Open Rhinoplasty

Open Structure Rhinoplasty Chapter

History of open rhinoplasty

On the surface, open, or external rhinoplasty differs from endonasal rhinoplasty by just a single incision along the midcolumella. However, both of these operations are based on vastly different core philosophies. Since its modern application, open rhinoplasty has emphasized structure and support. (1) Since then, rhinoplasty as a whole has followed suit and embraced the notion of reorientation and structuring rather then excisions as the means to achieving long term refinement and normal appearing outcomes.

Although open rhinoplasty is commonly thought to be a recent surgical innovation, “open rhinoplasty” predates closed rhinoplasty in its initial inception. Sushruta Ayurveda described the first open rhinoplasty 600 BC in ancient India. (2) The “Indian Rhinoplasty” was primarily a recreation of patient’s amputated noses with a local pedicled flap of tissue.

With respect specifically to modern open rhinoplasty, Rethi first introduced the columellar incision for open rhinoplasty for tip modification in 1921. (2) In 1957, Sercer advocated the open approach to the nasal cavity and nasal septum with the use of a columellar incision, calling the procedure “nasal decortication.”

Open rhinoplasty has since garnered tremendous controversy from being considered a disfiguring, overly aggressive surgery to perhaps the most widely accepted approach for many rhinoplasty surgeons. A recent survey demonstrated that 53% of rhinoplasty surgeons used open rhinoplasty 50% of the time or greater. (3) Open rhinoplasty has gained popularity, in part, due to the unparalleled views of nasal anatomy and the facility it allows to reshape the nose with grafting material.

Preoperative assessment

As in any surgical procedure, a thorough history is necessary to determine the candidacy of a patient for rhinoplasty. Any confounding medical conditions should be managed appropriately prior to functional surgery. Allergic rhinitis bears special mention as it should be treated aggressively prior to operative intervention to prevent prolonged postoperative swelling both intranasally and externally. (4) Patients should also be directly questioned regarding the use of illicit drugs, especially cocaine use. Chronic cocaine use not only may impact on anesthesia safety, but its alteration of microvascular circulation in the septum may predispose to perioperative wound healing complication including septal perforation.

The ability to diagnosis and analyze the individual anatomic characteristics of each nose are requisite in achieving exceptional surgical results. The physical examination helps to determine a patient’s functional and aesthetic nasal diagnosis. The nose should complement the length and width of the face. An overly long nose will make a long face look longer; a short nose will look out of balance on a long face. The length, projection and rotation of the nose, when they complement the face, will highlight other complimentary facial features. In particular, a balanced nose will make the eyes the focus of the face, making them look, and the whole face with them, exceptional.

The skin and soft tissue envelope play a significant factor in preoperative planning and surgical technique. Overly thin skin, while providing an excellent jacket for tip definition, will demonstrate minuscule irregularities, leaving little room for less than precisely executed surgery. Extremely thick skin, while concealing asymmetries, needs support and structure to prevent an amorphous, overly round nasal tip from resulting.

Palpation of the nasal tip provides the surgeon with valuable clinical information. Ballottement of the nasal tip and noting the resultant recoil provides insight to the inherent tip support mechanisms. The relative length of the medial and lateral crura, as well as the size and shape of the anterior septum can also be determined with nasal tip tactation.

The intranasal examination concentrates on each nasal functional subsection independently. The external nasal valves, septum, internal nasal valves, inferior turbinates, middle meati, and nasopharynx are examined serially. Any crusting must be removed to reveal the condition of the mucoperichondrium and possibility of occult nasal perforation. The septum may be palpated with a cotton tip applicator to help determine whether cartilage is present. In addition, both auricles should be palpated to determine the amount and character of the cartilage of the cymba and cavum concha.

