**2. Preoperative evaluations**

Like any other aesthetic procedure, a comprehensive preoperative evaluation, may directly affect the final outcome of the operation. The first step is usually started by a thorough psychological assessment, and then functional assessment of the nose is performed. Structural and aesthetic evaluations are usually the last stages followed by the treatment plan and finally operation [1].

### **2.1. Psychological evaluation**

Psychological assessment of the rhinoplasty candidates is the first step to build up a proper treatment plan. Unrealistic demands and personality disorders are best detected at this stage. An open discussion with the patient may clarify many potential problems. Any previous psychological medications or therapies should be clarified. Patient may be asked to bring up their ideal nose models; computerized simulation is another modality that may help the surgeon communicate with the patient and seek their real demands and expectations. It is clear

that an ideal surgery with perfect results in an unsatisfied patient is a big failure and is best prevented in this preoperative phase [2-3].

### **2.2. Functional evaluation**

The human nose bears a complex physiologic and functional role in breathing and smelling. For this reason it is logically expected that this delicate organ be preserved and even improved during aesthetic surgery. This evaluation usually starts with verbal interview with the patient. Any breathing problems may be easily detected. Exacerbating factors or problems are usually best described by the patient, and then the evaluation continues with direct inspection of the nose. Any deviation or deformity should be observed and documented. To assess the septum and turbinates sufficient light and a nasal speculum are necessary. A few drops of a vasocon‐ strictor such as phenylephrine in each nostril may be applied for better visualization [4-7].The final step is to check the valve. The Cottle test is a known method to assess the internal nasal valve. The patient is asked to take a deep breath through the nose, and then inhalation is repeated while the patient is retracting his/her nasal side wall. If a considerable improvement occurs (positive Cottle test), this means a serious weakness exists in the internal nasal valve (Figure1). [8].It is clear that a reinforcement or total reconstruction of the internal valve should be considered in treatment planning. This test should be done on both sides and documented properly.

**Figure 1.** Cottle test.

To assess the external valves the patient is asked to tilt the head backward and take a deep. The nose is closely observed by the surgeon. This test may be documented by simple standard photography. Excessive medial movements of the nostrils and/or collapse means that some kind of reinforcement technique needs to be considered in the rhinoplasty procedure [9-10].
