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Anatomy, Incisions and Approaches: Open and Closed RhinoplastyPosted by Daniel G. Becker on January 6th, 2011

Daniel G. Becker, MD FACSBecker Nose and Sinus Center, LLC400 Medical Center Drive, Suite BSewell and Princeton, New Jersey USA856 589-6673856 589-3443 faxdrbecker@therhinoplastycenter.com

Clinical Professor & Director of Facial Plastic SurgeryDepartment of Otolaryngology-Head and Neck SurgeryUniversity of Pennsylvania Medical CenterPhiladephia, Pennsylvania

Clinical ProfessorDepartment of Otolaryngology-Head and Neck SurgeryUniversity of Virginia Medical CenterCharlottesville, Virginia

Introduction

In the modern era of rhinoplasty, the introduction of external rhinoplasty was greeted by enthusiastic advocates and alsomet with spirited opposition. Over time, however, the tenor of this debate has become more ecumenical. Mostsurgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there are

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surgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there aresituations when a given approach offers advantages and may be considered preferable. Most also agree that there is alarge "grey area," where either the endonasal or the external approach would be appropriate, and the choice may beconsidered a "toss-up." Most surgeons readily acknowledge that surgeon comfort with a procedure is an appropriatelyimportant factor.

In this chapter we will review the Anatomy, the Incisions and the Approaches that are available to the surgeon. We willdiscuss technical aspects of each approach. We will discuss general indications for the external approach and for theendonasal approaches. We will discuss the pros and cons of each approach, and provide further thoughts on the decisionmaking process.

Anatomy, Incisions and Approaches

Nasal anatomy

Although the anatomy of the nose has been fundamentally understood for many years, only relatively recently has therebeen an increased understanding of the long term effects of surgical changes upon the function and appearance of thenose. A detailed understanding of nasal anatomy is critical for successful rhinoplasty. This section reviews the surface andstructural anatomy of the nose, with an emphasis on important surgical anatomy.

Accurate assessment of the anatomic variations presented by a patient allows the surgeon to develop a rational andrealistic surgical plan. Furthermore, recognizing variant or aberrant anatomy is critical to preventing functional compromiseor untoward aesthetic results. This section presents a limited diagrammatic overview of nasal anatomy (Figures 1-10). More detailed study of nasal and facial anatomy is recommended.1-3

Figure 1: Frontal

1 - glabella2 - nasion3 - tip-defining points4 - alar-sidewall5 - supra-alar crease6 - philtrum

Figure 2: Base

1 - infratip lobule2 - columella

2 - columella3 - alar sidewall4 - facet, or soft-tissue triangle5 - nostril sill6 - columella-labial angle or junction7 - alar-facial groove or junction8 - tip defining points

Figure 3: Lateral

1 - glabella2 - nasion, nasofrontal angle3 - rhinion (osseocartilaginous junction)4 - supratip5 - tip-defining points6 - infratip lobule7 - columella8 - columella-labial angle or junction9 - alar-facial groove or junction

Figure 4: Oblique

1 - glabella2 - nasion, nasofrontal angle3 - rhinion 4 - alar sidewall5 - alar-facial groove or junction6 - supratip7 - tip-defining point8 - philtrum

Figures 5-7 show the internal anatomy, beneath the skin.

Figure 5: Oblique

1 - nasal bone

1 - nasal bone2 - nasion (nasofrontal suture line)3 - internasal suture line4 - nasomaxillary suture line5 - ascending process of maxilla6 - rhinion (osseocartilaginous junction)7 - upper lateral cartilage8 - caudal edge of upper lateral cartilage9 - anterior septal angle10 - lower lateral cartilage - lateral crus11 - medial crural footplate12 - intermediate crus13 - sesamoid cartilage14 - pyriform aperture

Figure 6: Lateral

1 - nasal bone2 - nasion (nasofrontal suture line)3 - internasal suture line4 - nasomaxillary suture line5 - ascending process of maxilla6 - rhinion (osseocartilaginous junction)7 - upper lateral cartilage8 - caudal edge of upper lateral cartilage9 - anterior septal angle10 - lower lateral cartilage lateral crus11 - medial crural footplate12 - intermediate crus13 - sesamoid cartilage14 - pyriform aperture

Figure 7: Base

1 - tip-defining point2 - intermediate crus3 - medial crus4 - medial crural footplate5 - caudal septum6 - lateral crus 7 - naris

7 - naris8 - nostril floor 9 - nostril sill10 - alar lobule11 - alar-facial groove or junction12 - nasal spine

The septum is the midline structure inside your nose that divides the nose into left and right. The septum is an importantstructure in septorhinoplasty. Its anatomy is shown here.

