subjective
impressions can differ from objective realities,
and this is most often the case. Objectively deter-
mined postoperative changes can be interesting
for the patient and the surgeon, can facilitate
communication between them, can help in out-
come assessment, and can provide a guide for
future cases.
Generally, patients seek rhinoplasty mainly
for reduction in the dimensions of their nose. We
are many times faced with questions such as,
“how much do you think my nose will shorten?”
or “can you make my nose as small as possible?”
The nose is a polyhedral organ, and patients,
especially after rhinoplasty, note its details from
many aspects. It is an exposed organ, and, unlike
other organs, many relatives, friends, colleagues,
and others express their ideas about it. Generally,
patients forget the look of their preoperative nose
very soon after the operation and may not appre-
ciate true changes in it.
Surgeons, on the other hand, note other aspects
of the nose and know they cannot do everything.
They realize that some things cannot be, or should
not be, changed. But most ideas are subjective,
and documentation is imperative. Before this
study, for example, the authors believed that for
most patients, a perfect postoperative result is
achieved by minimal reduction in nasal length
(2–4 mm) and an increase in tip projection.
Surprisingly, this study showed that these perfect
results were achieved by a moderate reduction in
nasal length (average, 9.21 mm) and a decrease in
tip projection for the majority of patients. Such a
surprising amount of nasal length shortening may
be related to our Middle-Eastern patient popula-
tion (the preoperative nasal length was more than
the ideal length by an average of more than
13 mm). Further studies are needed in other eth-
nic populations using pre- and postoperative rhi-
nometry to address this issue.
Other studies also have reported decreased
projection measured in most of their patients
unless tip grafts were used [ 22– 24 ] . We used col-
umellar strut grafts routinely for all open rhino-
plasties and some closed operations, but tip grafts
were used only sparingly. Patients with a loss of
tip projection had apparently increased projec-
tion postoperatively, but rhinometry showed that
the reverse was true. This may be explained partly
by the effect of the reduction on the dorsum or
the decrease in nasal length or alar base width on
apparent tip projection.

124
A. Kalantar-Hormozi and A Beiraghi-Toosi
a
Fig. 10.9 ( a ) ( Left ): Preoperative. ( Right ): Postoperative following rhinoplasty. ( b ) ( Left ): Preoperative. ( Right ):
Postoperative following rhinoplasty

125
10 Rhinometry: Clinical Index for Evaluation of the Nose
b
Fig. 10.9 (continued)

126
A. Kalantar-Hormozi and A Beiraghi-Toosi
Fig. 10.10 ( a ) ( Left ): Preoperative. ( Right ): Postoperative after undergoing rhinoplasty. ( b ) ( Left ): Preoperative.
( Right ): Postoperative after undergoing rhinoplasty
a

127
10 Rhinometry: Clinical Index for Evaluation of the Nose
b
Fig. 10.10 (continued)

128
A. Kalantar-Hormozi and A Beiraghi-Toosi
a
Fig. 10.11 ( a ) Preoperative. ( b ) Postoperative demonstrating reduction in nasal length

129
10 Rhinometry: Clinical Index for Evaluation of the Nose
b
Fig. 10.11 (continued)

130
A. Kalantar-Hormozi and A Beiraghi-Toosi
Conclusions
Rhinometry can be used as a guide for preop-
erative planning and as an instrument for
assessing operation outcome and for compar-
ing different procedures that play a role in any
given aspect. Many surprising features of rhi-
noplasty may be extracted from the data it pro-
vides, such as the postoperative change in tip
projection we encountered. It can change ideas
of plastic surgeons about the changes their
operative approaches produce and can be a
guide for patients. It is recommended as a part
of pre- and postoperative physical examina-
tion for patients undergoing rhinoplasty.
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13. Alsarraf R (2002) Outcomes instruments in facial
plastic surgery. Facial Plast Surg 18(2):77–86
14. Klassen A, Jenkinson C, Fitzpatrick R, Goodacre T
(1998) Measuring quality of life in cosmetic surgery
patients with a condition-speci fi c instrument: the
Derriford Scale. Br J Plast Surg 51(5):380–384
15. Most SP, Alsarraf R, Larrabee WF Jr (2002) Outcomes
of facial cosmetic procedures. Facial Plast Surg 18(2):
119–124
16. Rankin M, Borah GL, Perry AW, Wey PD (1998) Quality-
of-life outcomes after cosmetic surgery. Plast Reconstr
Surg 102(6):2139–2145; discussion 2146–2147
17. Alsarraf R (2000) Outcomes research in facial plastic
surgery: a review and new directions. Aesthetic Plast
Surg 24(3):192–197
18. Alsarraf R, Larrabee WF Jr, Anderson S, Murakami
CS, Johnson CM Jr (2001) Measuring cosmetic facial
plastic surgery outcomes: a pilot study. Arch Facial
Plast Surg 3(3):198–201
19. Luce EA (1999) Outcome studies and practice guide-
lines in plastic surgery. Plast Reconstr Surg 104(4):
1187–1190
20. Sharp HR, Rowe-Jones JM (2003) Assessing outcome
in aesthetic rhinoplasty. Clin Otolaryngol Allied Sci
28(5):430–435
21. Hormozi AK, Toosi AB (2008) Rhinometry: an impor-
tant clinical index for evaluation of the nose before and
after rhinoplasty. Aesthetic Plast Surg 32(2):286–293
22. Bafaqeeh SA (2000) Open rhinoplasty: effectiveness
of different tripplasty techniques to increase nasal tip
projection. Am J Otolaryngol 21(4):231–237
23. Rich JS, Friedman WH, Pearlman SJ (1991) The
effects of lower lateral cartilage excision on nasal tip
projection. Arch Otolaryngol Head Neck Surg
117(1):56–59
24. Vuyk HD, Oakenfull C, Plaat RE (1997) A quantita-
tive appraisal of change in nasal tip projection after
open rhinoplasty. Rhinology 35(3):124–128

