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Breathing Difficulty
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Other
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Previous nasal surgery
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Previous nasal truama
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Allergies to
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Treated for allergies by
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with
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Discussed and patient understands
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Chronic nasal spray use
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Cocaine use
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Hypertension
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Bleeding or clotting disorder
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Drug Allergies:
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Drug Allergies: NKDA
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Current Med
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If yes, please list
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Personal Physician:
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Last Seen
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Findings
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Healthy
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New Free Draw
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Rhinoplasty Clinical Evaluation for
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Objectives for Improvement
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UPPER NOSE
• • •
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Other
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NASAL TIP
• • •
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Other
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NOSE:UPPER LIP JUNCTION
• • •
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Other
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CHIN AND PROFILE BALANCE
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Chin projection
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Excessive
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Vertical height chin
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Excessive
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Inadequate
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Other:
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INTRANASAL AND AIRWAY
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Airway obstruction: Left %
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Right %
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Septal deviation
• • •
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Septal-vomer shelves
• • •
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Ethmoid spur
• • •
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Enlarged turbinate
• • •
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Other
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SPECIFIC LIMITATIONS DISCUSSED WITH PATIENT
• • •
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Other
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Diagram
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Recommended Procedures
• • •
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Other
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Rhinoplasty Operative Planning for
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Date of Surgery
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APPROACH
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INCISIONS
• • •
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PRIMARY TIP
• • •
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Lateral Crus Cephalad Resection: mm?
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leave Caudal: mm?
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Other
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PRIMARY DORSUM
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Cartilaginous
• • •
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Reduce: mm?
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Augment: mm?
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Source:
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Resect/Replace: mm?
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mm
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Other:
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Bony
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Reduce
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Augment
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Source:
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Lateral protrusion reduction
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Other
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SEPTUM
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Approach
• • •
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SMR
• • •
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Leave: mm dorsal
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mm caudal struts
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Septoplasty
• • •
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Other
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Other
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Caudal Septum
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Resect: mm
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Other
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Diagram
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Diagram
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TURBINATES
• • •
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OSTEOTOMIES
• • •
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SECONDARY TIP
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MCFS- Medial Crural Fixation Suture
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CCS- Control Columellar Strut
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x mm
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Incorporate
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LCSS-
• • •
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LCSG- Lateral Crural Spanning Graft: mm
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x mm
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DSS- Dome Spanning Suture(s): Left
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Right
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PCS- Projection Control Suture
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Advance tip
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Recess tip
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TRS - Tip Rotation Suture
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RCG-Rotation control grafts: mm
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x mm
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Medial crus caudal trim
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Transect rimstrip: mm
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Overlap, suture
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Resect rim segment
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mm lat. to dome
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config.
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Morselization
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lat to dome
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Domes:
• • •
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Location:
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Tip Augmentation
• • •
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Columellar:tip Size
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Medial crust
• • •
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SECONDARY DORSUM
• • •
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Dorsal graft(s) Size:
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Source
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Suture fixation
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Other
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TIP-LIP COMPLEX
• • •
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Augment Caudal Septum Size
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Source
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Other
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Diagram
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ALAR BASE
• • •
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Other
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VESTIBULAR LINING
• • •
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Cutaneous
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Vestibular
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Alar base augmentation: mm
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Source
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Other
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CLOSURE
• • •
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Other
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SPLINTING
• • •
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ABNORMAL NASAL AND NASOFACIAL PARAMETERS
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ANTEROPOSTEROIR VIEW
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Nasal-facial proportions:
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Nasal length:
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Nasal width (overall):
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Disproportion upper two-thirds with lower third
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Upper third nose: Nasal bones:
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Dorsum:
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Base:
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Dorsal/lateral humps:
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Septum:
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Middle third nose:
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Dorsal/lateral humps:
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Upper laterals:
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Dorsum:
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Base:
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Lower third nose:
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Tip configuration:
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Tip definition:
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Tip skin:
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Alar cartilages:
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Domes:
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Lateral convexities:
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Lateral crus: Cephalad excess
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mm lateral to dome
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Medial/Middle crura:
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Position:
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Columella:
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Nostril show:
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Infratip lobule show:
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Alar base width:
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Alar rims:
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Upper lip:
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Incisor show
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Chin
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BASILAR VIEW
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Nasal base configuration:
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Tip projection
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Alar cartilages:
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Domes
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Lateral crura:
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Medial crura:
• • •
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Alar base width
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Alar base lobule components:
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Excess vestibular
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excess skin
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Nostrils:
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Orientation:
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Size:
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Shape:
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Alar rims:
• • •
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Columella:
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Position:
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Contour:
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Length:
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Septum:
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Infratip lobule:
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Base-lobule ratio
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Maxilla:
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LATERAL VIEWS
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Nasal-facial proportions:
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Nasal length:
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Maxilla:
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Pyriform aperture (maxilla at alar base plane):
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Malar prominence
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Nasal proportions:
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Ratio tip projection off facial plane to length:
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Length:
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Tip projection off facial plane:
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Height of dorsum:
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Upper third nose:
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Nasion (soft tissue takeoff):
• • •
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Nasal bones:
• • •
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Middle third nose:
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Upper lateral cartilages:
• • •
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Lower third nose:
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Tip projection above dorsal line of nose:
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Tip projection off facial plane
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Tip definition:
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Medial crus:
|
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Middle crus:
|
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Lateral crus:
|
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Size:
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Total vertical height
|
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Position:
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Configuration:
• • •
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Lateral weakness (indentation):
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Skin:
|
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Alar base- infratip lobule ratio:
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Columella-lobule angle:
• • •
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Columella:
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Show:
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Length:
|
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Alar rim sweep/arch:
• • •
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Caudal septum
|
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Caudal septum-nasal spine complex:
|
Upper lip
• • •
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Lower lip:
• • •
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Chin:
• • •
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OBLIQUE VIEWS
|
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Upper third nose:
|
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Nasion:
• • •
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Nasal bones:
• • •
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Middle third nose:
|
|
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Upper lateral cartilages:
• • •
|
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Lower third nose:
|
|
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Tip projection (ADL):
|
Tip projection (OFP):
|
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Tip definition:
|
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Lateral crus:
|
|
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Position:
|
Length:
|
|
Configuration:
• • •
|
Domes:
• • •
|
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Medial crus:
• • •
|
Middle crus:
• • •
|