Figure 8: Septum

1 - quadrangular caratilage2 - nasal spine3 - posterior septal angle4 - middle septal angle5 - anterior septal angle6 - vomer7 - perpendicular plate of ethmoid bone8 - maxillary crest, maxillary component9 - maxillary crest - palatine component

Figures 9-10 highlight the important fact that the skin over the nose has muscles and blood vessels. This may seemobvious, but it is important because the surgeon must fully recognize the importance of this fact. The surgeon mustcarefully avoid operating in the incorrect tissue planes, which can result in violation of the muscle and blood vessels andsubsequent abnormal scarring.

Figure 9: 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

Figure 10: Vasculature

1 - dorsal nasal artery2 - lateral nasal artery3 - angular vessels4 - 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 trans-columellar incisions. Approaches provide surgical exposure of the nasal structuresincluding the nasal tip and include cartilage-splitting (transcartilaginous incision), retrograde (intercartilaginous incision withretrograde dissection), delivery approach (intercartilaginous + marginal incisions), and external (transcolumellar andmarginal incisions) (Table 1). Based on an analysis of the individual patient's anatomy, appropriate incisions, approaches,and tip-sculpturing techniques may be selected.3-5

Table 1: TIP SUPPORT MECHANISMS, INCISIONS, & APPROACHES

Major tip support mechanisms

1. size, shape, and strength of lower lateral cartilages2. medial crural footplate attachment to caudal septum3. 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 inter-domal ligament)2. cartilaginous dorsal septum3. sesamoid complex of lower lateral cartilages4. attachment of lower lateral cartilages to overlying skin-soft tissue envelope5. nasal spine6. membranous septum

Incisions – methods of gaining access

IntercartilaginousTrans-cartilaginousMarginal (NOT to be confused with rim incision)Trans-columellar

Approaches – provide surgical exposure

Cartilage-splittingRetrogradeDelivery – Marginal + inter-cartilaginous incisionExternal approach – marginal + trans-columellar incision

Sculpting techniques – surgical modifications

Complete strip – ie cephalic resection, or volume reduction of lateral cruraIncomplete strip (Dome division)Transdomal/Domal suturesAugmentation graftingTip graftOther

BASED ON THE ANATOMIC SITUATION, AN ALGORITHM OF RECOMMENDED INCISIONS, FAVORABLEAPPROACHES AND SCULPTURING TECHNIQUES PRESENT A USEFUL STARTING POINT IN OPERATIVEPLANNING

I. Trans-cartilaginous incision or cartilage-splitting approach – technical considerations

As demonstrated in the accompanying figures, use a two-prong retractor and the middle finger of the non-dominant handto expose the lower lateral cartilage (LLC).

Locate the caudal and cephalic margins of the lateral crura. (The surgeon must identify the cephalically positioned lateralcrus when it is present prior to executing this incision.) Make an incision through vestibular skin only 5 to 8 millimeterscephalic to the caudal margin of the lateral crus of the LLC incision. With scissors, dissect free the vestibular skin in acephalic direction to just beyond the cephalic edge of the lateral crus (Figure 11).

Then, incise the lateral crural cartilage and free the cephalic portion (to be removed) from its remaining soft tissueattachments by dissecting superficially to it in the supra-perichondrial plane.

Use a skin hook to retract the caudal vestibular skin and another skin hook to retract the nostril margin. An assistant mayhold the skin hook that retracts the nostril margin, while the surgeon grasps the cartilage to be removed and completes theexcision by dividing any last soft tissue attachments with scissors (Figure 12). 3-5

II. Delivery approach – technical considerations

A. Intercartilaginous Incision

Using a two prong retractor, evert the caudal margin of the nostril and, by applying pressure with the middle finger of thenon-dominant hand, present the gap between the caudal margin of the upper lateral and the cephalic margin of the lowerlateral cartilages. With a scalpel, make an inter-cartilaginous incision in this location (Figure 13). 3-5

B. Marginal Incision

Using a two prong retractor, evert the caudal margin and, by applying pressure with the middle finger of the non-dominanthand, define the caudal margin of the lower lateral cartilage. Pressing cephalad on the nasal dome will cause the caudalmargin to present itself laterally. Remember that the non hair-bearing area is a guide to the caudal margin of the lateralcrus. Furthermore, palpation of the cartilage edge with the handle of the scalpel can be helpful before cutting. Using thetwo prong retractor to obtain proper exposure, make the marginal incision just caudal to the caudal edge of the lowerlateral cartilage (Figure 14).