Part IV
Primary Rhinoplasty

133
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_11, © Springer-Verlag Berlin Heidelberg 2013
11
11.1
Introduction
The history of cosmetic rhinoplasty started with
plastic repair of the nose as early as the Edwin
Smith Papyrus that is thought to be at least
1,700 years old. Although replacement of por-
tions of the nose from injuries or disease was the
main indication for rhinoplasty, Dieffenbach, in
1845, introduced the concept of reoperation to
improve the cosmetic appearance of the recon-
structed nose. Roe, in 1891, reduced the hump of
the nose. After that time, cosmetic rhinoplasty
has been improved and modi fi ed by many
authors.
11.2
Early Rhinoplasty
The Edwin Smith Papyrus (purchased in Egypt
by Smith in 1862) is thought to be at least
1,700 years old and copied from treatises at least
1,000 years older [ 1 ] . Translated in 1930 by
Breasted [ 2 ] , the papyrus cited cases of a broken
nose, a break in the nasal bone, and a commi-
nuted fracture in the side of the nose that were
treated with insertion of plugs of linen saturated
with grease into the nostrils.
The earliest recording of reconstruction of the
nose was Sushruta (Susruta) (approximately 600
BC) who described in his Sushruta Samhita
(Sushruta’s Collection) an innovative method of
rhinoplasty that was reconstruction following
amputation of the nose as a punishment for crimes
[ 3, 4 ] . This method is mentioned as the Indian
method of rhinoplasty in the books of plastic
surgery.
In 1816, Carpue [ 5 ] published the account of
the successful performance of operative proce-
dures on British military of fi cers, one who had
lost his nose to the toxic effects of mercury treat-
ments while being treated for liver infection and
the other lost the nose from a saber cut. He used
the Indian rhinoplastic reconstruction with a fl ap
of skin taken from the forehead. In 1818, von
Graefe [ 6 ] published his major work entitled
Rhinoplastik . He modi fi ed the Italian method
using a free-skin graft from the arm instead of the
original delayed pedicle fl ap. von Pfolspeundt, in
Buch der Bundth-Ertznei [ 7 ] , described a process
“to make a new nose for one who lacks it entirely,
and the dogs have devoured it” by removing skin
from the cheek or forehead and suturing it in
place.
11.3
Cosmetic Rhinoplasty
In 1845, Dieffenbach [ 8 ] wrote a comprehensive
text on rhinoplasty, entitled Operative Chirurgie ,
and introduced the concept of reoperation to
improve the cosmetic appearance of the
History of Cosmetic Rhinoplasty
Melvin A. Shiffman
M. A. Shiffman , M.D., J.D.
Section of Surgery , Newport Specialty Hospital ,
17501 Chatham Drive , Tustin , CA 92780-2302 , USA
e-mail: shiffmanmdjd@gmail.com