The initial examination is performed with no topical decongestant. The patient is asked to grade nasal breathing overall on a 0 to 10 scale, with 0 being “No air flow” and 10 being “Perfect air flow”. The patient is then told to gently occlude one nostril and then the other, grading breathing on the same scale of each side independently. Next, a cerumen curette is inserted into one side of the nose to gently support and lateralize the external, and then the internal, nasal valves. The patient is asked to grade the resultant airflow again from 0 to 10 while gently occluding the contralateral nostril. The location of support that gives maximal improvement is carefully recorded. The procedure is then repeated on the other side. Care is taken not to overly lateralize the nasal sidewalls, but rather only to mimic the support that surgical grafting would yield. After decongestion, the entire evaluation is repeated again in order to weigh the effects of mucosal edema on obstruction. These maneuvers, when combined with a thorough examination, can accurately predict the area of maximal obstruction from the anterior nasal chamber, and can help guide the surgeon as to the best treatment. (5)

Standardized photography plays an important role in documentation and analysis of postoperative outcomes analysis. Preoperative computer imaging, where photographs are morphed to represent possible surgical outcomes, is a useful tool in tempering expectations and understanding a patient’s aesthetic desires.

Indications

There is no universal set of criteria dictating open versus closed approaches to rhinoplasty. Indications vary tremendously amongst surgeons according to personal preference and experience with each technique. Table 1 indicates typical conditions in which various surgeons might utilize open rhinoplasty techniques.

In the complex or revision case, the open approach offers unparalleled exposure and control of each structure being operated upon. In the finesse rhinoplasty, the open approach likewise offers unparalleled exposure and control of each structure being operated upon. We feel that the open approach should be used in all cases unless the surgeon feels he or she can accurately diagnosis the underlying deformities; and correct them as well closed as open. We have seen time and time again that cartilaginous and bony skeletal findings are at variance to what was expected preoperatively. It is well-established that changes can occur in the nose after rhinoplasty for years after surgery. Regardless of the complexity of the case, the ability of the surgeon to maximally control and stabilize a nose against the vagaries of postoperative healing, and to insure as much as possible against an untoward result, is best supported by the open approach. When the changes sought are to last a lifetime, a little longer surgical or postoperative recovery time is a small price to pay. In our experience, the postoperative recovery time following rhinoplasty is largely dependent on the surgeon’s experience with rhinoplasty and the amount of prior scar encountered, and has little to do with the selected approach.

Contraindications

Rhinoplasty should be avoided in patients who have unrealistic expectations about a rhinoplasty outcome. Body dysmorphic disorder occurs commonly in patients seeking rhinoplasty, as high as 20% in some studies. (6) A surgeon should not agree to take on a rhinoplasty in which he can not communicate with his patient in the patient’s native language. If an interpreter is used, care should be taken that interpretation is precise and not prejudiced. Family members, and in particular children of the patient, should not be relied upon as interpreters. Finally, a surgeon should not agree to take on a rhinoplasty that he has reservations about, either surgical or personal. As we have gained experience in rhinoplasty, we have come to understand the value of referring a complex or bewildering patient to a colleague who might not share our particular concerns.

Anesthesia Options

General / IV sedation

Anesthesia is typically performed under general or IV sedation in the presence of an anesthesiologist for a full rhinoplasty. More limited cases may be performed under local anesthesia with either more limited on no sedation. Appropriate knowledge of regional and local blocks will maximize patient comfort and minimize patient bleeding. Typically, infraorbital, supratrochlear, and anterior palatine blocks will maximize patient comfort while minimizing immediate postoperative pain. The use of small amounts of local infiltration (less than 5 ml for the external nose) in the precise surgical planes allows for meticulous vasoconstriction without distortion of tissue planes and the underlying cartilaginous anatomy. Care is taken not to infiltrate directly along the dorsum in order not to obscure the dorsal nasal line. Paradorsal infiltration provides for adequate anesthesia when supplemented by intranasal dorsal septal infiltration. The nasal septum is routinely anesthetized with a combination of topical cocaine (4 ml of 4%) as well as additional direct infiltration, if there is no medical contraindication. Middle turbinate infiltration insures improved anesthesia when working on the posterior septum and along the dorsum. Since this is surgery, our bias is only to perform rhinoplasty, regardless of extent, in an accredited surgery center.

Surgical technique

Columellar Incision Placement and Planning

The surgeon’s recognition of specific anatomic differences pertinent to the columella will minimize columellar scar visibility. In most cases, the incision is made with an “inverted V” incision along the midcolumella with a number 11 blade (though some surgeons prefer a stair-step incision). The incision is ideally placed over the mid portion of the conjoined medial crura as they provide a stable platform upon which the scar can heal with minimal contraction. Typically, the narrowest portion of the columella corresponds to this location. (Figure 1)

In revision rhinoplasty a prior scar may be present on the columella. If the scar is located in a favorable position, orientation and appearance, the surgeon can make the incision through the same midcolumellar scar. If the scar is raised, depressed, discolored or widened, but in an appropriate location, the surgeon might excise the scar and utilize meticulous closure techniques.

