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Dean Toriumi, M.D.

Maximizing Rhinoplasty Outcomes


New Methods Used to Improve Patient Satisfaction

Over the past two years I have made many changes to improve patient satisfaction, with a goal of developing a reliable method of ensuring the highest levels of satisfaction among our rhinoplasty patients.

Success in rhinoplasty ultimately involves a happy patient. From treating thousands of patients, it is clear that there is no set aesthetic standard that can be applied to all patients. In fact, some patients request aesthetic parameters that diverge from the norm. In light of these variances in aesthetic goals I have focused more intensively on  reaching a clear understanding of patients' specific desires.

The first part of this process involves performing computer imaging on the rhinoplasty patient during the initial consultation. I do the computer imaging myself while the patient is present. Rarely do any surgeons do the imaging "live" in front of the patient. This is because it requires adept use of the imaging software and a clear understanding of nasal aesthetics. In many offices someone other than the surgeon does the computer imaging. This is not reliable as only the surgeon knows what is a realistic expectation based on the surgeons experience. Some surgeons show images that are unrealistic and may have difficulty achieving that proposed outcome. I only do very realistic imaging to convey a realistic expectation.

Once the computer imaging is completed we give the patient a copy of the imaging with the understanding that it is not a guarantee but a proposed aesthetic outcome; with our expertise, though, we usually come very close. The computer imaging demonstates images with specific contours. During surgery there is some degree of variance between the imaging and the actual intraoperative result. It is helpful to have a range or preference to try to achieve as opposed to a single set contour. For this reason we have patients fill out a preoperative rhinoplasty questionairre (shown below).


With the information on this questionnaire I am able to work toward an aesthetic range such as a smaller narrower nose. Many secondary patients see me to have their nose lengthened. It helps a great deal to know if they prefer a nose that is longer or shorter than the imaging. I am also able to make accommodations for skin thickness or variant nasal anatomy.

The other new addition to our treatment protocol is to make an extensive number of measurements at the time of surgery. We make measurements at the initial opening of the nose when the structures of the nose are exposed. We measure tip projection, tip rotation, nasal length, middle nasal vault width, tip width, etc. During the surgery we make sequential measurements as the operation proceeds moving in the direction necessary to attain the proposed aesthetic goals. We take two measurements of the middle nasal vault (upper middle nasal vault and lower nasal vault). The calipers used to make the measurements are shown below.


For instance if the middle nasal vault width starts at 12 mm and 10 mm and the patient wants a narrower nose I would likely make the middle nasal vault 9 mm and 8 mm at the completion of the operation. This will give the patient a narrower nose as requested in the preoperative rhinoplasty questionnaire and computer imaging. Making the measurements provides a safety net to make sure that I am in the correct range at the end of the operation.

Using this combination of the preoperative rhinoplasty questionnaire, computer imaging, and the intraoperative measurements, our patient satisfaction has increased dramatically. I have found that it takes less time for patients' noses to look good after surgery as the accuracy of the contours are much closer to the computer imaging within weeks after surgery. This effort has proven to improve patient satisfaction dramatically.

The patient shown below presented for primary rhinoplasty. She wanted a narrower nasal tip and shorter nose. Her preoperative rhinoplasty computer imaging is shown below.

The preoperative frontal view computer imaging shows a narrower nasal tip and shorter nose with more upper lip visible on the frontal view. In order to create balance between her upper two thirds of her nose and the lower third (nasal tip) her middle nasal vault was made wider in the preoperative computer imaging.


The preoperative lateral view computer imaging shows a shorter nose, removal of her small dorsal hump and increased nasal tip rotation and longer upper lip.

We discussed the computer imaging with her preoperatively and agreed on the proposed computer imaging. In her preoperative rhinoplasty questionnaire she noted that she wanted aesthetic changes similar to the computer imaging such as shortening of her nose, removal of her dorsal hump, and narrowing of her nasal tip. I pointed out the improvement that could be gained by shortening her nose and lengthening her upper lip. This is a nuance of her surgery and was easily clarified using the imaging.

I performed an external rhinoplasty approach on her nose using her septal cartilage to make the changes to her middle nasal vault and nasal tip. I also straightened her nasal septum to improve her nasal breathing.

Postoperatively she did well and has attained a result that is very close to the preoperative computer imaging. She is very happy with her outcome.

Seven-month postoperative frontal view shows narrowing of her nasal tip and slight widening of her middle nasal vault to help balance her upper two-thirds of her nose with her nasal tip. If we left her middle nasal vault as narrow as it was preoperatively her nose would still look imbalanced. Postoperatively her nose looks more balanced.


The postoperative lateral view shows that her nose was rotated and shortened, and her small dorsal hump was removed. Note that her upper lip is longer after surgery.

The postoperative oblique view shows a smoother dorsal line and a lifted nasal tip. In this view her upper lip looks much better.

The postoperative base view shows a narrower nasal tip that is more triangular in shape. There is also excellent healing of the columellar incision.

I believe that use of this combination of preoperative computer imaging, preoperative rhinoplasty questionnaire, and intraoperative measurements will continue to improve patient satisfaction. This one-of-a-kind approach to rhinoplasty maximizes patient communication to avoid confusion with the desired aesthetic outcome.

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