Basic Closed Rhinoplasty

Rhinoplasty describes an array of operative techniques that can be used to alter the aesthetic and functional properties of the nose. ^[1] Surgical access to the nose can be gained via incisions placed inside the nose (endonasal approaches) or via incisions placed inside the nose combined with incisions placed outside the nostrils (external approach), usually on the columella. Prior to the increased popularity of the external (open) rhinoplasty approach in the last decade, the terms rhinoplasty and endonasal rhinoplasty were almost synonymous. This somewhat artificial division between external (open) and endonasal (closed) rhinoplasty has become an established part of current rhinoplasty nomenclature. Despite this, both approaches share many of the same incisions, and many of the same principles apply regardless of the approach chosen.

Proponents of endonasal rhinoplasty emphasize the following advantages:

• Decreased need for surgical dissection

• Decreased potential for nasal tip support reduction

• Reduced postoperative edema

• Corresponding decrease in the potential for overall scarring or iatrogenic insult to the nose

• Ability to make exacting changes in situ

• Via tactile palpation, a more immediate and predictable ability to feel changes made to the nose

• Ability to make targeted improvements without taking the nose apart

• Shorter operative times

• Theoretical reduction in morbidity, especially in older patients

• Elimination of any risk (however minimal) for developing a visible external columellar scar

• Reduced postoperative edema

• Quicker return to a normal appearance

The experienced rhinoplasty surgeon can use either an endonasal or an external rhinoplasty approach, based on the patient's rhinoplasty indications. ^[2] This article is a basic review of endonasal rhinoplasty techniques and concepts. The reader is encouraged to read the many high-yield articles and books listed in the references.

The history of nasal surgery is indeed long. The Edwin Smith surgical papyrus from ancient Egypt outlines the diagnosis and treatment of nasal deformities some 30 centuries ago. ^[3] In approximately 800 BCE, Sushruta, of India, described a nasal reconstruction approach based on the transfer of a pedicled forehead skin flap. ^[4] In the 16th century, Tagliacozzi of Bologna, Italy, used brachial-based delayed flaps to reconstruct noses. The science and art of rhinoplasty remained essentially stagnant until the 19th century. Approaches to correcting nasal deformities were used by early plastic surgery pioneers such as Dieffenbach in the 1840s, who used a buried forehead flap to cover the nasal dorsum. ^[5]

The first published account of a modern endonasal rhinoplasty can be traced to an American otolaryngologist, John Orlando Roe. His original article published 1887 was titled "The deformity termed 'pug-nose' and its correction, by a simple operation" and described the treatment of saddle nose deformities. ^[6] In 1892, Robert F. Weir, another American surgeon, also published his techniques for correcting the saddled nose. ^[7]

In 1898, Jacques Joseph, an orthopedic surgeon by training, presented his revolutionary concepts of nasal surgery to the Medical Society of Berlin. Many aspiring rhinoplasty surgeons traveled to Germany to watch Joseph perform his rhinoplasties. His general reputation as the father of modern rhinoplasty can be supported by his influence in shaping many rhinoplasty concepts and techniques. In fact, many of the basic rhinoplasty maneuvers remain essentially the same today as when Joseph first described them. Joseph's concepts and techniques were further disseminated (especially in the United States) by surgeons such as Gustav Aufricht, Joseph Safian, and Samuel Fomon. Fomon's teachings and medical review courses on endonasal rhinoplasty helped in the education of countless early modern rhinoplasty surgeons, such as Maurice Cottle of Chicago and Irving Goldman of New York.

In the relatively short history of modern rhinoplasty, many additional rhinoplasty masters have contributed to the advancement of the field. Countless surgeons continue to advance our understanding of the art and science of rhinoplasty through their scholarly and clinical works. The continued sharing and dissemination of rhinoplasty knowledge has hopefully benefited the patient and surgeon alike.

Most patients seek rhinoplasty surgery to improve the aesthetic features of the nose. Others may elect to have a rhinoplasty for functional improvement of the nasal airway. Most often, both cosmetic and functional issues are addressed during rhinoplasty.

Etiologies of nasal deformity can be (1) hereditary/familial (eg, large dorsal hump), (2) traumatic (eg, after a motor vehicle accident), (3) iatrogenic (eg, unfavorable result from previous rhinoplasty), or (4) congenital (eg, cleft palate nasal deformity).

Septal deviation, inferior turbinate hypertrophy, deviated nasal bones, and narrow internal nasal valve area can all negatively impact the nasal airway. These issues must be addressed during rhinoplasty surgery.

Indications include (1) aesthetic deformity, (2) patient request for a change in nasal shape, and (3) improvement of anatomic nasal airway obstruction.

A great majority of rhinoplasties performed are purely elective in nature. As such, the surgeon must exercise judgment in selecting patients who want to have this type of surgery. This judgment is guided by surgical principles, the patient's psychologic state, and the ethical consideration of minimizing any iatrogenic harm to otherwise healthy patients. A brief list of common contraindications includes the following:

• Unstable mental status (eg, unstable patient with schizophrenia)

• Unrealistic patient expectations

• Previous rhinoplasty within the last 9-12 months (applies only to major rhinoplasties)

• Poor perioperative risk profile

• History of too many previous rhinoplasties, resulting in an atrophic skin–soft tissue envelope and significant scarring

• Nasal cocaine users