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

See the list below:

• Obtain routine complete blood cell counts, a serum chemistry profiles, and coagulation profiles.

See the list below:

• No specific imaging studies are obtained unless indicated for assessment of related pathology (ie, CT scan for posttraumatic deformities).

• Obtain a routine chest radiograph and electrocardiogram for patients older than 50 years.

Anesthesia and preparation

The authors prefer a combination of local anesthesia with intravenous sedation as opposed to general anesthesia (faster postoperative recovery). 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 essential vasoconstriction and limits bleeding within the operative field. Iodine is used for field preparation, and draping is performed in the standard fashion.

Another requisite is adequate lighting (overhead lights and headlights).

Incision and exposure

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 tenotomy 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 at the level of the alar cartilage perichondrium. 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 supraperiosteal plane. The exposure is completed by undermining along the piriform margins and to the upper lateral cartilages as needed.

Septoplasty

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 tip or dorsum grafts can be placed at this time (eg, spreader, onlay).

Nasal tip

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.

A study by Bitik et al suggested that preservation or reconstruction of the nasal tip’s native anatomical support structures can preclude the need for columellar strut grafts in primary open rhinoplasty. The study, which involved 100 patients who underwent the procedure without the use of strut grafts, found that postoperatively, nasal tip projections and rotations achieved in these patients, as well as nasal profile proportions obtained, matched preoperative goals with statistically significant accuracy.[13]

A study by Bertossi et al suggested that the pull-up spreader high (PUSH) technique provides long-term stability with regard to aesthetic changes in open rhinoplasty, along with improvements in nasal airflow. The study involved 50 patients who underwent PUSH rhinoplasty, with aesthetic results, in terms of upward rotation and definition of severely depressed nasal tips, still considered pleasing at 3-year follow-up. Patients considered their nasal airflow to be improved 3 years postoperatively, although acoustic rhinomanometry indicated that in one patient, airflow has worsened from its preoperative state.[14]

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 excisional techniques (eg, for cleft lip nasal deformity). Grafts for alar collapse and internal nasal valve obstruction can also be placed.

Osteotomies

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

Dorsum modification is best visualized and precisely modified with an open approach. In noses with a prominent dorsum, debulking of the excess cartilage with direct excision or rasping is needed.

In noses with inadequate projection of the nasofrontal angle, dorsal onlay grafts may be placed and secured using conchal, rib, or calvarial grafts.

Closure

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, meticulous closure of the transcolumellar incision with 6-0 Prolene interrupted sutures is requisite.

The nasal dorsum is splinted with cheek-to-cheek Steri-strips. Alternatively, a thermoplast splint can be fabricated for additional external support in the perioperative period. Vaseline gauze packing is placed intranasally as an internal splint removed on the first postoperative day.

The 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.

A literature review by Kullar et al indicated that perioperative and postoperative antibiotics do not reduce the infection risk in patients who undergo noncomplex rhinoplasty or septorhinoplasty. According to the review, when patients do have an increased infection risk—ie, when comorbidities are present, revision surgery is performed, a prolonged operation is necessary, alloplastic implants are employed, or nasal packing is used—clinicians should consider treatment with a first-generation cephalosporin, such as cefazolin (or, in patients with a β-lactam allergy, a non–β-lactam antibiotic, such as clindamycin). The investigators also state that when used perioperatively, antibiotic therapy should begin within 1 hour of incision and end within 24 hours postsurgery, unless the patient requires a prolonged treatment course.[15]

Patients are seen at 1 day, 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.

Early complications in open rhinoplasty include the following:

• Hemorrhage

• Acute infection

• Ecchymosis

• Cerebrospinal fluid leak

Late complications in open rhinoplasty include the following:

• Chronic infection

• Septal perforation

• Overcorrection

• Undercorrection

• Nasal tip numbness and edema

• Hypertrophic columellar scar with or without keloid formation

• Contour irregularities

• Columellar flap necrosis

• Nasal obstruction

• Anosmia

• Patient dissatisfaction

A retrospective study by Irvine et al indicated that in patients undergoing open rhinoplasty, a significant correlation exists between risk of nasal skin compromise and advanced age, smoking (prior or current history), and a higher number of prior rhinoplasty procedures. The investigators state that in most patients with a compromised post-rhinoplasty nasal blood supply, the skin can be salvaged if the compromised state is promptly treated.[16]

A literature review by Crosara et al of primary complete rhinoplasties found no statistically significant difference between the reoperation rates for open rhinoplasty and closed rhinoplasty, with the former being 2.73% and the latter being 1.56%.[17]

A literature review by Gupta et al did not find either open or closed rhinoplasty to be preferable to the other, with patient satisfaction being similar for both techniques. The studies involved indicated that open rhinoplasty, via “an extended incisional approach and utilization of a cephalic dome septal rotation suture,” may produce better nasal tip projection and depression than the closed procedure. However, while patients in both the open and closed groups noted reduced nasal sensation postoperatively, only patients who underwent open rhinoplasty were found to have decreased columellar sensation. In addition, the closed group was apparently characterized by minimal scarring.[18]

The studies determined open and closed surgery to be comparable regarding postoperative function, although one report found function to be superior following the open technique.[18]

However, the authors are proponents of the open technique because the benefit of direct observation outweighs the commonly cited disadvantage of 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 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.[5, 4, 6, 7, 8]

American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNS)

In 2017, the AAO-HNS released the following clinical practice rhinoplasty guidelines[19] :

• Clinicians should query patients about their motivations for seeking rhinoplasty and their expectations regarding the surgery’s outcome; the clinician should also counsel patients as to whether their expectations are realistic and should make sure that there is a medical record of the discussion
• Patients seeking rhinoplasty should be evaluated for comorbidities that could result in the surgery being modified or contraindicated, including obstructive sleep apnea (OSA), body dysmorphic disorder (BDD), bleeding disorders, and chronic topical vasoconstrictive intranasal drug use
• Preoperative assessment should include evaluation of the patient for nasal airway obstruction, as conducted by the surgeon or his/her designee
• Patients should be advised by the surgeon or his/her designee about rhinoplasty’s potential impact on nasal breathing, possible surgical complications, and the chance that future nasal surgery will be required
• Patients with documented OSA should be advised by the clinician or his/her designee with regard to rhinoplasty’s effect on nasal airway obstruction and possible OSA-related considerations in perioperative management
• Patients should receive information from the surgeon or his/her designee about the management of postoperative discomfort
• Antibiotic therapy, when administered perioperatively by the surgeon or his/her designee, should not routinely last more than 24 hours postsurgery
• Perioperative systemic steroids may be administered, by the surgeon or his/her designee, to rhinoplasty patients
• The guidelines recommend against routine nasal packing at the conclusion of surgery, whether or not the rhinoplasty patient has undergone septoplasty