134
M.A. Shiffman
reconstructed nose. In 1891, Monks [ 9 ] described
the successful use of heterogeneous free-bone
grafting to reconstruct saddle nose defects. In
1891, Roe [ 10 ] presented an example of his work
with a young woman on whom he reduced a dor-
sal nasal hump for cosmetic indications. This was
one of the fi rst procedures for purely cosmetic
purposes. In 1892, Weir [ 11 ] experimented unsuc-
cessfully with xenografts (duck sternum) in the
reconstruction of sunken noses. In 1896, Israel
[ 12 ] described the use of heterogeneous free-
bone grafting to reconstruct the saddle nose
defect. The grafting of the cartilage of the auricu-
lar concha in rhinoplasty was described by Suslov
in 1897, and modi fi cations of the technique were
reported by Koltun in [ 13 ] .
Joseph [ 14 ] published his fi rst account of
reduction rhinoplasty in 1898. The surgeries were
performed with external incisions that later were
done through incisions in the nose. In 1928,
Joseph [ 15 ] published his book, Nasenplastik und
Sonstige Gesichtsplastik (Rhinoplasty and Facial
Plastic Surgery). He popularized the aesthetic
rhinoplasty and described modern techniques in
1932 [ 16 ] .
Sheehan [ 17 ] advocated a columellar incision
and tunneling along the columella and tip of the
nose to the nasal bones. The costal cartilage graft
was bent at a right angle and placed at the tip of
the nose to the nasal bones and in the wound of
the columella in order to lift the tip. Réthi [ 18 ]
described the transcolumellar skin incision for
rhinoplasty that is frequently referred to as the
Réthi incision or technique [ 19 ] . Roy [ 20 ]
described a technique of lifting the nasal tip
through a mucosal incision separating the tissues
from the columella and from the tip of the nose to
the nasal bones. A costal cartilage graft was
placed in the nasal vestibular wound in direct
contact with the quadrangular cartilage taking its
support from the superior maxilla, pushing up the
tip of the nose.
A number of different alloplastic materials
were reported being used in rhinoplasty. Holt and
Lloyd [ 21 ] used methyl methacrylate, Cottle et al.
[ 22 ] used hyaluronidase, Voloshin [ 23 ] used
Plexiglas, and Nolting [ 24 ] used a steel bridge.
Goodman [ 25 ] initiated the shift from the
closed technique of rhinoplasty to an open tech-
nique, and this was re fi ned and popularized by
Anderson et al. [ 26 ] .
Gunter and Rohrich [ 27 ] described the open
rhinoplasty technique for secondary rhinoplasty
that resulted in a shift in surgical approach to sec-
ondary rhinoplasty.
Sheen [ 28 ] described the use of a spreader
graft to reconstruct the roof of the middle nasal
vault following rhinoplasty.
References
1. Eisenberg I (1982) A history of rhinoplasty. S Afr
Med J 62(9):286–292
2. Breasted JH (1930) The Edwin Smith surgical papy-
rus, vol I. University of Chicago, Chicago
3. Hauben DJ (1984) 800–600 BC. Acta Chirug Plast
28:65–68
4. Baskaradoss VK, Jose RM (2006) Life and times of
Sushruta: fact and fi ction. Indian J Plast Surg 39:
109–110
5. Carpue JC (1816) An account of two successful oper-
ations for restoring a lost nose from the integuments
of the forehead in the cases of two of fi cers of his maj-
esty’s army: to which are pre fi xed, historical and
physiological remarks on the nasal operation includ-
ing descriptions of the Indian and Italian methods.
Longman, London
6. von Gräfe KF (1818) Rhinoplastik. Berlin, Forstner
7. von Pfolspeundt H (1868) Bruder des deutschen
ordens. In: Haeser H, Middledorpf A (eds) Buch der
Bundth-Ertznei. G. Reiner, Berlin
8. Dieffenbach JE (1845) Die Operative Chirurgie. FA
Brockhause, Leipzig
9. Monks G. In
gery . Accessed 1 Aug 2010
10. Roe JO (1887) The deformity termed ‘Pug Nose’ and
its correction by a simple operation. Med Record
31:621
11. Weir RF (1892) On restoring sunken noses without
scarring the face. New York Med J 56:443
12. Israel J (1896) Two new methods of rhinoplasty. Arch
Klin Chir 63:255–265
13. Koltun RK (1964) Therapeutic results with the use of
new modi fi cations of Suslov’s rhinoplasty. Vestn Khir
Im II Greek 92:64–68
14. Joseph J (1898) Uber die operative verkleinerung
einer nase. Berlin Klin Wochnschr 40:883
15. Joseph J (1928) Nasenplastik und Sonstige Gesichts-
plastik. Curt. Kabitzsch, Leipzig
16. Joseph J (1932) Nasenplastik und Sonstige Gesichts-
plastik, 3rd edn. Curt. Kabitzsch, Leipzig

