Basic Open Rhinoplasty

Rhinoplasty modifies the functional properties and aesthetic appearance of the nose through operative manipulation of the skin, underlying cartilage, bone, and lining. 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. ^[1] Closed rhinoplasty involves incisions only in the interior of the nose.

The 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 1500s, 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 advanced their early teachings 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. ^[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." For the next 15 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. ^[3] In the 1990s, Gunter became an advocate of the open approach. ^[4]

The debate continues today over the advantages and disadvantages of an open versus closed approach to rhinoplasty. ^{[5, 4, 6, 7, 8]}

Rhinoplasty may be performed to correct various problems, including (1) intrinsic and extrinsic nasal pathology, (2) unsatisfactory aesthetic appearance, (3) abnormalities resulting from previous rhinoplasties, (4) airway obstruction, and (5) congenital nasal anomalies.

Conditions that may necessitate rhinoplasty can be divided into congenital and acquired etiologies.

Congenital etiologies include the following:

• Cleft lip or palate nasal deformity

• Congenital nasal anomalies

• Ethnic or genetic characteristics

Acquired etiologies include the following:

• Traumatic deformities

  • Nasal fractures

  • Nasoorbitoethmoidal fractures

  • Septal hematomas

  • Bites

  • Burns

• Infections (eg, syphilis)

• Malignancies

• Allergic and vasomotor rhinitis

• Toxins (eg, cocaine)

• Inflammatory conditions

  • Connective-tissue diseases

  • Autoimmune diseases

History

A complete history must be obtained from the patient as part of the clinical evaluation. The patient must explain the functional and aesthetic problems for which they present. Important questions include symptoms and duration, past interventions, allergies, substance use or abuse, medications, and a complete general medical history. Patient motivation for rhinoplasty is a critical portion of the preoperative evaluation. Male patients with the personality traits summarized as SIMON (single, immature, male, overly expectant, narcissistic) should be identified during the 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 of the superior, middle and inferior thirds of the nose. Specifically, 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, turbinates, and lining are evaluated. Additional attention is directed to the structure and form of the nasal tip and dorsum. Specific tests, when warranted, include the Cottle maneuver, the mirror test, and examinations with vasoconstriction.

Photography

For the benefit of patients and physicians, the authors advocate photographic documentation during the preoperative consultation, during the procedure, and after the procedure is complete. Specifically, the authors photograph the nose in the anteroposterior, lateral, worm's eye, bird's eye, and three-quarter profile views.

Indications for open rhinoplasty include the following:

• Nasal tip modification

• Internal nasal valve dysfunction

• Thick nasal skin

• Repair of septal perforations

• Patient is a member of certain non-Caucasian ethnic groups

• Posttraumatic nasal deformity with a deviated septum or dorsum

• Major augmentation with tip, columellar, spreader, and/or shield grafts

• Cleft lip and palate nasal deformity

• Nasal tumor excision

• Educational tool for trainees

• Secondary rhinoplasty ^{[9, 10]}

• Thin skin where accurate sculpting is important

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. ^{[11, 12]}

Disadvantages of open rhinoplasty include (1) transcolumellar scar and potential for 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.

See the list below:

• Intranasal substance abuse (eg, cocaine)

• Psychological or psychiatric instability

• SIMON (single, immature, male, overly expectant, narcissistic) personality traits

• Comorbid medical conditions that preclude surgical clearance

• Preoperative diagnosis of nasal dysfunction (with or without aesthetic deformity) that may be better treated with a closed approach (ie, septoplasty for airway obstruction) or medical management

• Patient refusal of external scar

• Very thick nasal skin in which postoperative edema can be permanent