You are in: eMedicine Specialties > Plastic Surgery > NOSE Rhinoplasty, Basic Open TechniqueArticle Last Updated: Dec 18, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 11
  Author: Jugpal S Arneja, MD, Assistant Professor, Section of Plastic Surgery, Wayne State University School of Medicine; Consulting Staff, Section of Plastic Surgery, Children's Hospital of Michigan, Detroit Medical Center Affiliated Hospitals Jugpal S Arneja is a member of the following medical societies: American Academy of Pediatrics, American Burn Association, American Cleft Palate/Craniofacial Association, American College of Surgeons, American Society of Maxillofacial Surgeons, American Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons, and Royal College of Physicians and Surgeons of Canada Coauthor(s): G Balbir Singh, FRCSC, Head, Section of Plastic Surgery, St Boniface Hospital; Associate Professor, Department of Surgery, University of Manitoba Editors: Fred Menick, MD, Clinical Associate Professor, Department of Surgery, Division of Plastic Surgery, University of Arizona; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; R Edward Newsome, MD, Associate Professor, Program Director and Chief, Department of Surgery, Section of Plastic Surgery, Tulane University Health Sciences Center; Nicolas (Nick) G Slenkovich, MD, Practice Director, Colorado Plastic Surgery Center at Swedish Medical Center; Al Aly, MD, FACS, Consulting Surgeon, Iowa City Plastic Surgery Author and Editor Disclosure Synonyms and related keywords: osteotomy, nasal repair, nose surgery, nose job, cosmetic surgery, aesthetic nasal surgery, esthetic nasal surgery, open structure rhinoplasty, open rhinoplasty, transcolumellar approach, nasal valve dysfunction, nasal obstruction, airway abnormalities, septal deformity, septal perforation, nasal augmentation, bifid nasal tip, nasal hump, stair-step deformity, saddle-nose deformity, polly beak deformity, open roof deformity, nose reconstruction, nasal reconstruction, nasal tip sculpting, nasal base surgery INTRODUCTIONSection 2 of 11
  Rhinoplasty alters the aesthetic appearance and functional properties of the nose with surgical manipulation of the skin, underlying cartilage, and bone. The incision type that the surgeon uses classifies the rhinoplasty as open or closed. In open rhinoplasty, the surgeon makes a small incision in the columella between the nostrils and then makes additional incisions inside the nose. Closed rhinoplasty involves incisions only in the interior of the nose. History of the ProcedureThe Ebers Papyrus from Egypt (dating from ~3500 BCE) included a discussion of nasal reconstruction secondary to rhinectomy for punishment. In 800 BCE, Sushruta performed nasal reconstruction with a pedicled forehead flap. In the 1600s, Tagliacozzi introduced delayed arm-based flaps for nasal reconstruction. In the 1750s, Quelmatz advocated daily digital pressure for septal deformities. In 1845, Diffenbach made external skin incisions to change the shape of the nose. In 1887, Roe performed the first cosmetic rhinoplasty secondary to a pug nose deformity. In the early 1900s, Killian and Freer pioneered submucous resection septoplasty. Peer and Metzenbaum performed the first manipulation of the caudal septum in 1929. In 1947, Cottle performed a hemitransfixion incision with conservation of the septum and became a strong advocate of the closed approach. In the 1990s, Sheen followed in their path and also advocated the closed approach. With respect specifically to open rhinoplasty, Rethi first introduced the columellar incision for open rhinoplasty for tip modification in 1921. 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." For the next fifteen years, open rhinoplasty fell out of favor until Padovan presented his series in the early 1970s, advocating open rhinoplasty. Also in the 1970s, Goodman further promoted the case for the open approach. In the 1990s, Gunter became a staunch supporter of the open approach. The debate continues today between the advantages and disadvantages of an open versus closed approach to rhinoplasty. ProblemRhinoplasty may be performed to correct a variety of problems, including (1) internal nasal pathology creating airway obstruction, (2) unsatisfactory aesthetic appearance, (3) abnormalities resulting from previous rhinoplasties, and (4) congenital nasal anomalies. EtiologyConditions that may necessitate rhinoplasty can be divided into congenital and acquired etiologies. Congenital etiologies include the following:
Acquired etiologies include the following:
ClinicalHistory A complete history must be obtained from the patient as part of the clinical evaluation. The patient must explain the functional and aesthetic problems with which he or she is concerned. Important questions include symptoms and duration, past interventions, allergies, substance use or abuse, medications, and a general medical symptom review. Male patients with the personality traits summarized as SIMON (single immature male overexpectant narcissistic) should be identified during the complete patient history. Physical A complete physical examination is also essential. A complete head-to-toe cursory examination is performed, and any problems are noted. Preoperative consultation with an anesthesiologist is arranged if warranted. A specific facial and nasal evaluation follows, with the facial analysis including skin type, surgical scars, symmetry, and balance of facial aesthetic units. An external examination is performed, and the structure, external nasal angles, and bony and soft tissue characteristics are noted. An internal examination follows, during which the nasal septum, internal and external nasal valves, and turbinates are evaluated. Additional attention is directed to the nasal tip and dorsum. Specific tests, when warranted, include the Cottle maneuver, the mirror test, and examinations with vasoconstriction with and without nasal breathing devices. Photography For the benefit of patients and physicians, the authors advocate photographic documentation during the preoperative consultation and both during and after the operation. Specifically, the authors photograph the nose in the anteroposterior, lateral, worm's eye, and three-quarter profile views. INDICATIONSSection 3 of 11
Indications for open rhinoplasty include the following:
Advantages of open rhinoplasty include (1) direct exposure, inspection, and assessment of the osseocartilaginous framework; (2) precise modification and stabilization of the abnormality (tip and dorsum modification, graft placement, osteotomies); and (3) excellent tool for training purposes. Disadvantages of open rhinoplasty include (1) transcolumellar scar and columellar flap necrosis, (2) extensive dissection of skin off the osseocartilaginous framework with increased scarring, (3) increased operative time (compared with closed rhinoplasty), and (4) postoperative nasal tip edema and numbness. CONTRAINDICATIONSSection 4 of 11
WORKUPSection 5 of 11
Lab Studies
Imaging Studies
TREATMENTSection 6 of 11
Surgical TherapyAnesthesia and preparation (See Images 1-3.) The authors prefer a combination of local anesthesia with intravenous sedation as opposed to general anesthesia (patients have a much faster postoperative recovery with the local anesthesia and intravenous sedation). Anesthesia is begun with local infiltration of 1% Xylocaine with 1:100,000 epinephrine to perform a total external and internal nasal block. This is augmented with endonasal 4% cocaine packings. Careful infiltration and packing placement for a minimum of 10 minutes provides the important vasoconstriction necessary to keep the operative field free of blood. Iodine is used for field preparation, and draping is performed in the standard fashion. Another important adjunct is adequate lighting (overhead lights and headlights). Incision and exposure (See Images 4-6.) A No. 15 blade is used to make a transverse, midcolumellar gullwing (authors' preference) or stair-step incision. A second infracartilaginous incision is made to the caudal margin of the medial crura, superiorly extending to the angle and dome, then laterally to the lateral crura. The midcolumellar incision is connected to the infracartilaginous incision. The columellar flap is elevated with blunt scissor dissection to the superior aspect of the medial crura. The nasal tip skin is then elevated off the alar cartilages with gentle retraction and scissor dissection. The essential aspect of this step is dissection just over the perichondrium of the alar cartilages. A superficial plane of dissection can result in columellar flap necrosis. The nasal dorsum is further exposed by dividing the intracrural ligament and elevating the flap off the osseocartilaginous pyramid in the subperiosteal plane. The exposure is completed by undermining along the piriform margins and to the upper lateral cartilages as needed. Septoplasty (See Images 7-8.) At the level of the superior septal angle, a submucoperichondrial flap is elevated on one or both sides. The lateral cartilages are then separated off the septum, and the septum is then directly observed. The caudal septum can be exposed bilaterally down to the maxillary spine and crest if needed. After adequate exposure, the septum can be corrected as necessary. The septum can be completely removed (with preservation of a dorsal L strut), removed and replaced, or augmented. Also, any grafts can be placed at this time (eg, spreader, onlay, dorsal). Nasal tip (See Images 9-12.) The tip may be modified most effectively with the open tip approach. Tip augmentation, elevation, support, projection, and/or modification can be performed depending on the deformity. The columella can be shortened or narrowed again, as desired. The nasolabial angle can be modified by deepening or augmenting the angle or the septum. Columellar strut grafts or onlay grafts can be placed, and suture refinement or cartilage scoring can be performed under direct observation to further shape the tip as needed. Alar cartilages The portions of the alar cartilages can be excised or augmented, depending on the modification desired. Symmetry between the domes can be achieved with suture or excision techniques (eg, for cleft lip nasal deformity). Grafts for alar collapse and nasal valve obstruction can also be placed. Osteotomies (See Image 13.) Lateral osteotomies to contour the nasal bones as desired can be performed in the same manner as with a closed rhinoplasty. A stab incision is made over the piriform fossa, the 2-mm guarded osteotome is placed, and the appropriate degree of osteotomy is performed in a low-to-high fashion to achieve a greenstick fracture of each individual nasal bone. In selected cases, medial osteotomies may also be performed to appropriately contour the rhinion. Nasal dorsum (See Images 14-21.) Dorsum modification is best visualized and precisely modified with an open approach. In noses with a prominent dorsum, debulking the excess cartilage with scissors is possible, with additional rasping as needed. In noses with inadequate projection of the nasofrontal angle, dorsal onlay grafts may be placed and secured. Conchal, rib, or calvarial grafts may be harvested as needed. Closure (See Images 22-24.) The final aspect of the procedure is careful skin redraping, external contouring, and shaping. The septal mucosal flaps are closed with interrupted 5-0 chromic gut sutures. Also, the infracartilaginous incision is closed with interrupted 5-0 chromic gut sutures. To avoid a step deformity of the columella, perform meticulous closure of the transcolumellar incision with 6-0 Prolene interrupted sutures. The nasal dorsum is splinted with cheek-to-cheek Steri-strips. Vaseline gauze packing is placed intranasally as an internal splint and for optimal comfort and ease of removal. They are removed in 48 hours at the first postoperative visit. Postoperative DetailsThe patient is sent to the recovery room and subsequently to the day surgery unit with the head elevated, ice packs in place, and analgesia ordered. The authors do not administer steroids postoperatively. Follow-upPatients are seen at 48 hours, 1 week, and 1 month postoperatively. Further follow-up visits are scheduled as needed thereafter. Communication between the patient, office staff, and surgeon is routine in order to address any concerns or problems that may arise. COMPLICATIONSSection 7 of 11
Early complications in open rhinoplasty include the following:
Late complications in open rhinoplasty include the following:
OUTCOME AND PROGNOSISSection 8 of 11
The authors are proponents of the open technique because it has the benefit of direct observation, greatly outweighing the commonly cited disadvantage of the transcolumellar incision and scar. The exposure is especially beneficial for work with the nasal tip, dorsum, and septum and provides the best possible teaching tool for the trainee. FUTURE AND CONTROVERSIESSection 9 of 11
Future debates will indeed continue regarding the open versus closed technique; however, the open technique seems to have secured a place in rhinoplasty for years to follow. MULTIMEDIASection 10 of 11
REFERENCESSection 11 of 11
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