If the scar is in a poor location, either too high or too low, the surgeon should consider placement of a new scar in the appropriate location. Resection of a poorly healed scar and placement of a new incision concomitantly are potentially dangerous due to shortening of the columella flap and risk for vascular compromise.

Marginal incisions are made along the lateral portion of the columella, just at the most lateral portion of the medial crus. If the incision is made too far posterior, the surgeon may have difficulty raising the flap and avoiding injury to the medial crus.

A robust and thick columellar flap insures appropriate vascularity to the flap and camouflage of any caudally positioned grafts. Modest hemostasis may be achieved with bipolar cautery of a bleeding columellar artery. Overly aggressive cautery at the nasal base may result in unfavorable wound healing and midcolumellar scarring.

Placement of marginal incision

Some surgeons utilize a separate marginal incision to assist in lifting the soft tissue envelope from the cartilaginous structures of the nose. However, the marginal incision can be joined with the columellar incision with a Converse scissors rather than a separate incision made with a 15 blade. With the columellar flap elevated, the surgeon can dissect in a subperichondrial plane along the lower lateral cartilage. When the caudal aspect of the lower lateral cartilage is seen, the marginal incision can be joined with a converse scissors. Attention should be paid to preserving the soft tissue triangle.

Approaches to septal deviation

A clear advantage of open rhinoplasty is versatility in addressing septal deviations. The open rhinoplasty surgeon can tailor a graduated approach to the septum to balance the exposure needed to address the septal deformity with the amount of disruption of surrounding supportive structures. Each of these structures provides support and stability to the nose and the proper reconstruction involves potentially added time and grafting materials.

If the septal deflection occurs within the non-L strut portion of the septum, the septum can be addressed in a standard Killian or hemi-transfixion incision.The Killian incision may be preferred due to less disruption of tip support mechanisms. If the septal deflection involves the caudal aspect of the septum, the surgeon will need to dissect between the medial crura to reach the anterior portion of the septum and reposition it. Alternatively, a hemi-trasfixion incision can be used if minimal disruption to the medial crural ligaments is desired. In addition, if the columella, tip position or nasolabial angle are not in appropriate position, it is advantageous for the surgeon to divide the attachments between the medial crura and septum to more easily reset projection by repositioning the medial crura with respect to the septum. Likewise, desired changes to the posterior septal angle that can enhance the nasolabial angle are most easily performed through this anterior approach.

If the columella, tip position, and nasolabial angle are in appropriate position and the patient needs spreader graft placement, the septum can be addressed by separating the upper lateral cartilages from the dorsal septum and inserting grafting material. This approach can also be utilized in component dorsal hump reduction, where separation of the upper lateral cartilages is performed prior to diminishing cartilaginous height of the nasal dorsum, and then reattached after removal of the hump. (7)

Deviations of the caudal and dorsal septum represent a challenge to rhinoplasty surgeons. Straight deviations of the caudal septum can be addressed by swinging door maneuvers and fixation to the nasal spine with a long lasting resorbable suture (4-0 or 5-0 PDS). Scoring maneuvers and suture techniques can assist in straightening a moderately deviated septum. If the septum is markedly twisted, excision of the deviated portion and reconstruction of the L-strut can be performed. Deviations of the dorsal septum can be addressed by a combination of spreader graft placement, scoring, incisions and camouflage onlay grafting.

Stabilizing the nasal base

Just as a skyscraper needs a solid foundation upon which to place its steel girders and glass, a nose needs a stable nasal base upon which the cartilaginous structures and soft tissue envelope can lie. The nasal base essentially refers to the columella and the nasal septum, and their relationships to the entire nose. Looking at the base view of the nose, the relationship of the columella to the nasal tip approximates 2 to 1 in the ideal Caucasian nose. Stabilizing the nasal base is a key concept in open rhinoplasty that allows the surgeon the ability to set the tip position and nasolabial angle and withstand the long term healing forces of contraction