Great care must be taken as the lateral incision nears the midline. Make sure that the incision follows the cartilage edgeand does not take a "short-cut" along the alar rim, which can damage the facet area. Great care must be taken not to cutacross a narrow dome or intermediate crus. 3-5

C. Delivery of lower lateral cartilages

Re-insert the two prong retractor into the nostril with the intercartilaginous and marginal incisions and re-present the caudalmargin of the lower lateral cartilage with the aid of pressure from the third finger of the non-dominant hand.

Use a slightly-curved, fine-pointed dissecting scissors to lift and dissect the soft tissues from the surface of the lower lateralcartilage (Figure 15).

Perform this dissection by inserting scissors into the marginal incision laterally, and then separate the perichondrium of thelower lateral from the overlying external skin and soft tissue with a spreading motion. If this is difficult, caudal traction onthe vestibular skin underlying the lower lateral cartilage, with a fine two prong hook, will facilitate this maneuver (Figure 16)

by pulling the lateral crus into the vestibule and thus opening up the potential dissecting plane. Avoid damaging theoverlying muscle and nasal vasculature.3-5

Do not work too far laterally. The lateral one quarter of the lower lateral cartilage should be avoided by the surgeon innearly all cases.

Place the hook end of a Nievert (or other similar) retractor through the inter-cartilaginous incision and draw the now-freelateral crus down, like a visor, until it presents outside of the vestibule. It can be held in this position by the Nievert, or byanother suitable instrument. Examine the lower lateral cartilages for unique anatomical features and asymmetries(Figure17).

III. The external (open) rhinoplasty approach

Background

The external rhinoplasty approach to the nose provides maximal exposure of the lower lateral cartilages, upper lateralcartilages, middle nasal vault, and bony nasal vault. 3,6-13 The incisions used in this approach include a transcolumellarincision connected to bilateral marginal incisions. The actual configuration of the transcolumellar incision is not as critical asthe placement of the incision. The incision should be made at the level of the midcolumella where the caudal margins of themedial crura lie close to the skin and can support the incision to help prevent a depressed scar. An inverted -V incision, orsome other "broken-line" incision, is used to break up the scar and lengthen it to minimize scar contracture. The surgicaldissection must be performed in the proper areolar tissue planes to minimize tissue damage and scarring, maintainhemostasis and maximize redraping of the skin-soft tissue envelope. Dissection in proper tissue planes will help preservevascular structures of the flap, insure flap viability, and minimize bleeding, postoperative edema, and scarring.2

A. Marking the trans-columellar incision. Injecting the nose.

Begin by outlining the transcolumellar incision used in the external rhinoplasty approach with a marking pen. Mark aninverted-V transcolumellar incision at the level of the midcolumella. The midcolumellar incision should be marked midwaybetween the top of the nostril and the base of the columella, where the caudal margin of the medial crura lie just beneaththe skin to provide support for the incision. The midcolumellar incision will be connected to bilateral marginal incisions whichare placed just caudal to the caudal margin of the lateral crura. The marginal incision should not be made along the rim ofthe nostril (rim incision). The marginal incision may be marked with a marking pen as well.

After making appropriate markings on the nose, local infiltrative anesthesia (1% lidocaine with 1/100,000 epinephrine) isapplied. The technique of the author is described in another chapter of this textbook, and is also illustrated below (Figure18). No more than a few milliliters of local are injected. Later in the operation, a small additional amount of local infiltrativeanesthesia may be applied.

FIGURE 18: Mid-columellar incision is shown here. Local infiltrative anesthesia (1% lidocaine with 1/100,000 epinephrine) isalso illustrated.

B. Midcolumellar incision.

Using an 11 blade with a "sawing motion," follow the mid-columellar markings to complete the midcolumellar incision.Proceed medial to lateral on one side of the columella, and then the other. Take special care to keep the bladeperpendicular to the skin edges, thereby preventing bevelling of the skin edges. (Bevelling of the skin edges may lead to a"trapdoor" deformity with eventual unacceptable scar). As one incises laterally, be careful to stay superficial to avoid

"trapdoor" deformity with eventual unacceptable scar). As one incises laterally, be careful to stay superficial to avoiddamage to the caudal margin of the medial crura. (Figure 19)

Use a 15 blade to make the columellar extension of the marginal incision on both sides of the columella, 1 to 2mm behindthe leading edge of the columella (Figure 20). This incision is made along the caudal margin of the medial and intermediatecrura. By minimizing the dissection over the medial crus, damage to this cartilage can be avoided.

