8. Open Rhinoplasty.pdf

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Home Articles Open Rhinoplasty

Open RhinoplastyPosted by Alwyn R. D'Souza on February 9th, 2011

Annabelle C. Leong and Alwyn R. DSouza

Abstract

The tenets of rhinoplasty focus on restoring or maintaining the strength and support of the nasal skeleton while altering thecontour to achieve the desired aesthetic result. The debate continues unabated over the advantages and disadvantages ofan open versus a closed endonasal approach. The open technique offers the obvious benefit of direct observation, whichoften outweighs the commonly-cited disadvantage of transcolumellar incision and scar. The enhanced exposure isespecially beneficial for workon the nasal tip, dorsum and septum and additionally, offers the best possible teaching too l forthe trainee. The goal of this chapter is to provide the reader a logical and systematic road map upon which to manage thesurgical correction of nasal deformities w ith the open rhinoplasty approach.

Introduction

Literature suggests that Rethi first introduced the high transcolumellar incision for tip modification in 1921 [1]. In 1957,Sercer extended the incision and described nasal decortication, defining it as a temporary separation of the nasal skin

from the nasal pyramid [2]. Open rhinoplasty subsequently fell out of favor until Padovan, Sercers student, presented hisseries in the early 1970s, reporting the use of the open approach to the septum [3]. Andersen and Wright are generallycredited with popularising the open rhinoplasty approach and combining its use with open septoplasty techniques [4, 5] .

Indications

The open rhinoplasty approach allows definitivediagnosis of underlying nasal deformities, particularly in the region of thecaudal, superior and dorsal septum, premaxillary spine and lobule. Assessment of the osseocartilaginous framework is

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especially important in revision surgery. It provides enhanced access to perform precisestructural modifications with graftplacement and osteotomies. Tip projection maybe controlled and refined, such thatless dorsal reduction may then berequired. Furthermore, scar tissue and redundant subcutaneous tissue may be cautiously excised more easily under directvision. The delicate valve region can be well- protected, whilst the absence of intercartilaginous incisions reduces the risk ofpossibility of subsequent nasal valve obstruction due to scar formation and disruption of one of the important tip supportmechanisms. The open approach is also ultimately an excellent too l for training and educational purposes [5].

Indications for open rhinoplasty therefore include the following [6]:

Nasal tip modification, such as bulbous, over/underprojed tipRevision rhinoplastyPost-traumatic severe external nasal or septal deformityCorrection of nasal valve dysfunctionRepair of septal perforationsAugmentation rhinoplasty requiring multiple graftsCleft lip and palate nasal deformityThin skin where accurate sculpting and camaflage is importantSome casese o f thick nasal skin

The contraindications of the open approach include [7]:

Intranasal substance abuse (eg. cocaine)

Psychological or psychiatric instabilitySIMON (single, immature, male, overly expectant, narcissistic) personality traitsPreoperative diagnosis of nasal dysfunction (with or without aesthetic deformity) that may be better treated w ith aclosed approach (ie. septoplasty) or medical managementPatient refusal of external scarVery thick nasal skin in which postoperative edema may be permanent.

Advantages of open approach include:

Direct observation of nasal anatomyDirect access to relevant anatomy to manipulate and correct derformities.Excellent teaching tool for rhinoplasty sugeons

Disadvantages of open rhinoplasty include:

The transcolumellar scar that may heal poorly and become visiblePotential for columellar flap necrosisExtensive dissection of skin off the osseocartilaginous framework with the potential for increased scarringProlonged postoperative nasal tip oedema and numbnessLonger operative time when compared with endonasal approach
http://emedicine.medscape.com/article/878817-overviewhttp://emedicine.medscape.com/article/840646-overview


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Post operative suture removal which can be sometimes uncomfortable

Preoperative Assessment

Every patient should be thoroughly assessed on aesthetic and functional criteria with regards to their nose, as well aspsychologically, to obtain informed consent with realistic outcomes. This also includes digital photography and morphing toaccurately delineate the goals of rhinoplasty in every case. The surgical plan is re-reviewed with the patient at a secondappointment before proceeding with the operation.

History

Presenting functional and aesthetic problems, including symptom severity and duration, previous surgical procedures,allergies, medications, including recreational drug use such as cocaine, and a complete general medical history are elicited.

Clinical Examination

A complete physical examination is vital, with specific facial and nasal evaluation concentrating on skin type and thickness,surgical scars, symmetry and overall balance of facial aesthetic units.

Examination of the nasal septum, internal and external nasal valves, turbinates and lining is undertaken, paying attention tothe structure and form of the nasal tip and dorsum. A critical factor in planning tip surgery is the inherent strength and

support of the nasal tip - the tip recoil. Depressing the tip toward the upper lip provides a quick and reliable test of theability of the tips supportive structure to spring back into position. If the recoil is instantaneous and vigorous and the tipcartilages resist the deforming influence of the finger, more definitive tip surgery can usually be performed without fear ofsubstantial support loss. The size, shape, attitude, and resilience of the alar cartilages can be estimated by ballottement ofthe lateral crus between two fingers surrounding its cephalic and caudal margins.