The concept of projection can be bifurcated between nasal base projection versus nasal lobule projection. Surgeons should distinguish the two events as independent but related phenomena. If the columella distance is short, likely the base projection is deficient. If the lobule distance is short, likely the lobule position is deficient. Projecting by the nasal base allows surgeons to improve the columella to lobule relationship and minimizes the use of tip graft placement. In addition, less tension is placed on the columellar scar when projecting from the nasal base. (8)

Projection, when assessed on base view, is the sum of the lengths of the columella, infratip lobule and lobule. These three components are separate, but interrelated. Classically, the ratio of [columella: infratip lobule/lobule length] is [2:1]. When the columella is short, medial crural length is increased by recruiting cartilage from the region of the medial crural feet into the columella. When the infratip lobule length is short, intermediate crural length is increased by recruiting cartilage from the medial or lateral crura. Alternatively, a tip graft can increase the length of the lobule.

The nasal base can be stabilized, either with or without medial crural lengthening, by a variety of methods. Each technique has unique advantages and disadvantages and should be tailored to the specific needs of each patient. The tongue-in-groove technique, popularized by Kridel, utilizes suture imbrication of the medial crura to the caudal septum. (9) In this technique, the medial crura are dissected from the anterior portion of the septum, and then re-secured in a more desirable position with a suture. (See figure 2) The suture placed can be absorbable or non-absorbable depending on the intended goal of the surgeon.

The tongue-in-groove technique can be used in the long nose or short nose patient. In the long nose patient, shortening of the nose by retrodisplacment of the medial crura is achieved. In the short nose patient, length can be achieved by recruiting medial crural cartilage anteriorly into the columella and infratip lobule. The septum must be midline when utilizing this technique, since any deviation will translate to a crooked columella and tip. The surgeon should recognize accompanying changes associated with this technique including lengthening of the upper lip and changes at the nasolabial angle. In patients with excessive length of the caudal septum, the area responsible for excessive length can be trimmed. (10)

The columellar strut is a cartilaginous graft placed between the medial crura. It can provide support alone to the nasal tip, or can assist in projection of the nasal tip after medial crural cartilage has been recruited into the columella. (See figure 3) To prevent postoperative clicking of the columellar strut, the strut should not extend to the nasal spine. (11) The columellar strut is useful in cases which require maintenance or small increases in projection.

In patients with severe septal deficiencies, an extended columellar strut can be fashioned. An extended columellar strut is a strut which is secured to the anterior nasal spine/premaxilla region. An extended columella strut is preferably fashioned out of costal cartilage due to the amount of length and structure needed in these cases. (13) Two point stability is needed for precise control of rotation and projection when using an extended columellar strut. Inferiorly, a nonabsorbable suture can be placed through the periosteum of the nasal spine through the extended columellar strut. If the periosteum surrounding the nasal spine is absent, drill holes can be placed through the nasal spine with subsequent suture placement. Superiorly, the extended columellar strut can be stabilized in a variety of methods. A notch can be created in the superior portion of the strut which can integrate with a costal cartilage dorsal graft. Alternatively, a notch can be created along the length of the strut so that it can integrate with the septum. (See Figure 4) Lastly, the strut can also be secured with extended spreader graft placement.

Caudal extension graft placement allows the surgeon versatility in addressing a variety of complex projection issues. (12) Caudal extension grafts are cartilaginous grafts which extend the length of the septum. These grafts can be placed superiorly or inferiorly.. The grafts are suture imbricated to the septum with a permanent suture to provide maximal long term stability. (See Figure 5)

Caudal extension grafts are useful in many applications. In the short nosed patient, the caudal extension graft can help lengthen the nose if placed superiorly. The alar cartilages are then sutured onto the graft, causing a lengthening of the distance between the radix and domes. In the patient with a deficient premaxilla or columella, the caudal graft can be placed with additional projection inferiorly, filling the relative tissue void. In patients with mild caudal septal deviations who require projection, the caudal extension graft can be positioned on the side away from the deviation to allow the septum to appear straight.

Addressing the nasal tip

Once the nasal base has been set, a variety of maneuvers can be employed to address nasal lobule definition. The aesthetics of the nasal tip vary from patient to patient. Most patients seek natural curves and shapes to provide a nasal tip that fits the rest of the nose and facial features.

