1. Planning the operation

The pre-operative phase consists of one or more interviews, which are essential in order to establish an appropriate human relationship and the correct degree of trust between doctor and patient. I always seek to develop good relations with my patients from the very beginning and to make them feel at ease so that they can explain precisely what it is that they are unhappy with and what they wish to alter. Moreover, the defects they complain of are often the cause of psychological states of concern and anxiety, that I need to understand in order to obtain a full picture of the problem.

Examination is essential to identify the pathological defects responsible for the aesthetic and/or functional problems reported. To this end, rhinoscopy plays an important part by making it possible to obtain an objective appraisal of the situation of the nasal cavities through the nostrils, and to detect the presence of a nasal septum deviation and/or turbinate hypertrophy responsible for impaired respiration. Equal importance attaches to external examination of the nasal pyramid, which can reveal weakness with collapse of the nasal walls during inspiration, caused by defects of the nasal valve. Palpation of the nasal pyramid also plays an important part in determining the robustness of the various anatomical units, especially the tip.

Examination is essential to identify the pathological defects responsible for the aesthetic and/or functional problems reported. To this end, rhinoscopy plays an important part by making it possible to obtain an objective appraisal of the situation of the nasal cavities through the nostrils, and to detect the presence of a nasal septum deviation and/or turbinate hypertrophy responsible for impaired respiration. Equal importance attaches to external examination of the nasal pyramid, which can reveal weakness with collapse of the nasal walls during inspiration, caused by defects of the nasal valve. Palpation of the nasal pyramid also plays an important part in determining the robustness of the various anatomical units, especially the tip.

The assessment of aesthetic flaws involves not only nasal examination but also the use of photographs of the patient taken in the six codified poses: frontal, right and left profile, right and left three-quarter profile, and from below. These photos are used to develop digital simulations that can prove very useful with a view to a better understanding of the modifications desired by the patient and furnishing advice as to the best options. Simulation of the different results obtainable on the same image make it possible for the patient to decide on the one regarded as most pleasing.

A view of the possible postoperative end result is very useful for patient also in order to see whether they are psychologically capable of identifying themselves with their new appearance. In my opinion, even the most skilled surgeons should never forget that all their technical experience must not be used in order to obtain the aesthetic result most to their personal liking but be placed at the service of their patients and their wishes. This obviously does not mean that the surgeon cannot explain what is technically feasible and what is not, provide precious advice on modifications, and develop a plan of aesthetic modification together with the patient.

La visione dell’eventuale situazione postoperatoria finale è molto utile per identificarsi, anche psicologicamente, nel cambiamento estetico futuro. A mio parere, anche il chirurgo più esperto non dovrebbe mai dimenticare che tutta la sua esperienza tecnica non deve essere usata per ottenere il risultato estetico che ritiene migliore ma deve essere al servizio del paziente per realizzare quanto desidera. Ciò non toglie che il chirurgo possa spiegare quanto tecnicamente sia realizzabile e quanto no, dare preziosi consigli sulle modifiche e infine concordare insieme un piano di cambiamento estetico.

2. Examinations and interview with the anaesthetist

It is best to explain the surgical procedures involved in the operation to the patient in simple terms and make sure that any inherent difficulties are clearly understood. A detailed description of the postoperative period and recovery time is also of crucial importance, so that the patient is fully aware of what to expect. It must be emphasized that time should never be an issue during the preoperative examination or examinations, in the sense that everything must be clearly defined and understood by the patient and the surgeon alike with no haste or approximation. The following tests are prescribed in preparation to the operation: azotemia, blood sugar, creatinine, bilirubin (total and direct), transaminase (GOT - GPT), CPK, γGT, cholinesterase, electrolytes, serum protein electrophoresis, complete blood count, platelet count, prothrombin time, PTT, INR, fibrinogen, urine examination, electrocardiogram and chest X-ray.

The rhinoplasty preparation protocol also includes an interview with the anaesthetist or an examination, if required. About one month before the operation, in order to reduce bleeding, the patient must stop taking aspirin and contraceptive pills and must promptly report the use of other medicinal substances, so that it can be decided whether they too should be stopped.

3. The day of the rhinoplasty

On the day of the operation, patients must have fasted completely (both solid and liquid food) for at least eight hours. On entering the clinic, after carrying out the admittance procedures and being shown to their room, they undergo an anaesthesiological examination to make sure that their general condition of health is suitable for the operation. All metallic objects such as necklaces, bracelets, rings, watches and studs must be removed from the patient’s body prior to positioning on the gurney and wheeling to the operating theatre, in order to avoid any interference with the electrical equipment used during the operation.

It is my habit to talk to the patients both in their rooms, in order to go over the details of the planned modification together, and in the theatre, with a view to providing reassurance before the general anaesthetic.

3. The day of the rhinoplasty

On the day of the operation, patients must have fasted completely (both solid and liquid food) for at least eight hours. On entering the clinic, after carrying out the admittance procedures and being shown to their room, they undergo an anaesthesiological examination to make sure that their general condition of health is suitable for the operation. All metallic objects such as necklaces, bracelets, rings, watches and studs must be removed from the patient’s body prior to positioning on the gurney and wheeling to the operating theatre, in order to avoid any interference with the electrical equipment used during the operation.

It is my habit to talk to the patients both in their rooms, in order to go over the details of the planned modification together, and in the theatre, with a view to providing reassurance before the general anaesthetic.

DR. ARMANDO BOCCIERI

PASSION FOR RHINOPLASTY

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