135
11 History of Cosmetic Rhinoplasty
17. Sheehan JE (1923) Correction of nasal deformities.
Br Med J 2(3282):981–982
18. Réthi A (1929) Uber die korrecktiven operativnen der
nasendeformitäten. De Hocherabtragung Chirurg 1:
1103
19. May H (1951) The Réthi.incision in rhinoplasty. Plast
Reconstr Surg 8(2):123–131
20. Roy JN (1937) A new method of rhinoplasty for
sinking of the tip of the nose. Can Med Assoc J 36(6):
603–605
21. Holt JA, Llloyd RS (1948) Rhinoplasty; the use of
methyl methacrylate implants. Arch Otolaryngol
47(4):395–405
22. Cottle MH, Weiss JA, Pottorff E, Herzon E (1950)
Hyaluronidase in rhinoplasty. Arch Otolaryngol
52(3):369–372
23. Voloshin MR (1951) Use of plexiglass in rhinoplasty.
Vestin Ororhinolaringol 13(1):73
24. Nolting H (1951) Stainless steel bridge for rhino-
plasty. Ned Tijdschr Geneeskd 95(1):93
25. Goodman WS (1873) External approach to rhino-
plasty. Canadian J Otolaryngol 2(3):207–210
26. Anderson JR, Johnson CM, Adamson P (1982) Open
rhinoplasty: an assessment. Otolaryngol Head Neck
Surg 90(2):272–274
27. Gunter JP, Rohrich RJ (1987) External approach for
secondary rhinoplasty. Plast Reconstr Surg 80(2):
161–174
28. Sheen JH (1984) Spreader graft: a method of recon-
structing the roof of the middle nasal vault following
rhinoplasty. Plast Reconstr Surg 73(2):230–239

137
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_12, © Springer-Verlag Berlin Heidelberg 2013
12
12.1
Introduction
Rhinoplasty is among the most commonly per-
formed procedures by the facial plastic surgeon.
Whether it is done for primarily functional or
aesthetic concerns, it is imperative that the sur-
geon be highly aware of the functional and struc-
tural tenets of the nose. Certainly, its important
functions include warming and humidi fi cation of
inspired air, along with olfaction. To the rhino-
plastic surgeon, however, air fl ow is chief among
the nose’s purposes. Passage of air through the
nasal airway involves a complex interaction
among multiple potential fi xed anatomic compo-
nents such as the septum, along with variable fac-
tors such as mucosal edema or the nasal cycle.
Importantly, there are often-overlooked contribu-
tions of fi xed and dynamic obstruction which can
be found in different locations in the anterior
nasal passage which are intimately associated
with the upper and lower lateral cartilages.
While rhinoplasty itself dates back hundreds
of years, the term functional rhinoplasty is a rela-
tively new addition to the nomenclature, fi rst
becoming popular in the 1990s. Functional con-
siderations in rhinoplasty, though, long precede it
[ 1 ] . The need to uphold functional principles
during aesthetic rhinoplasty is imperative. While
addressing various cosmetic concerns intraopera-
tively, it is certainly not dif fi cult to overlook or
even create functional problems. Modern teach-
ing emphasizes the importance of two principles
that are paramount in functional rhinoplasty sur-
gery: the internal nasal valve (INV) and the exter-
nal nasal valve (ENV).
12.2
Terminology
Bernoulli’s principle explains the fundamentals
of the dynamic collapse seen in the nose with
inspired air and subsequent negative intranasal
pressures. The pressure drop during inspiration
results in folding of weaker, more susceptible
structures. The internal nasal valve, fi rst described
by Mink [ 2 ] , is best described as the point of
maximal narrowing in the anterior nasal airway
between the septum, upper lateral cartilage, and
the anterior inferior turbinate. The angle of the
valve is described as normally being 10–15° in
the Caucasian nose. Insuf fi ciency of the INV may
be iatrogenic, idiopathic, or post-traumatic and
can be seen in the elderly as the nasal cartilages
relax or lose their attachments [ 3, 4 ] . Patients
with a narrowed INV will generally respond pos-
itively to the Cottle maneuver or modi fi ed Cottle
maneuver, whereby the INV angle is stented open
by either external or internal force.
Collapse of the external nasal valve is seen
more caudally and involves primarily the ala and
can be seen externally with more effortful nasal
inspiration. It is found more often in patients with
Trends in Functional Rhinoplasty
Joshua D. Weissman and Sam P. Most
J. D. Weissman , M.D. • S. P. Most , M.D. (*)
Division of Facial Plastic and Reconstructive Surgery ,
Stanford University School of Medicine ,
801 Welch Road , Stanford , CA 94305 , USA
e-mail: jweissman@stanford.edu; info@drmost.com