Achieving a desirable lobule shape can be performed by various maneuvers. Cephalic trims allow the surgeons to sculpt the lower lateral cartilages and place visual emphasis on the nasal tip. (See Figure 6) In addition, cephalic trims in combination with dome binding sutures may allow the surgeon to transform a convex lower lateral cartilage to a more aesthetically pleasing flatter lower lateral cartilage. A variety of opinions exist regarding the optimal amount of lower lateral cartilage to be left behind, but inherently stronger lower lateral cartilages may allow for more aggressive cartilage sculpting while softer cartilages may not allow the surgeon to excise any cartilage. In general, conservative reshaping and reorienting of the cartilages with suture stabilization are preferred over aggressive excision.

Nasal tip narrowing can be achieved by various suture techniques. Intradomal suturing changes the domal angle of divergence, creating a narrower appearing dome. Individual domal suturing allows for increased lobule projection and domal highlights. Kridel described the lateral crural steal, where the domes of the lower lateral cartilage are undermined from the vestibular skin and lateral crus cartilage is recruited into the domal region, adding to tip projection and rotation. (14) Tebbets described the placement of a variety of suturing techniques to flatten and improve the shape and configuration of the lower lateral cartilages. (15)

Convex lower lateral cartilages may contribute to a full nasal lobule appearance. Conservative cephalic trims and suture placement may help flatten the appearance of the lower lateral cartilages. In cases resistant to standard techniques, a lateral crural strut graft can be placed to flatten the lower lateral cartilages. (16) (See Figure 7) These grafts are placed as underlays between the lateral crura and the vestibular mucosa. Lateral crural struts can also be useful in repositioning lower lateral cartilages. (16) Septal cartilage is the ideal material for lateral crural struts given its contour and strength.

Cephallically positioned cartilages represent a difficult surgical problem. Weakness of the soft tissue of the ala may predispose these patients to postoperative alar collapse and retraction. Structural grafting in areas of weakness with either alar batten or rim grafts is typically required to improve nasal tip highlighting. (See Figure 8,9) More difficult techniques, like repositioning of the lower lateral cartilages into more favorable positions or excision and replacement of the lower lateral cartilages, are occasionally required. (14)

Underprojected or poorly defined nasal tip lobules may require structural grafting. There are variety of tip grafts available for the surgeon to utilize. Crushed cartilage can be used for a small amount of augmentation. Shield grafts provide a major structural force and can serve to project and occasionally lengthen a nose. (See Figure 10) Shield grafts projecting significantly above the domes will require a buttress graft to prevent the shield from folding backwards and lateral crural grafts to camouflage any visible borders. Alar rim grafts may be necessary to assist in masking the graft as well. Basic tenents of tip grafting in the lobule include avoidance of sharp, palpable edges and camouflage with crushed cartilage or perichondrium in thin skin patients. They also require strong columellar and alar structural support to prevent displacement with scar contracture.

The open approach provides excellent exposure for cartilage splitting techniques. Cartilage splitting techniques are based on Anderson’s tripod theory that compares both lower lateral crura and the conjoined medial crus to the three legs of a tripod. Abnormal length in one of the legs may require division and overlap to balance the tripod. All three legs may be shortened to produce symmetric tip deprojection. Adamson has created the M-Arch Model, a more sophisticated and holistic model based upon the tripod theory to further our understanding of tip dynamics and techniques. (16) Lateral crural overlay is useful in patients with overprojected and caudally rotated tips, while medial crural overlay is helpful in patients with overprojection from overly long medial crura. Medial crural overlay is also helpful in patients with hanging infratip lobules. These cartilage splitting techniques, collectively called “vertical lobule divisions”, are much different that Goldman-like techniques. In the Goldman dome division, the cartilages typically are divided at or lateral to the domes, and then to increase projection and tip definition, the medial cartilages secured to one another. No repair is made to recreate an intact strip of cartilage. In vertical lobule division, after the cartilages are divided, they are overlapped and then re-sutured, recreating an intact strip of lower lateral cartilage. Additionally, a columellar strut or other medial stabilizing graft is used to insure greater lobule stability than before the division. Finally, the Goldman techniques are all used to increase projection, while vertical lobule division always decreases projection. (17,18)

Middle vault

The middle vault represents an important transition point for both aesthetic and functional reasons. Functionally, the middle vault is the location of the internal nasal valve, the narrowest portion of the airway. Aesthetically, the middle vault provides the transition from the bony structures to the nasal tip. It is often in this area that specific residual problems may arise: persistent deviations, unnatural pinching, and slight elevations at the bony-cartilaginous junction. Sheen originally described the long nose syndrome, in which the upper lateral cartilages are long in comparison to the nasal bones. (19) Patients with the long nose syndrome are more likely to have middle vault collapse over time after dorsal hump removal.

