Basic Closed Rhinoplasty
- Author: A John Vartanian, MD, MS, FACS; Chief Editor: Mark S Granick, MD, FACS more...
Rhinoplasty describes an array of operative techniques that can be used to alter the aesthetic and functional properties of the nose. 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. 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 Bibliography.
History of the Procedure
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. In approximately 800 BCE, Sushruta, of India, described a nasal reconstruction approach based on the transfer of a pedicled forehead skin flap. 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.
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. In 1892, Robert F. Weir, another American surgeon, also published his techniques for correcting the saddled nose.
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
Berger CA, Freitas Rda S, Malafaia O, et al. Prospective study of the surgical techniques used in primary rhinoplasty on the Caucasian nose and comparison of the preoperative and postoperative anthropometric nose measurements. Int Arch Otorhinolaryngol. 2015 Jan. 19 (1):34-41. [Medline]. [Full Text].
Tebbetts JB. Open and closed rhinoplasty (minus the "versus"): analyzing processes. Aesthet Surg J. 2006 Jul-Aug. 26(4):456-9. [Medline].
Goldwyn RM. Is there plastic surgery in the Edwin Smith Papyrus?. Plast Reconstr Surg. 1982 Aug. 70(2):263-4. [Medline].
Sushruta. Sushruta Samhita (English translation by K.L. Bhishagratna). 1998. Calcutta, India: Kaviraj Kunjalal Publishing; 1907-17.
Dieffenbach JF. Die Operative Chirurgie. Liepzig, Germany: F.A. Brockhaus; 1845.
Roe JO. The deformity termed "pug-nose" and its correction, by a simple operation. New York: The Medical Record; 1887. 31: 621.
Weir RF. On restoring sunken noses without scarring the face. New York: The Medical Record; 1892.
Tardy ME Jr, Becker D, Weinberger M. Illusions in rhinoplasty. Facial Plast Surg. 1995 Jul. 11(3):117-37. [Medline].
Kasperbauer JL, Kern EB. Nasal valve physiology. Implications in nasal surgery. Otolaryngol Clin North Am. 1987 Nov. 20(4):699-719. [Medline].
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. [Medline].
Samaha M, Rassouli A. Spreader graft placement in endonasal rhinoplasty: technique and a review of 100 cases. Plast Surg (Oakv). 2015 Winter. 23 (4):252-4. [Medline].
Harel M, Margulis A. Dorsal augmentation with diced cartilage enclosed with temporal fascia in secondary endonasal rhinoplasty. Aesthet Surg J. 2013 Aug 1. 33(6):809-16. [Medline].
Bagheri SC, Khan HA, Jahangirnia A, Rad SS, Mortazavi H. An analysis of 101 primary cosmetic rhinoplasties. J Oral Maxillofac Surg. 2012 Apr. 70(4):902-9. [Medline].
Kim DW, Rodriguez-Bruno K. Functional rhinoplasty. Facial Plast Surg Clin North Am. 2009 Feb. 17(1):115-31, vii. [Medline].
Paun SH, Nolst Trenite GJ. Revision rhinoplasty: an overview of deformities and techniques. Facial Plast Surg. 2008 Aug. 24(3):271-87. [Medline].
Saltman BE, Pearlman SJ. Incidence of alarplasty in primary and revision rhinoplasty in a private practice setting. Arch Facial Plast Surg. 2009 Mar-Apr. 11(2):114-8. [Medline].