C. Define the columellar flap.

Using angled Converse scissors, or another suitable dissecting scissors, elevate the thin vestibular skin of the flap thatcovers the medial crura. Insert the scissors beneath the columellar extension of the marginal incision and dissect mediallyin the correct plane of dissection, below the musculoaponeurotic layer. (Figure 21)

Repeat this maneuver on the opposite side. The scissors should then pass superficial to the caudal margin of the ipsilateraland then contralateral medial crus. Guide the scissors through the opposing columellar extension of the marginal incision. During this dissection, take special care to avoid damaging the flap. Use the scissors to spread the tissues in the plane ofdissection. (Figure 22)

Use the Converse scissors to complete the mid-columellar incision without bevelling the incision or damaging the medialcrura. Take special care to avoid bevelling this incision. (Figure 23)

D. Marginal incision.

Beginning laterally, make a light incision through vestibular skin 1 to 2 mm caudal to the caudal margin of the lateral crura. Follow the caudal margin of the lateral crura as you extend the incision medially. (Figure 24)

E. Bipolar the paired columellar arteries.

Use a narrow double prong hook to retract the flap. The paired columellar arteries typically need to be cauterized withbipolar cautery. (Figure 25)

E. Flap Elevation - three-point countertraction. (Figure 26)

To elevate the skin soft tissue envelope over the nasal tip, 1) place a wide double prong hook along the margin of thenostril rim caudal to the lateral crus, 2) place a small double prong hook on the columellar flap, and 3) place a small doubleprong hook on the vestibular skin side of the intermediate crus (Figure 26, above). Then, use Converse scissors to dissectthe columellar flap from the caudal margin of the medial and intermediate crus as the counter-traction acts to expose theareolar tissue plane. The scissors are used to expose the caudal aspect of the lateral crus as well. Then, the dissectionadvances cephalically over the surface of the lateral crus. As the dissection continues along the surface of the lateral crus,soft tissue is elevated leaving only perichondrium on the cartilage. As dissection proceeds laterally along the lateral crus,cut the vestibular skin along the caudal margin of the lateral crus, thereby completing the marginal incision. Make small,calibrated cuts under direct vision to avoid inadvertently cutting through the lateral crus. Limit dissection of the lateral crusto the areolar tissue plane deep to the muscle. A cotton tip applicator can be used to complete the dissection of the lateralcrus once the deep aerolar tissue plane has been identified. A portion of the dissection on the opposite side wasperformed when you undertook the cartilage delivery approach; nevertheless, repeat these maneuvers on the oppositeside to complete elevation of the skin-soft tissue envelope over the nasal tip.

Retrograde approach

An alternative approach to this dissection is to begin dissection through the marginal incisions (retrograde dissection).14 In this approach, identify the proper tissue plane and elevate the skin-soft tissue envelope off of the lateral crus. Thenproceed medially with scissor dissection toward the domes and intermediate crura. This maneuver is performed bilaterally

proceed medially with scissor dissection toward the domes and intermediate crura. This maneuver is performed bilaterallyto achieve elevation of the skin-soft tissue envelope.

Retrograde dissection is helpful in cases where the surgeon is having difficulty following the caudal margin of theintermediate and lateral crus. This is not unusual in cases where there is buckling of the intermediate crus or domes. Retrograde dissection may not be the approach of choice for secondary rhinoplasty when the lateral crura has been excisedor previously resected. However, the retrograde approach can be extremely helpful in secondary rhinoplasty cases inwhich the primary surgery was performed via an external approach, when the medial crura dissection is hindered byexcessive scarring.

G. Midline dorsal dissection. (Figure 27)

Divide fibrous connections in the midline near the surface of the domes to release the flap and allow dissection cranially. Donot dissect tissue from between the domes; otherwise a midline band of tissue may be left on the flap. Shift the dissectionto the midline where the anterior septal angle is identified with a spreading action of the Converse scissors or other suitabledissecting scissors. Once the blue hue of the cartilaginous middle-third of the nose has been identified, create a midlinetunnel over the cartilaginous middle vault. Then use a cotton tip applicator to bluntly dissect the soft-tissue envelopecranially and laterally (Figure 27, above). This maneuver will frequently expose sizable blood vessels that can be spared asthey are dissected laterally. Depending on the degree of exposure that is needed, some fibrous connections may need tobe cut near their attachment to the cartilaginous nasal vault. Muscle and vessels can be spared by dividing tissues close tothe surface of the cartilages.

H. Closure of columellar incision

For the transcollumellar incision, it is important to have a tension free closure. (Figure 28, below) Consider using a deepsuture if there is any tension. Evert skin edges, pay meticulous attention to proper skin edge alignment, and be careful toavoid notching. Be careful not to BEVEL the incision to avoid a "trap-door" abnormality.

Figure 28 – Before and after external rhinoplasty. Tension-free closure improves final scar appearance.