138
J.D. Weissman and S.P. Most
narrowed nostrils and thin alar sidewalls and may
be idiopathic or iatrogenic [ 4 ] .
As a review of modern trends in functional rhi-
noplasty, this chapter merits discussion of a
modi fi ed means of evaluation of valve insuf fi ciency
as proposed by the senior author (SM). Whereas it
has traditionally be taught that the INV contrib-
utes to dynamic airway collapse, hence, the term
internal nasal valve collapse, the recently pro-
posed classi fi cation scheme [ 3 ] views it more as a
static region in light of the observation that the
components of the INV (the septum, upper carti-
lage, inferior turbinate) do not appreciably move
during inspiration. The more fi tting term internal
nasal valve narrowing, correctly implying a static,
non-dynamic process, seems appropriate. The
area which does move/collapse with negative
pressure, rather, is the lateral nasal wall, which is
termed lateral wall insuf fi ciency (LWI), and this
is divided into two regions: zone 1 and zone 2.
Zone 1 LWI occurs cephalad as the upper lat-
eral cartilage complex moves inward during
inspiration with subsequently more signi fi cant
movement of the lateral wall. Externally, this
may be seen as medial collapse in the supra-alar
region, although it is possible that it can only
been seen intranasally. Zone 2 LWI, on the other
hand, more approximates the classically described
external nasal valve collapse, as it is located more
caudal and involves primarily the ala and can
reliably be seen externally [ 3 ] .
While a detailed discussion of nasal anatomy
is outside the scope of this chapter, it does bear
mentioning the recent description of the pyriform
ligament [ 5 ] – a broad ligament which extends
between the periosteum of the pyriform rim and
the upper/lower cartilage complex, incorporating
the sesamoids. This ligament is likely intimately
associated with lateral nasal wall collapse.
Regardless of the nomenclature, surgical
alteration of the nasal pyramid, whatever the
purpose, can have profound implications for
air fl ow and must be recognized by the surgeon.
It has been estimated that during aesthetic rhino-
plasty, the INV is narrowed by 25%, and the
cross-sectional area at the pyriform aperture
drops by 11–13%, as measured by acoustic rhi-
nometry [ 6 ] .
12.3
Outcomes Measures
While there have been many advances in our lit-
erature over the decades, improvements do need
to be made in our critical assessment of outcomes.
A new era of healthcare is upon us – one that
promises to favor evidence-based strategies and
treatments. Steps are being made in the right
direction. Historically in this fi eld of research,
outcomes often relied on physician anecdotal
reporting, non-validated questionnaires, or ques-
tionnaires not intended to assess nasal congestion –
such as the Sino-Nasal Outcome Test (SNOT),
developed for rhinosinusitis [ 7 ] . Rhee [ 8 ] recently
commented on the explosion of quality of life
(QOL) instruments in the past decade, which
have become the gold standard for patient-
reported outcomes. With the development of the
Nasal Obstruction Symptom Evaluation (NOSE)
scale [ 9 ] in 2004, a validated QOL symptom sur-
vey exists which is more applicable to the realm
of functional rhinoplasty with its assessment of
nasal congestion. Since its introduction, the
NOSE scale has been used as a QOL measure for
studies on septoplasty [ 10, 11 ] , nasal valve cor-
rection [ 12 ] , functional rhinoplasty [ 13 ] , radiof-
requency treatment of turbinates [ 14 ] , anterior
septal reconstruction [ 15 ] , and lateral nasal sus-
pension [ 16 ] . The visual analogue scale (VAS) is
another commonly utilized measure across medi-
cine to garner a global assessment of subjective
phenomena, and it has been validated for many
uses in medical, dental, and nursing realms [ 17 ] .
Less certainty even exists for objective mea-
sures of ef fi cacy in the realm of lateral nasal wall
treatment. Acoustic rhinometry, rhinomanometry,
and peak inspiratory fl ow tests have attempted to
fi ll the void. They lack, however, the consistency
and availability to make an impact. Moreover,
there is poor correlation between these objective
measures and subjective responses by study
patients [ 18 ] . Signi fi cant shortcomings in most of
these methods are likely due to the fact that lat-
eral wall collapse is a dynamic, not static process,
and may be inherently altered by the presence of
measuring instruments in the nose.
There have been many articles recently that
address our shortcomings in critical review of