Reconstruction of the middle vault is often to preserve width and function. Rarely, excision of the middle vault is performed for aesthetic purposes to provide a narrower appearance. Prophylactic prevention of collapse is performed in those patients with large hump removals and long middle vaults with placement of spreader grafts. (20)

In those patients with smaller humps and shorter middle vaults, component reduction of the dorsal hump may result in excellent aesthetic and functional results. Rohrich describes separating the upper lateral cartilages from the dorsal septum prior to hump removal and then reconstructing the middle vault by incorporating the full width of the upper lateral cartilages. (7) Pastorek describes utilizing “mucosal spreaders” by removing small incremental portions of the hump and preservation of the entire span of the upper lateral cartilages. (21)

The deviated middle vault requires a combination of techniques to provide straightening of this difficult problem. In some patients, scoring of the cartilage combined with asymmetric spreader grafts will provide adequate straightening of the middle vault.

Upper Vault and Dorsum

Providing an aesthetically pleasing lateral view requires a smooth transition from the dorsal to middle component of the nose. Removing the cartilaginous and bony hump as a unified piece will assist in the transition.

After most hump reductions, medial and/or lateal osteotomies of the nasal bones and ascending processes of the maxillas are typically required. The osteotomies allow for a narrower appearance to the dorsum and will close the open roof that hump reduction creates. Webster first described the “high-low-high” path of a properly executed lateral osteotomy. The lateral osteotomy begins high, above the lateral insertion of the inferior turbinate. It then courses low, towards the face of the maxilla, and then high again, up towards and even past the medial canthus. This osteotomy line prevents over-narrowing of the pyriform aperture and protects the lateral ligaments between the lateral crus and pyriform aperture, preserving lateral crural and external nasal valve strength. Medial osteotomies are performed so that they begin medially and fade laterally. By avoiding a straight cephalad medial osteotomy, a rocker deformity is avoided by not involving the thicker bone of the root of the nose in the osteotomy.

The dorsum can be augmented with a variety of techniques. Small amounts of elevation can be created with septal onlay grafts or crushed cartilage. Larger amounts of dorsal augmentation can be achieved with multiple layered cartilage grafts or diced cartilage grafts wrapped in fascia or Surgicel (“Turkish delight” grafts). (22)(Figure 13) Even more dramatic augmentation can be achieved with alloplastic material, costal cartilage, or split calvarial bone grafts. Alternatively, substantial dorsal augmentation can be achieved with stacked 1mm sheets of expanded tetraflouroethylene (ePTFE) (W.L Gore & Assoc., Elkton, MD)

Alar Base Reductions

In patients with overly wide or flaring nostrils, alar base excisions may be required. The nostril shapes and widths are carefully assessed at the end of the rhinoplasty. Tip deprojection may have created new alar flaring, while tip projection may have improved pre-existing flare. The alar base is best reduced by creating a medial advancement rotation flap of the ala. A portion of the sill of the nostril can be excised, and then an incision carried laterally just above the alar-facial groove. The ala can then be rotated into the defect left on the sill. If flare is present, and additional excision of the caudal cut edge can be performed prior to closure. (23)

Finishing the Case

The columellar incision is closed with interrupted 6-0 permanent monofilament sutures. If the columellar closure is under tension, a single 5-0 PDS suture can be placed in the midline to relieve the tension prior to skin closure. 5-0 absorbable sutures are placed along the marginal incisions. The nose it taped, and then a cast applied over the tape. Packing may be loosely placed inside each nostril until the patient is fully awake, and then is typically removed before the patient is discharged. Intranasal splints may be necessary along the septum if any tears of the mucoperichondrium occurred during septoplasty or additional stability is desired for the caudal septum.