DISCUSSION:

Indications for Endonasal versus External, and Pros and Cons of each

An operative algorithm often provides a helpful starting point in selecting the incisions, approaches and techniques used innasal tip surgery (Table 2). In every case, the patient's anatomy directs the selection of appropriate technique. As theanatomic deformity becomes more abnormal, a graduated, stepwise approach is taken. However, other factors, such asthe need for spreader grafts, complex nasal deviation, surgeon preference, and other factors may also appropriately affectthe ultimate selection of approach.5

Table 2. Based on the anatomic situation, an algorithm of recommended incisions, favorable approaches, andsculpturing techniques present a useful starting point in operative planning.

The endonasal approach may be generally preferred for patients requiring conservative profile reduction, conservative tipmodification, selected revision rhinoplasty patients, and other situations in which conservative changes are beingundertaken (Figure 29).

Figure 29: In a patient with relatively conservative changes are being undertaken, the endonasal approach may beadvantageous, as in this patient seeking only conservative profile reduction.

Advantages of less invasive approaches include less dissection, less edema, less "healing." However, less invasiveapproaches provide by their very nature less exposure, which in some cases may be a disadvantage.

Indications for external rhinoplasty approach3,6,7,9 (Table 3) generally include asymmetric nasal tip, crooked nosedeformity (lower two thirds of nose), saddle nose deformity, cleft-lip nasal deformity, secondary rhinoplasty requiringcomplex structural grafting, and septal perforation repair. Other indications may include complex nasal tip deformity, middlenasal vault deformity, Selected nasal tumors. Some surgeons prefer the open approach for less complex nasal tipdeformities due to the precision that they feel it offers them, in their hands, compared to the endonasal approach.

Table 3: Indications for External Rhinoplasty Approach

Asymmetric nasal tipCrooked nose deformity (lower two thirds of nose)Saddle nose deformityCleft-lip nasal deformitySecondary rhinoplasty requiring complex structural grafting

Secondary rhinoplasty requiring complex structural graftingSeptal perforation repair

Advantages of the external approach include the maximal surgical exposure available, potentially allowing more accurateanatomic diagnosis. The external approach also provides the opportunity for precise tissue manipulation, suturing andgrafting. Disadvantages include the transcolumellar incision, wide field dissection resulting in loss of support, nasal tipedema.

Regardless of approach, one must be mindful of the need to maintain appropriate structural support. When the approach isdisruptive of tip support, counter measures, such as the placement of a columellar strut, are warranted. When the supportto the upper lateral cartilages has been disrupted, spreader grafts may be appropriate.

External and Endonasal Approaches to the Upper Third

The bony pyramid can be reliably reduced, repositioned or augmented through a closed approach. However, Larrabeereports that open rhinoplasty may allow more precise refining of its contour.15 Larrabee reports that the incidence of profileirregularities may be reduced when procedures are performed via the open approach.

Larrabee points out that while there is a tendency to treat the bony pyramid in an essentially closed fashion when using theopen approach, the benefits of increased exposure to the dorsum available with the open rhinoplasty approach should beexploited whenever possible.

In my experience, a closed approach has been reliable for addressing most bony profile problems. However, when Iperform an open rhinoplasty, at times I will undertake hump reduction under direct visualization. When using anosteotome, I use an 8mm non-guarded osteotome. (Wider osteotomes can create an injury to the skin-soft tissueenvelope.) When rasping during open rhinoplasty, I employ a powered rasp under direct visualization.16

External and Endonasal Approaches to the Middle Nasal Vault

The determination of the need for spreader grafts may play a significant role in determining whether open approach will beused, even when the tip could be satisfactorily addressed by endonasal approaches. Modern rhinoplasty techniquesincreasingly emphasize preservation of cartilaginous and bony substructure. This is of particular importance in the middlenasal vault, as preservation of support for the upper lateral cartilages helps to avoid collapse of the middle vault and theassociated internal nasal valve. Middle vault and nasal valve collapse can cause overnarrowing of the middle third of thenose, with the "inverted V" deformity and nasal obstruction. When support and contour of the middle vault requirereconstitution, spreader grafts can be used.

Use of spreader grafts in primary rhinoplasty is becoming much more common.10, 17-18 Spreader grafts can be effective inmaintaining the contour of the middle vaults after hump reduction. While it may be technically easier to place spreadergrafts via an external approach, spreader grafts can be placed via the endonasal or the external(open) approach.6,9-10,19-

20

Narrowing of the middle nasal vault that occurs when the T configuration of the nasal septum is resected with dorsal humpremoval may be problematic in the high risk patient.10 Spreader grafts act as a spacer between the upper lateral cartilageand septum, preventing excessive narrowing in the high risk patient or correcting an over-narrow middle vault when itexists.