139
12 Trends in Functional Rhinoplasty
rhinoplasty – some speci fi cally regarding treatment
of the incompetent nasal valve [ 3, 8, 12, 19– 21 ] . In
a revealing systematic review, Spielmann et al. [ 20 ]
identi fi ed 43 papers meeting their inclusion criteria
of study of treatment of nasal valve collapse. There
were no randomized controlled trials, just one that
delivered level 3b (case–control study), and all
remaining studies were level 4. They propose that
the plethora of described rhinoplasty techniques
may re fl ect underlying uncertainty. In a similar
review, Rhee [ 19 ] et al. found 44 articles, of which
two were level 2b (cohort study), and the remainder
were level 4. While the bulk of evidence found sup-
ported surgery, both reviews highlight the need for
better designed, more rigorous studies of higher
levels of evidence.
There are a multitude of techniques in the lit-
erature that have been reported for the treatment of
lateral nasal wall collapse. As technical surgeons,
we are more con fi dent in our knowledge of their
anatomic and mechanical nuances, but as physi-
cians treating patients, we are less versed in com-
parative ef fi cacy of these methods. Improvements
are being made with increasing utility of validated
QOL surveys, namely, the NOSE scale, but much
work remains to be done about fi nding a consistent
objective measure of outcome. It is imperative that
we embrace, utilize, and report our data in well-
developed studies to advance our fi eld and treat-
ment of patients.
12.4
Surgical Techniques
In the following sections, the authors aim to pro-
vide a review of important and popular techniques
utilized for functional rhinoplastic purposes. The
authors will attempt to divide these techniques
according to the primary area of intended effect –
internal nasal valve or external nasal valve –
though it is important to understand that due to
limitations in this nomenclature as detailed above,
most of these methods do not fi t neatly into one
category or the other. Moreover, methods intended
to treat true internal nasal valve narrowing (a
static factor) as well as those meant to treat lat-
eral wall collapse (dynamic) in the area of the
internal valve will often be grouped together.
12.5
Internal Nasal Valve
The spreader graft was originally described in
1984 by Sheen [ 22 ] as a means of reestablishing
the architecture of the middle nasal vault. The
spreader graft is useful in the patient who presents
with a narrow middle vault preoperatively, as well
as for those who are prone to midvault collapse.
Predisposing characteristics include short nasal
bones, weak ULC, and/or thin overlying skin.
Such noses will appear overly narrowed after roof
resection because there is less support for the mid-
dle vault, leading to the inverted V deformity – so
called because collapse of the middle vault leads
to emphasis of the caudal aspect of the nasal bones
against the collapsed sidewalls. The spreader graft
technique, which can be done through an external
or internal approach, involves dissection of a sub-
mucoperichondrial pocket as is standard for septo-
plasty. Through an external rhinoplasty approach,
the ULC is separated from the septum in an
upward-sweeping motion with a D -knife. The
dorsal septum is then addressed or resected
according to whatever the patient needs. We then
use harvested septal cartilage, though bone can
also be substituted, fashioned into narrow stick-
like grafts and placed alongside the dorsal septal
edge on each side, medial to the ULC. The grafts
are then sutured between the septum and ULC.
This placement allows for extra width of the dor-
sum as seen externally and also increases the static
angle of the internal nasal valve by increasing the
separation between the septum and the ULC in
the midvault.
The onlay spreader graft is a similar method
of recreating the dorsal roof and widening the
INV and is most useful in cases of a saddle nose
deformity [ 23 ] . Instead of two grafts, with one on
each side of the dorsal septum, the onlay spreader
is a single, wide rectangle-shaped graft that is
laid from the bony dorsum to the nasal tip atop
the septum. It is sutured laterally to each ULC.
The autospreader was described as a means of
using the native ULC in place of a spreader graft
to recreate the roof of the midvault after aesthetic
dorsal hump takedown [ 24 ] . Its use has been
shown to lead to signi fi cant improvement in nasal
airway function as measured by the NOSE [ 25 ] .

