Over the recent years, there has been a true revolution in rhinoplasty. Descriptive anatomical studies as well as innovative techniques have encouraged new understandings with regards to the various approaches in rhinoplasty. The advent of the extended open approach and piezoelectric surgery has opened the door to new osteotomy patterns under direct visualization.
Rhinoplasty - A Brief Introduction
Rhinoplasty is perhaps one of the most complex cosmetic surgery procedures performed in the world today. It is characterized by the intricate interplay between form and function, with patient satisfaction being dependent not only on improvement of nasal aesthetics but also resolution of pre-existing airway symptoms, if any.
While the surgical treatment of existing nasal deformities is tailored to the needs of the individual patient, there are generally some essential components to form the foundation basis for a successful technical execution of rhinoplasty. These include, but not limited to; septoturbinotomy, opening the nose, humpectomy/spreader flaps, tip-plasty, supratip-plasty, columellar strut, dorsal augmentation, nasal base reduction, osteotomies and rim grafts.
As with any procedure, it is imperative for the performing surgeon to have a complete understanding of pre-operative considerations as well as possible post-operative complications, such as bleeding, ecchymosis, edema, and persistent or new iatrogenic deformity prior to offering rhinoplasty to patients.
Open vs Closed Approach: Pros & Cons
The advantages and disadvantages of closed vs open rhinoplasty have been widely discussed with many studies being continuously conducted and articles written.
Closed Approach: One of the most significant advantages of the closed approach is that it leaves virtually no external scar, and requires less dissection, therefore is able to decrease the possibility of edema formation, and generally, operative time as well.
On the flip side, the closed approach requires a greater degree of experience on the surgeon’s part, as visibility of the nasal framework is limited. Furthermore, indications for the closed approach are significantly more limited, such as for correction of isolated deformities of the nasal tip or dorsum.
Open Approach: Adopting the open approach has numerous advantages, including improved visualization without distortion; hence, enabling a more precise diagnosis and correction of deformities. The improved exposure not only facilitates the manipulation of techniques and surgical procedure, but can also be very valuable when it comes to education and demonstration of cases as it allows for the simultaneous visualization of the anatomy and planned maneuvers, where possible.
On the other hand, the disadvantages of the open approach may include prolonged edema, extended surgical time, frequent need for additional stabilization of the cartilaginous framework, and can potentially cause external transcolumellar scars. The latter, however, is typically well concealed and rarely is a concern. Lastly, it has been reported in one of the published journals that the open approach may also potentially weaken the nasal tip supporting structures by as much as 35%.
Incision Techniques in Open Approach
Image credit: Dr. Alwyn D'Souza via https://www.rhinoplastyarchive.com/articles/open-rhinoplasty
While there are many different incision patterns available in open rhinoplasty; the 3 most commonly employed incision techniques are the Columellar V Incision, the Stair-Step (also known as Staircase) Incision, and the Inverted V Incision.
Columellar V Incision: The Columellar V incision is used favourably in patients to correct cleft lip nose deformity. Vertical incisions are rarely used, if ever at all, as a single vertical incision across the columellar can greatly increase the risks of contracture.
Stair-Step/ Staircase Incision: The Stair-Step or Staircase incision is inconvenient to apply in Asian rhinoplasty as results usually have a higher incidence of visible scarring and unilateral notching.
Inverted V Incision: The Inverted V incision is considered to be the most preferred incision technique used by most surgeons due to it being able to significantly reduce visible scarring - unless the incision design is misplaced or if the columellar flap is injured during elevation.
Rhinoplasty: Art or Science
As rhinoplasty continues to be, perhaps, the most complex surgical procedure there is; and the keys to success is more than just having a thorough pre-operative analysis with established diagnosis and execution of an individualised procedure tailored to the specific anatomic abnormalities and concerns of the patient. It also challenges the performing surgeon’s skills, knowledge and understanding in the anatomy of the nose, nasal structure, skills, techniques, pre-operative considerations and post-operative management, of which, every single aspect is just as equally important.
It is a procedure that beautifully marries both the art and science of aesthetics in itself; and without a doubt, one of, if not the, most complicated surgical procedures there is in the field of aesthetics and cosmetics; with the end results being a testament to the skills of the performing surgeon.
With such demanding prerequisites for the successful execution of this challenging procedure, the understanding of nasal anatomy physiology as well as the ability to employ and adopt the right techniques to address each and every individual patient, is at least as equally important, if not more so than, the performing practitioner’s surgical skills.
Hope you have enjoyed the article & video! Stay tuned for our future posts about more techniques and information related to our advanced aesthetic and cosmetic training courses!
Rebuilding Nose Rhinoplasty for Asians by JaeYong Jeong (Translated by TaekKyun Kim) - 2018
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