Postoperative Care

Postoperative systemic antibiotics are not typically prescribed, unless an alloplastic implant has been placed. Patients are typically seen the day after surgery to insure that a postoperative nasal hematoma is not present and to review with the patient postoperative instructions. Typically, patients are told to apply an antibiotic ointment to the suture lines three times daily, and to use saline nasal spray frequently. Patients are seen then on day four or five to remove the columellar and alar sutures, if present. Steri-strips help to support the skin edges for an additional few days. The nasal cast is removed on day seven or eight, and any septal splint is also removed at that time. All patients are advised to perform “nasal exercises”. They are instructed to apply one minute of firm, steady pressure along the osteotomy sites at the nasal-facial grooves hourly while awake. This helps to insure that the bones do not drift laterally during the healing process, as sometimes they will do. Patients are advised not to fly for two weeks after surgery, and not to engage in contact sports for six weeks. They are cautioned to apply sun protection diligently to avoid hyperpigmentation and burns of the dorsal nasal skin. They are cautioned that it will take one full year for the nose to fully heal. Any revision, should it be required, should not be performed for at least that length of time.

Conclusions

Rhinoplasty is among the most satisfying yet challenging surgeries that can be performed on the face. The surgery is a life long learning experience for even the most skilled surgeon. Meticulous surgical technique is paramount to achieving optimal results. Open rhinoplasty offers uncompromising exposure and the opportunity to stabilize all parts of the nose, reducing unpredictability while enhancing outcome.

References

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11. Toriumi DM, Becker DG: Rhinoplasty Dissection Manual. Philadelphia, Lippincott, 1999.

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13. Toriumi DM: Structure approach in rhinoplasty. Facial Plastic Clinics of North America 8:515-537, 2000.

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18. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme–a study in 200 consecutive primary and secondary rhinoplasty patients. Plast Reconstr Surg. 2005 Jul;116(1):268-81.

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20. Kridel RW, Konior RJ. Controlled nasal tip rotation via the lateral crural overlay technique.

21. Shah AR, Constantinides M. Nuances in tip modification: specific applications of cartilage splitting in rhinoplasty. Facial Plast Surg. 2006 Feb;22(1):36-41.

22. Sheen JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984 Feb;73(2):230-9.

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24. Pastorek NJ. Personal communication. March 2005.

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26. Bennet, G.H., Lessow, A., Song, P., Constantinides, M., The Long-term Effects of Alar Base Reduction, Archives of Facial Plastic Surgery, 7(2): 94-7, 2005.

Table 1

Indications

Asymmetric alar cartilages
Tip graft suturing
Augmentation rhinoplasty
Excision of nasal tumors
Severe tip over projection/under projection
Difficult revision rhinoplasty
Infantile nostrils
Difficult nasal tip modification
Internal nasal valve dysfunction
Thick nasal skin
Repair of septal perforations
Posttraumatic nasal deformity with a deviated dorsal or caudal septum
Cleft lip and palate nasal deformity
Educational tool

Figure 1. Incision planning in open rhinoplasty requires the surgeon to identify the anatomy of the underlying cartilage. Improved scar closure is expected with the stability of underlying medial crus. The narrowest portion of the columella (Red) typically corresponds to an appropriate location to place an incision due to the anatomy of the underlying cartilage. If the incision is placed too far inferiorly (Blue), the scar may contract and create an unfavorable appearance.

Figure 2. The tongue-in-groove technique allows the surgeon the ability to secure the medial crura to the septum.

Figure 3. The columellar strut strengthens the support between the medial crura.

Figure 4. The extended columellar strut is useful in situations where large amounts of support are required and there is caudal septal deficiency.

Figure 5. The caudal extension graft allows the rhinoplasty surgeon a versatile means of adjusting tip rotation and projection.

Figure 6. Cephalic trims represent a method of creating increased tip definition by resecting precise amount of lower lateral cartilage.

Figure 7. Lateral crural strut grafts are placed underneath the lower lateral cartilage in order to flatten and sometimes reposition the lower lateral cartilage.

Figure 8. Alar rim grafts provide support to the rim of the ala and improve triangularity of the nasal base.

Figure 9. Alar batten grafts are supportive grafts to the external nasal valve. In patients with cephalically positioned cartilages, they may provide needed support to areas prone to collapse.

Figure 10. A variety of tip grafts can be incorporated depending on each patient’s individual aesthetic needs. Strict adherence to smooth, rounded corners and adequate soft tissue coverage will help provide camouflage to the tip graft.

“The nose should fit the face”
A strong jawline would suggest a stronger nose.