Open and Closed Rhinoplasty

Most surgeons recognize the broad utility of both endonasal and external rhinoplasty approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. In this article, the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.

Key points

  • Most surgeons now recognize the broad utility of both endonasal and external rhinoplasty approaches. In this chapter the pros and cons are discussed and further thoughts on the decision-making process are provided.

  • Based on an analysis of the individual patient’s anatomy, appropriate incisions, approaches and tip-sculpting techniques may be selected.

  • Much can be gained from considering the experiences of surgeons who have had the opportunity to see the consequences over time. The important philosophic concept is not open or closed, but instead, the emphasis on anatomical diagnosis and preservation of structural support.

  • There is no ideal approach. Each surgeon will develop a unique approach based on the concepts outlined and based on the techniques and experiences he or she has developed in the course of an eclectic training.

Introduction

In the modern era of rhinoplasty, the introduction of external rhinoplasty was greeted by enthusiastic advocates and also met with spirited opposition. Over time, however, the tenor of this debate has become more ecumenical. Most surgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. Most also agree that there is a large “gray area,” where either the endonasal or the external approach would be appropriate, and the choice may be considered a toss-up. Most surgeons readily acknowledge that surgeon comfort with a procedure is an appropriately important factor.

In this article the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.

Introduction

In the modern era of rhinoplasty, the introduction of external rhinoplasty was greeted by enthusiastic advocates and also met with spirited opposition. Over time, however, the tenor of this debate has become more ecumenical. Most surgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. Most also agree that there is a large “gray area,” where either the endonasal or the external approach would be appropriate, and the choice may be considered a toss-up. Most surgeons readily acknowledge that surgeon comfort with a procedure is an appropriately important factor.

In this article the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.

Anatomy, incisions, and approaches

Nasal Anatomy

Although the anatomy of the nose has been fundamentally understood for many years, only relatively recently has there been an increased understanding of the long-term effects of surgical changes on the function and appearance of the nose. A detailed understanding of nasal anatomy is critical for successful rhinoplasty. Accurate assessment of the anatomic variations presented by a patient allows the surgeon to develop a rational and realistic surgical plan. Furthermore, recognizing variant or aberrant anatomy is critical to preventing functional compromise or untoward esthetic results. This section presents a limited diagrammatic overview of nasal anatomy ( Figs. 1–4 ). More detailed study of nasal and facial anatomy is recommended.

Fig. 1
Surface anatomy. ( A ) Frontal. 1. Glabella; 2. Nasion; 3. Tip-defining points; 4. Alar-sidewall; 5. Supra-alar crease; 6. Philtrum. ( B ) Base. 1. Infratip lobule; 2. Columella; 3. Alar sidewall; 4. Facet, or soft tissue triangle; 5. Nostril sill; 6. Columella-labial angle or junction; 7. Alar-facial groove or junction; 8. Tip defining points. ( C ) Lateral. 1. Glabella; 2. Nasion, nasofrontal angle; 3. Rhinion (osseocartilaginous junction); 4. Supratip; 5. Tip-defining points; 6. Infratip lobule; 7. Columella; 8. Columella-labial angle or junction; 9. Alar-facial groove or junction. ( D ) Oblique. 1. Glabella; 2. Nasion, nasofrontal angle; 3. Rhinion; 4. Alar sidewall; 5. Alar-facial groove or junction; 6. Supratip; 7. Tip-defining point; 8. Philtrum.

Fig. 2
Bony-cartilaginous anatomy. ( A ) Oblique. 1. Nasal bone; 2. Nasion (nasofrontal suture line); 3. Internasal suture line; 4. Nasomaxillary suture line; 5. Ascending process of maxilla; 6. Rhinion (osseocartilaginous junction); 7. Upper lateral cartilage; 8. Caudal edge of upper lateral cartilage; 9. Anterior septal angle; 10. Lower lateral cartilage–lateral crus; 11. Medial crural footplate; 12. Intermediate crus; 13. Sesamoid cartilage; 14. Pyriform aperture. ( B ) Lateral. 1. Nasal bone; 2. Nasion (nasofrontal suture line); 3. Internasal suture line; 4. Nasomaxillary suture line; 5. Ascending process of maxilla; 6. Rhinion (osseocartilaginous junction); 7. Upper lateral cartilage; 8. Caudal edge of upper lateral cartilage; 9. Anterior septal angle; 10. Lower lateral cartilage lateral crus; 11. Medial crural footplate; 12. Intermediate crus; 13. Sesamoid cartilage; 14. Pyriform aperture. ( C ) Base. 1. Tip-defining point; 2. Intermediate crus; 3. Medial crus; 4. Medial crural footplate; 5. Caudal septum; 6. Lateral crus; 7. Naris; 8. Nostril floor; 9. Nostril sill; 10. Alar lobule; 11. Alar-facial groove or junction; 12. Nasal spine.