As described by Sheen19, a submucoperichondrial tunnel on one or both sides of the dorsal aspect of the septum may beprepared by elevating the mucoperichondrium bridging the upper lateral cartilages to the septum. This dissection provides aspace to be filled by a cartilage strip insinuated and secured by suture-fixation into the pocket, lateralizing the upper lateralcartilage(s), improving the airway and effectively maintaining the width, or widening when indicated, the appearance of themiddle third of the nose. Spreader grafts are well-addressed and well-illustrated in other chapters in this textbook.

Spreader grafts may be comfortably carried out through traditional, less invasive endonasal techniques. In more complexreconstructions, particularly complicated by multiple abnormalities, an external rhinoplasty approach may facilitate accuratedissection and graft suture fixation. Some surgeons find that the external approach is simply a technically easier method toundertake spreader graft placement.

It should be noted that the use of the external rhinoplasty approach may lead to a greater need for spreader grafts topreserve the nasal valve and middle nasal width, which may put at risk due to the loss of support to the upper lateralcartilages caused by more extensive skin undermining.

Identifying the high risk patient during initial preoperative analysis is essential to the prevention of excessive narrowing ofthe middle nasal vault with internal nasal valve collapse.10 Sheen19 identified an anatomical variant that he labelled the"narrow nose syndrome." Short nasal bones, long weak upper lateral cartilages, thin skin, and a narrow projecting nosepredispose to middle vault collapse.9-10 As described by Toriumi10, commonly performed surgical maneuvers can result inloss of support to the middle vault. A large en bloc hump removal should be avoided, as the T-shaped support of the nasalseptum is eliminated and the intranasal mucosa (which provides important support to the upper lateral cartilage) is at riskof injury. Cephalic trim (volume reduction) of the lateral crura disrupts the scroll (recurvature) and frees the caudal marginof the upper lateral cartilage. Lateral osteotomies may further medialize the upper lateral cartilages. The upper lateralcartilages can fall toward the narrowed dorsal septal edge, producing middle vault and internal valvular collapse.10 Collapseof the middle vault may highlight the caudal edges of the nasal bones to produce the characteristic "inverted V"deformity.10,19

In the majority of patients the combination of these maneuvers will not result in a problem; however, in high risk patientsthis combination of maneuvers may contribute to excessive narrowing of the middle vault with internal valve collapse.

Experience is required to develop reliable surgical judgment regarding the appropriate use of spreader grafts. After spreadergrafts are secured in position via the open approach, or if they are placed endonasally after dissection of the soft tissueenvelope, the middle vault may appear slightly wide. Over time, this area of the nose tends to narrow as edema resolvesand scar contracture pulls the upper lateral cartilages medially.10

External and Endonasal Approaches to the Nasal tip

Complex nasal tip procedures can be performed via endonasal and external approaches. Certain grafting techniques suchas lateral crural strut grafts, and certain manipulations of the tip cartilages such as lateral crural overlay and intermediatecrural overlay, and "tongue-in-groove" retrodisplacement of the medial crura onto the caudal septum, may be performedvia either approach, but certainly the exposure afforded by the open approach may be preferable (Figure 30).21-24

Figure 30: This patient had a significant caudal septal deviation and severe concavity of the right lateral crus. Correction ofthe tip deformity required excision and "flipping" of the right lateral crus. While this can be performed using an external or adelivery approach, the surgeon found that the exposure afforded by the external approach was preferable.

External and Endonasal Approaches to Revision Rhinoplasty

In revision surgery, once the nose is open, any supportive relationships that exist between the scar tissue and underlyingstructure is lost, and cartilage grafting may be required to support and contour the skin/soft tissue envelope that will nowundergo renewed scar contracture and healing. If not, healing and scar contracture may leave a worse deficit than before.Therefore, in revision cases with relatively mild deformities or those that can be corrected with precise pocket grafting,

Therefore, in revision cases with relatively mild deformities or those that can be corrected with precise pocket grafting,closed approach is preferred. The surgeon should seek an endonasal approach, but may find that in complex cases anopen approach is unavoidable. Spreader grafts, batten grafts, onlay grafts are examples of maneuvers that can be well-placed via precise pocket, endonasal techniques (Figure 31).25

Figure 31: This patient required a triple layer onlay graft to address her saddle nose abnormality. This graft was well-placedvia a precise pocket, endonasal approach.

