"Practical suggestions on facila plastic surgery--how I do it". External marking in rhinoplasty planning

Photographs, drawings, and examination at consultation have value in rhiniplastic planning. However, the surgeon is not operating on photographs, drawings, or an alert sitting or standing patient; he is operating on a nose with what was forward now facing upward. We find it most helpful to plan and mark almost the entire procedure on the external nose and surrounding structures just before the patient is put supine and sedated or anesthetized. In primary rhinoplasty, it is possible to mark essentially all skeletal anatomy within 1 mm tolerances by palpation, pushing the tip up and back, observing the changes from the outside, and looking at the inside. We believe that the anatomy and planned changes can and should be depicted by appropriate marks put on the skin. There mere act of drawing in the procedure forces us to think it through from beginning to end, a most worthwhile endeavor. Moreover, we learned very shortly after we began forcing ourselves to quantitate the anatomy and proposed changes, that we ran into fewer and fewer surprises as we worked. Photographs taken of the markings become by far the best "operative note" we can have. Comparison of these with the patient or his photographs showing the result allow us to make accurate judgments about long term effects of each surgical maneuver. Much that seemed mysterious before is found to be quite scientifically explainable. We do not propose in this short report to show how we mark every nose. Rather we shall show with drawings and a few examples how we go about marking a nose. The reader may use the suggested marking techniques or may evolve his own. The important thing is that he work out a system meaningful to him. It will be noted that we have used differing techniques for depicting similar concepts from case to case. In other words, we have not settled immutably on one system because we are still searching for the best.