Fig. 3
Septum. 1. Quadrangular cartilage; 2. Nasal spine; 3. Posterior septal angle; 4. Middle septal angle; 5. Anterior septal angle; 6. Vomer; 7. Perpendicular plate of ethmoid bone; 8. Maxillary crest maxillary component; 9. Maxillary crest–palatine component.

Fig. 4
Nasal musculature and blood vessels. The surgeon must fully recognize the importance of this plane and must carefully avoid operating in the incorrect tissue planes, which can result in violation of the muscle and blood vessels and subsequent abnormal scarring. ( A ) Musculature. A: Elevator muscles. 1. Procerus; 2. Levator labii alaequae nasi; 3. Anomalous nasi. B: Depressor muscles. 4. Alar nasalis; 5. Depressor septi nasi. C: Compressor muscles. 6. Transverse nasalis; 7. Compressor narium minor. D: Minor dilator muscles. 8. Dilator naris anterior. E: Other. 9. Orbicularis oris; 10. Corrugator. ( B ): Vasculature. 1. Dorsal nasal artery; 2. Lateral nasal artery; 3. Angular vessels; 4. Columellar artery.

Incisions and approaches

Incisions are methods of gaining access to the bony and cartilaginous structures of the nose and include transcartilaginous, intercartilaginous, marginal, and transcolumellar incisions. Approaches provide surgical exposure of the nasal structures such as the nasal tip and dorsum. The main rhinoplasty approaches include cartilage-splitting (transcartilaginous incision), retrograde (intercartilaginous incision with retrograde dissection), delivery approach (intercartilaginous + marginal incisions), and external (transcolumellar and marginal incisions) ( Box 1 ). Based on an analysis of the individual patient’s anatomy, appropriate incisions, approaches, and tip-sculpturing techniques may be selected ( Fig. 5 ).

Box 1

  • Major tip support mechanisms

  • 1.

    Size, shape, and strength of lower lateral cartilages

  • 2.

    Medial crural footplate attachment to caudal septum

  • 3.

    Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages

    (Nasal septum is also considered a major support mechanism of the nose.)

  • Minor tip support mechanisms

  • 1.

    Ligamentous sling spanning the domes of the lower lateral cartilages (ie interdomal ligament)

  • 2.

    Cartilaginous dorsal septum

  • 3.

    Sesamoid complex of lower lateral cartilages

  • 4.

    Attachment of lower lateral cartilages to overlying skin-soft tissue envelope

  • 5.

    Nasal spine

  • 6.

    Membranous septum

  • Incisions: methods of gaining access

  • Intercartilaginous

  • Transcartilaginous

  • Marginal (NOT to be confused with rim incision)

  • Transcolumellar

  • Approaches: provide surgical exposure

  • Cartilage-splitting

  • Retrograde

  • Delivery: Marginal + intercartilaginous incision

  • External approach: marginal + trans-columellar incision

  • Sculpting techniques: surgical modifications

  • Complete strip: that is, cephalic resection, or volume reduction of lateral crura

  • Incomplete strip (dome division)

  • Transdomal/domal sutures

  • Augmentation grafting

  • Tip graft

  • Other

Tip support mechanisms, incisions, and approaches

Fig. 5
Incisions and endonasal approaches. ( A ) Transcartilaginous incision and approach. ( B ) Intercartilaginous incision and approach. ( C , D ) Marginal incision. ( E G ) Delivery approach combines marginal and intercartilaginous incisions. ( H ) The open rhinoplasty approach combines marginal and columellar incisions. ( I ) Before and after external rhinoplasty. Tension-free closure improves final scar appearance.
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Nov 21, 2017 | Posted by in Dental Materials | Comments Off on Open and Closed Rhinoplasty
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