Endonasal and external approaches to the deviated caudal and dorsal septum

For severe caudal septal deviation, the open approach may provide a more facile and efficacious approach, when swingingdoor, doorstop and other similar maneuvers have failed.26-27 Although many techniques to address a severe caudaldeviation can be done open or closed, it is an issue of balancing the downsides of a technique against the increased chanceof achieving the technique as desired. To some extent, this is ultimately a personal judgment, guided by critical self-evaluation.

Philosophical Considerations – A Graduated Approach. The Big Picture

When considering the decision-making around the choice of approach, much can be gained by considering the experiencesof surgeons who have had the opportunity to see the consequences over time of the choices they have made.

The important philosophical concept is not open or closed, but instead, the emphasis on anatomic diagnosis and

The important philosophical concept is not open or closed, but instead, the emphasis on anatomic diagnosis andpreservation of supportive structures.

A central tenet of rhinoplasty decision-making has been the concept of a graduated approach. This concept is based on theidea that achieving the desired goals with the least amount of surgical dissection provides the best chance of success.However, the critical issue here is how much exposure is needed for reliable execution of any specific technical maneuver.

Adamson28 has astutely observed that there is no ideal approach, each surgeon will develop a unique approach based uponthe concepts outlined and based on the techniques and experiences he or she has developed in the course of an eclectictraining. The skillful surgeon can make astute intraoperative anatomic diagnosis via the endonasal or external approach.Notwithstanding this, an important factor that can compromise results is the potential difficulty in diagnosis of variousdeformities and abnormalities using closed approaches, Another factor is the manual difficulty in correcting such deformitiesonce diagnosed, especially effecting such maneuvers as vertical cartilage division, graft placement, and suturing techniques. Those trained in the closed approach will still tend to perform the majority of their rhinoplasties in this fashion, reserving theopen approach for more difficult noses. This assessment will vary from surgeon to surgeon (Figure 32).

Figure 32: While some surgeons may choose address this revision rhinoplasty via a closed approach, the author felt that, inhis hands, the exposure obtained from the external approach offered the best opportunity for successful correction of thetip deformity.

Perkins29 describes an evolution in his personal philosophy that reflects some of the issues involved in the decision makingprocess, and provides valuable insight into the evolution in the decision making that has occurred over the last 15-20years. While the concept of a graduated approach to achieve a pleasing aesthetic result has been foremost in his personalphilosophy, the evolving need to achieve more refined results and prevent late complications has resulted in his increaseduse of the open approach, which allows the opportunity to use certain grafting techniques. Perkins continues to stronglyadvocate the philosophy that the approach selected should provide the least intervention in the shortest time to achieve asatisfactory result and satisfy the patient's goals. However, his choice of approach has changed due to late complicationsthat he has seen occur. The 2 areas that he found most commonly cause late complications in rhinoplasty are the midnasalpyramid and lateral alar sidewalls. Paramount to provide a structural foundation for the middle vault (ie spreader grafts). While issues such as these can be addressed using the endonasal approach, it is sometimes far easier to place structuralgrafts via the external approach. Also, when marked reduction of overprojection is required, it is often easier to use theexternal columellar approach.

Although I was asked to write a chapter on "Open Versus Closed Rhinoplasty,." I have instead written a chapter on "OpenAnd Closed Rhinoplasty." While this may seem like a semantic point, I believe that the surgeon should understand theadvantages offered by every surgical approach. The concepts of minimizing dissection, born from endonasal techniques,

advantages offered by every surgical approach. The concepts of minimizing dissection, born from endonasal techniques,also apply to external rhinoplasty. Every surgeon should be able to "think like an endonasal surgeon" – that is, tounderstand the advantages of limiting the surgical dissection. But, one should also be able to recognize when the additionalexposure offered by the external approach may be useful and even necessary. When the external approach is undertaken,the surgeon must understand the commitment that has been made to additional support maneuvers.

There is no single answer to the question, "open versus closed rhinoplasty." In each patient, diligent attention must bepaid to the patient's goals and to the patient's anatomy. The wise surgeon includes external and endonasal rhinoplasty aschoices in his or her armamentarium, and understands the critical issues of maintaining or adding structural support forimproving long-term outcomes. The choice for a specific patient will ultimately depend upon the surgeon's personal opinionas to which approach, in their hands, will provide the best chance of long-term success with the least amount of surgicaldissection.

References

1. Tardy ME. Brown R. Surgical Anatomy of the Nose. Raven Press 1990.

2. Toriumi DM, Mueller RA, Grosch T, Bhattacharyya TK, Larrabee WF. Vascular Anatomy of the Nose and the ExternalRhinoplasty Approach. Arch Otol Head Neck Surg 122: 24-34, January 1996.