140
J.D. Weissman and S.P. Most
Though it can be performed via an external or
internal approach, it is performed more easily
externally. After standard exposure, the over-
projected portion of the separated edge of the
ULC is incised longitudinally, taking care to
leave the underlying mucoperichondrium intact.
The medial segment is then rotated internally so
that it lies between the septum and the ULC. It is
secured with a suture. This is performed on each
side of the septum, thus preserving the angle of
the INV (Fig. 12.1 ).
A recently described technique involves a spe-
cial stitch, named the fl aring suture, rather than a
graft [ 26 ] . Intended as a means to better increase
the INV cross-sectional area, the fl aring suture is
a 4-0 Nylon suture placed in vertical mattress
fashion through the caudal/lateral aspect of one
ULC. The stitch is then passed over to the oppo-
site side and placed through the contralateral
ULC in a similar fashion, ultimately being tied
over the dorsum in order to affect a “ fl are” later-
ally along the ULCs (Fig. 12.2 ). Performed in
conjunction with spreader grafts, this technique
allows for a more tangible increase in the angle of
the INV and the cross-sectional area, its authors
report. Patients should be counseled about poten-
tial widening of the middle third of the nose,
although as with the spreader graft, this effect
may bene fi t patients with a preoperative narrow-
ing of the middle vault.
The butter fl y graft is conceptually similar to
the fl aring suture. Originally described in the
1960s by Hage [ 27 ] , it was reintroduced more
recently as a method for secondary functional
rhinoplasty [ 28 ] with subsequent reporting show-
ing that it is also effective for primary rhinoplasty
[ 29 ] . The technique is performed using an inter-
nal or external approach with ultimate placement
of the graft, which is harvested conchal cartilage,
super fi cial to the anterior septal angle and caudal
portion of the ULCs and deep to the cephalic
edges of the LLCs. This a single cartilage graft
and is made into a sort of widened pie-shaped
con fi guration. This graft serves as a “butter fl y”
spring to open the angle of the INV.
The splay graft [ 30 ] can be thought of as a vari-
ation of the butter fl y graft. Described as a tech-
nique for restoring the middle vault dimensions as
well as stenting the INV, the splay graft can be
used in cases where the ULCs have been over-
resected or are inherently weakened – instances
where the spreader graft would be suboptimal. Its
authors also believe that it addresses the spreader
graft’s inadequate support of the posterior portion
of the INV. The splay graft can be performed via
internal or external approach, though can be
expected to be easier externally. Following expo-
sure and separation of the ULCs from the septum,
the mucoperichondrium is delicately separated
from the deep surface of the ULCs. The authors
Fig. 12.1 The autospreader: The medial segment of the
overprojected edge of the separated ULC is incised and
rotated internally to lie between the septum and the ULC,
thus re-creating the roof of the midvault (Byrd et al. [ 24 ] )
Fig. 12.2 The fl aring suture: A suture is placed through the
caudal/lateral aspect of one ULC and then passed over the
septum through the contralateral ULC in a similar fashion.
Once tied down, it affects a “ fl are” laterally (Park [ 26 ] )

141
12 Trends in Functional Rhinoplasty
report their preference for a conchal cartilage graft,
which is then shaped into a single graft that drapes
over the septum with wings inserted into the sub-
mucoperichondrial pockets under the ULCs.
Septal cartilage can be used instead but may
require crushing to soften its inherent rigidity. As
it was originally intended, the graft can be fash-
ioned to cross from one pyriform aperture to the
other, though such a long graft is not needed in all
cases. Once in position, it is fi rst sutured to the
dorsal septum in the midline, followed by suturing
the ULC to the wing of the splay on each side.
Widening of the midvault as seen externally is
possible with this technique, though as with oth-
ers, in certain instances, this change may be wel-
comed by the patient. There have been modi fi cations
of this technique, including one whereby an inter-
nal approach is used to dissect the submucoper-
ichondrial pockets, followed by creation of a
window in the septum through which the splay
graft is passed [ 31 ] .
Other techniques which bear mentioning
include an intranasal Z-plasty to correct nasal
valve stenosis [ 32 ] . This is similar to other surgi-
cal fl aps which have been reported, such as the
M-plasty [ 33 ] . There are also the Skoog [ 34 ] and
modi fi ed Skoog techniques [ 35 ] which involve
autografting the reduced nasal dorsum. A new
technique of addressing lateral wall collapse in
the area of the internal nasal valve involves the
use of radiofrequency energy [ 36 ] to cause vol-
ume reduction and retraction, though its clinical
ef fi cacy is uncertain.
12.6
External Nasal Valve
The incompetent external nasal valve can be cor-
rected by supporting the ala to prevent collapse.
Alar batten grafts [ 4 ] are curvilinear cartilage
grafts with intended placement into a pocket cre-
ated at the point of maximum collapse. The alar
batten graft can be inserted via an external or
internal rhinoplasty approach. When using the
internal approach, the pockets for the grafts are
dissected intranasally, and no retention sutures
are required. With the external approach, they
can be sutured to the lateral third of the lateral
crura so as to avoid graft migration. Ideally, the
graft would extend from the pyriform aperture to
the septum medially, thus bridging two fi xed
structures. One of the biggest criticisms of this
technique is of the fullness that can sometimes be
appreciated postoperatively in the area of the
graft, which makes it less popular for primarily
aesthetic rhinoplasty.
The lateral crural strut graft [ 37 ] is intended to
address the lateral crura which are weakened,
misshapen, in improper position, or containing
segmental de fi ciencies. Such conditions can lead
to external valve collapse, among other abnor-
malities that may be addressed during rhinoplasty
including deformed tips, alar rim retraction, or
alar concavity. These grafts are autogenous pieces
of cartilage (usually septal) that are secured to the
deep surface of the lateral crura, thus lending
shape and strength to the lateral crura (Fig. 12.3 ).
The external approach is preferred. In its original
description, it was done in conjunction with a
cephalic trim, followed by undermining of the
vestibular skin from the lateral crus. The anterior
two-thirds of the lateral crus is left with its ves-
tibular skin undisturbed. The graft is carved into
two pieces 3–4 mm wide, 15–25 mm long, placed
deep to the lateral crus in the undermined pocket,
Fig. 12.3 The lateral crural strut graft: The vestibular
skin underlying the lateral crura is fi rst undermined, fol-
lowed by placement of a cartilaginous strut meant to lend
shape and strength to the lateral crura (Gunter and
Friedman [ 37 ] )

