Key Points
- Rhinoplasty ranks among the most commonly performed cosmetic procedures in the United States, with over 200,000 procedures reported in 2014.
- The primary reason for surgery can be aesthetic, functional, or both, and may include adjunctive procedures on the nasal septum, nasal valve, nasal turbinates, or the paranasal sinuses.
- The average uncomplicated rhinoplasty procedure typically exceeds $4,000. However, the costs incurred due to complications, infections, or revision surgery (long-term antibiotics, hospitalization, and lost revenue from hours/days of missed work) add considerably to the total.
- The resultant psychological impact of rhinoplasty can also be significant.
Table 1. Definitions of Words Used in the Guideline
Rhinoplasty | Rhinoplasty is a surgical procedure that alters the shape or appearance of the nose while preserving or enhancing the nasal airway. The primary reason for surgery can be aesthetic, functional, or both, and may include adjunctive procedures on the septum, turbinates, or paranasal sinuses. (When these adjunctive procedures, however, are performed without an impact on nasal shape or appearance, they do not meet the definition of rhinoplasty used in this guideline). |
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Aesthetic | Concerned with beauty or the appreciation of beauty. |
Body Dysmorphic Disorder | Psychiatric disorder consisting of distressing or impairing preoccupation with nonexistent or slight defects in one's appearance. |
Cosmetic | Relating to treatment intended to restore or improve appearance. |
Rhinitis | Inflammation of the mucus membranes of the nose frequently caused by infection or allergic reaction. It typically manifests with symptoms of nasal itching, increased mucus drainage, congestion, or post nasal drainage. |
Obstructive Sleep Apnea | Sleep disorder involving at least five obstructive respiratory events per hour (detected during an overnight sleep study). |
Nasal cycle | The often unnoticed alternating partial congestion and decongestion of the nasal cavities in humans and other animals. It is a physiological congestion of the nasal turbinates due to selective activation of the autonomic nervous system on one side of the nose. |
Anterior rhinoscopy | Examination of the anterior part of the nose, including the inferior turbinate, the septum, and the nasal valves. |
Nasal packing | Nasal packing is material, either removable or absorbable, placed inside the nose to promote hemostasis, structural support, and reduction of scar formation. Traditional nasal packs include ribbon gauze, expandable non-biodegradable pads, and non-stick dressing material. (Yan M, Zheng D, Li Y, et al. Biodegradable nasal packings for endoscopic sinonasal surgery: a systematic review and meta-analysis. PLos One. 2014; 9(12): e115458.) There are many newer types of packing that are biodegradable. Silastic stents or nasal splints, and custom cut sheeting are not considered packing. |
Table 2. Nasal Anatomy Definitions
Upper Lateral Cartilage | The lateral cartilage piece of the nose, triangular in shape, meeting with the nasal bones superiorly and the lower lateral cartilages inferiorly, and fusing with the septum in the midline. |
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Lower Lateral Cartilage | Thin flexible plate of cartilage folded on itself and situated just below the upper lateral cartilage. It makes up the medial and lateral wall of the nostril. |
Internal Nasal Valve | Refers to the area bordered by the upper lateral cartilage laterally, the septum medially, the head of the inferior turbinate, and the floor of the nose. |
External Nasal Valve | Refers to the area bordered by the lateral limb of the lower lateral cartilage laterally, the medial limb of the lower lateral cartilage and the septum medially, and the floor of the nose. |
Nasal Septum | Wall of cartilage and bone that runs down the middle of the nose dividing it into left and right nasal passages. |
Nasal Turbinates | Long narrow curved shelves of bone covered in mucus membrane and protruding into the nasal passage. |
Management
Table 3. Structures to Assess in Rhinoplasty
Structure | Diagnostic Method | Example of an Abnormality or Problem |
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Adenoids | Nasal endoscopy | Adenoidal hypertrophy |
Anterior Septum | Anterior rhinoscopy, nasal endoscopy | Caudal septal deviation |
Inferior Turbinate | Anterior rhinoscopy, nasal endoscopy | Inferior turbinate hypertrophy |
Nasal Septum | Anterior rhinoscopy, nasal endoscopy | Deviated septum |
Nasal Valve | Cottle maneuver, modified Cottle maneuver | Nasal valve collapse |
Posterior Septum | Nasal endoscopy | Posterior septal spur |
Sinus Ostia | Nasal endoscopy | Chronic sinusitis, polyps, pus |
Table 4. Cosmetic Assessments
FACE-Q Rhinoplasty Instrument | Initially 40 questions for patients undergoing facial aesthetic surgery to assess satisfaction with facial appearance, social function, psychological well-being, and satisfaction with the nose with subsequent refinement to 25 questions for rhinoplasty surgery. |
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Glasgow Benefit Inventory (GBI) | 18 questions measuring the general perception of well-being and psychological, social, and physical well-being. Originally developed for multiple surgeries of the head and face including rhinoplasty with subsequent validation studies on rhinoplasty alone. |
Rhinoplasty Outcome Evaluation (ROE) | 6 questions examining three major domains: appearance, functional outcome, and social acceptance following rhinoplasty. |
Table 5. Functional Assessments
Nasal Obstruction and Septoplasty Effectiveness Scale (NOSE) | https://www.entnet.org/sites/default/files/NOSE-Instrument.pdf | A 5 question scale developed specifically to evaluate nasal obstruction, with frequent literature citation in septoplasty and functional rhinoplasty surgery. |
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Sino-Nasal Outcome Test (SNOT-22) | www.canvasc.ca/pdf/SNOT22.pdf | A 22 item questionnaire originally designed for rhinosinusitis, adapted to assess nasal patency in septoplasty, nasal valve, and functional rhinoplasty surgery. |