3. Toriumi DM, Becker DG. Rhinoplasty Dissection Manual. Lippincott, Williams and Wilkins, Philadelphia, PA 1999.

4. Tardy ME, Toriumi DM. Philosophy and Principles of Rhinoplasty. Chapter 31 in Otolaryngology-Head & Neck Surgery,2nd edition (ed. Cummings et al) Mosby Year Book, pp 278-294.

5. Tardy ME. Rhinoplasty: The Art and the Science. W.B. Saunders: Philadelphia, 1997.

6. Johnson CM Jr, Toriumi DM. Open Structure Rhinoplasty. Philadelphia, PA, Saunders, 1990.

7. Adamson PA. Open Rhinoplasty. In ID Papel & NE Nachlas (eds) Facial Plastic & Reconstructive Surgery (pp 295-304) St Louis: Mosby Year Book, 1992.

8. Larrabee WF, Jr. Open rhinoplasty and the upper third of the nose. Facial Plastic Clin N Amer 1(1):23-38, 1993.

9. Toriumi DM, Johnson CM. Open Structure Rhinoplasty – Featured Technical Points and Long-Term Follow-Up. FacialPlastic Surgery Clinics of North America 1(1): 1-22, August 1993.

10. Toriumi DM. Management of the Middle Nasal Vault. Operative Techniques in Plastic & Reconstructive Surgery2(1):16-30, February 1995.

11. Toriumi DM, Ries WR. Innovative Surgical Management of the Crooked Nose. Facial Plastic Surgery Clinics of NorthAmerica 1(1): 63-78, August 1993.

12. Toriumi DM, Johnson CM. Management of the Lower Third of the Nose – Open Structure Rhinoplasty Technique.Chapter 33 in Facial Plastic & Reconstructive Surgery (ed Papel and Nachlas), pp 305-313.

13.Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg 99(3): 863-867, 1997.

14. Thomas JR. External rhinoplasty:intact columellar approach. Laryngoscope 100(2 Pt 1):206-208, 1990.

15 Larrabee WF. Open Rhinoplasty and the Upper Third of the Nose. Facial Plastic Surgery Clinics of North America 1(1):1993, 23-38.

16 Becker DG. The Powered Rasp, Archives of Facial Plastic Surgery, 2001.

17. Constantian MB, Clardy RB. The Relative Importance of Septal and Nasal Valvular Surgery in Correcting AirwayObstruction in Primary and Secondary Rhinoplasty. Plastic and Reconstructive Surgery

18. Teichgraeber JF, Wainwright DJ. The Treatment of Nasal Valve Obstruction. Plastic and Reconstructive Surgery93(6):1174- 1184, 1994.

19. Sheen JH. Spreader Graft: A Method of Reconstructing the Roof of the Middle Nasal Vault Following Rhinoplasty. Plastic and Reconstructive Surgery 73(2):1984, 230-237.

20. Aiach G. Atlas de Rhinoplastie, Paris, France, Masson, 1989, pp 74-85.

21. Soliemanzadeh P, Kridel RWH. Nasal tip overprojection: algorithm of surgical deprojection techniquesand introductiontomedial crural overlay. Arch Facial Plastic Surg 2005;7:374-380.

22. Konior RJ, Kridel RWH. Controlled nasal tip postioning via the Open Rhinoplasty Approach. Facial Plastic Surgery Clinicsof North America Vol 1(1) 1993: 53-62.

23. Adamson PA. Nasal Tip Surgery in Open Rhinoplasty. Facial Plastic Surgery Clinics of North America 1(1):1193, 39-52.

24. Wise, JB, Becker SS, Sparano A, Steiger J, Becker DG. Intermediate Crural Overlay in Rhinoplasty: A DeprojectionTechnique that Shortens the Medial Leg of the Tripod without Lengthening the Nose. Archives of Facial Plastic Surgery. Vol8:240-244, 2006.

25. Perkins SW, Tardy ME. External Columellar Incisional Approach to Revision of the Lower Third of the Nose. Facial PlasticSurgery Clinics of North America Vol 1(1) 1993, pp 79-98.

26. Pastorek NJ, Becker DG. Treating the Caudal Septal Deflection. Archives of Facial Plastic Surgery, 2: 217-220, 2000.

27. Toriumi DM, Ries WR. Innovative Surgical Management of the Crooked Nose. Facial Plastic Surgery Clinics of NorthAmerica Vol 1(1) 1993, 63-78.

28. Adamson PA. Nasal Tip Surgery in Open Rhinoplasty. Facial Plastic Surgery Clinics of North America Vol 1(1) 1993, 39-52.

29. Perkins SW. The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty. FacialPlastic Surgery Clinics of North America 12(2004):35-

Tags: Anatomy, Clinical Associate Professor, Incisions, Rhinoplasty

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