142
J.D. Weissman and S.P. Most
and then secured with a couple of Vicryl sutures.
Longer struts are advocated in cases of severe
alar collapse affecting the external nasal valve
and may even require extension to the pyriform
rim. In such instances, separation of the lateral
crus from the accessory cartilages is required,
and the graft should sit caudal to the alar groove
to prevent postoperative visibility.
A method of alar expansion and reinforcement
has also been proposed [ 38 ] , with conceptual
familiarity to the fl aring suture described previ-
ously. An external rhinoplasty approach is advised
to fully expose and assess the lower lateral carti-
lages. Weakened or de fi cient LLCs are reinforced
with alar batten implants – the authors of the
chapter recommend high-density porous polyeth-
ylene (HDPP). Following stabilization of the tip
with an interdomal suture, lateral expansion
sutures were passed through the lateral crus, then
the vestibule, and then back through the mucosa
of the vestibule and the lateral crus. It is then
passed over the septum, with a similar pass
through the contralateral LLC, and then tied down.
It is very important to check the nose externally
for distortion at every step as this technique has
the potential to cause externally visible changes.
Paniello introduced nasal valve suspension
[ 39 ] as a treatment for external valve collapse.
This method allowed for passage of a retention
suture from an endonasal approach to a fi xation
point on the inferior orbital rim as accessed
through a transconjunctival incision. Half of the
original 12 subjects reported on did show mild
widening in the middle third of the nose, although
none were concerned by it. This approach was
later modi fi ed to include an external incision to
access the rim [ 40 ] and again for incorporation
with an external rhinoplasty approach, as described
by the senior author (Fig. 12.4 ) [ 16 ] . The latter
involves a standard external approach with expo-
sure of the LLC and the pyriform rim. The perios-
teum is then elevated to the level of the medial
inferior orbital rim. The anchor system is then
drilled into the bone. The authors prefer the Mitek
Soft Tissue Anchor Suspension system (Depuy
Mitek, Raynham, MA). There are two sutures
attached to the anchor: one is placed through the
caudal ipsilateral ULC and then the lateral third of
the cephalad aspect of the ipsilateral LLC, and
then it is tied to the other suture. By performing
this procedure on each side, the force vectors will
stabilize the lateral nasal wall against negative
inspiratory pressure without actually retracting
the ala. It is also advisable to place an interdomal
stitch to prevent splaying of the tip.
The authors evaluate patients with external
valve collapse and classify them as having “lat-
eral wall insuf fi ciency” (LWI, described above)
in an upper zone (zone 1) or lower zone (zone 2,
corresponding to more classic “external valve
collapse”). The current algorithm includes evalu-
ation and treatment with cartilage grafting the
lateral wall or using suture suspension or a com-
bination of both (Fig. 12.5 ).
The cephalic turn-in fl ap [ 41, 42 ] is a relatively
new technique described which achieves aesthetic
re fi ning rhinoplastic goals with preserved struc-
tural integrity of the nasal pyramid. It draws on a
variation of the cephalic trim, a maneuver that can
lead to attenuation of the lateral nasal wall and tip
support, among other undesired sequelae such as
overrotation and alar retraction. The external rhi-
noplasty approach is advocated, with exposure of
Fig. 12.4 Bone-anchored suspension suture: With
exposure of the LLC and the pyriform rim via the external
rhinoplasty approach, maxillary periosteum is elevated to
allow for placement of the anchor system near the level of
the medial inferior orbital rim. The sutures are then placed
through the region of the scroll to provide stabilization of
the lateral nasal wall (Roofe and Most [ 16 ] )