Photography

Photographic documentation during preoperative consultation and during and after the procedure should be obtained. Theauthors recommend high-resolution digital photography of the nose in the anteroposterior, lateral, basal, bird's eye andthree-quarter profile views, against a blue/grey background. Ideally the operating surgeon should perform the phototgraphy

to capture all required additional views.

Anaesthesia and Preparation

The procedure is carried out under a general anaesthetic. Local infiltration of 1% Xylocaine with 1:100, 000 adrenaline isused to achieve a complete external and internal nasal block, some hydrodissection as well as vasoconstriction.

CASE HISTORY

A 52 year old gentleman presented with worsening nasal airway obstruction after suffering an episode of trauma to hisnose. His primary concern was to improve his nasal function and he was less disturbed by the external appearance of his


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nose. Examination revealed significant collapse of the nasal dorsum with complete lack of septal cartilaginous support. Themargins of the fractured nasal bones were clearly visible under the skin-soft tissue envelope, separated by a depressedtriangular area in the centre. The nasal tip was severely under-rotated and under-projected. The skin-soft tissue envelopewas of medium thickness with some amount of scarring affecting the dorsal skin, alar margins and left soft tissue trianglearea. The alar base was excessively wide and from the basal view, appeared sausage-shaped with oblong nostrils.


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MANAGEMENT PLAN:

After detailed discussion with the patient, the surgical decision was to perform an open septorhinoplasty procedure with


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nasal tip grafting. A rib graft with an L-strut was inserted to rebuild the nasal dorsum, septum and the columella, whilesubalar struts were used to support the ala. Crushed cartilage was placed on top to camouflage the bone grafts; shieldcartilage grafts were also added to the nasal tip. No osteotomies or alar base reduction was done, as aesthetic outcomewas not of particular concern to the patient and the subsequent appearance of his nose at this stage was in keeping withhis ethnicity. Rim grafts were also inserted to support the alar rim, particularly on the left where there was some retraction.

The Incisions and Exposure

The ideal incision for open rhinoplasty is a mid-columellar incision with break points, avoiding single straight cut across thecolumella to minimise the risk of contracture. These include inverted-V, W and staircase incisions [8]. In the authorsexperience, the mid-columellar inverted V incision made with the 11 blade is desired most. The incision is marked beforethe infiltration of local anaesthetic. It is important to consider the thickness of the skin on incising, so that the medial cruraare not inadvertently incised. Moreover, the incision should be placed above the feet of the medial crura, especially inAfrican and Asian patients who tend to have relatively short medial crura and are hence at greater risk of postoperativetransverse columellar notching. The transverse co lumellar incision part should arc gently around the caudal margin of themedial crura to meet the marginal incisions at 90 degrees. The vertical marginal incisions should be placed slightly behind


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the true columella to hide it from view, bestowing the advantages of a wider columellar flap, and allowing the natural curveof the medial crus to be followed superiorly with ease.

The columellar flap should be kept as thick as possible, taking care to dissect in the immediate supraperichondrial plane.There may be some brisk bleeding from the inferior columellar artery or branches of the facial artery in the pyriformaperture. This can be contro lled with judicious bipolar diathermy to avoid compromising the blood supply to the flap andincreasing post-operative oedema. The columellar flap is elevated with tenotomy or Joseph scissors to the superior aspectof the medial crura hugging the border of the LLC. The nasal tip skin is then elevated off the alar cartilages with gentle 3-point traction and scissor dissection. It is important to stay in the immediate supra-perichondrial plane, as a superficial plane

of dissection may lead to skin necrosis, as well as exposing minor irregularities post operatively. The nasal dorsum isfurther exposed by dividing the intracrural ligament and elevating the flap off the osseocartilaginous pyramid in thesupraperiosteal plane. The exposure is completed by undermining along the piriform margins and to the upper lateralcartilages (ULCs) as needed.

Logical Steps

In the authors experience, the logical sequence of events in open rhinoplasty after performing the incision should follow onwith:

Septal correctionNasal tip modification,Correction of the dorsal hump and middle third deformities.

OsteotomiesThe incisions are then closed, and finally alar base reduction is carried out when indicated.

These are discussed in the following section.

I) Septal surgery

Septoplasty is the critical first step of rhinoplasty, offering an early opportunity to harvest septal cartilage for graftingprocedures later on, in addition to correcting functional deficits [9]. Dorsal deviations may contribute to internal valveinsufficiency and caudal septal deflections may impinge on the external nasal valve, whilst both may lead to a crooked nose

appearance.

Open septoplasty provides a superb view of the anterior septal angle. Excellent exposure of the caudal septum is achievedby excising the soft tissue from between the medial crura down to the premaxilla[9]. The nasal spine may be lowered toprovide an improved platform for a columellar strut. Submucoperichondrial flaps are elevated bilaterally on either side ofthe caudal septum, followed by separation of the ULCs from the septum.

Exposure of the septum can be obtained with different techniques, depending on the location of the deviation. In caseswhere the nasolabial angle needs to be altered, tip projection needs to be altered, large and/or anterior septal deflections;dissection should take place between the medial crura. Here the fibrous attachments of the medial crura are separated until


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the anterior septal angle is identified. When the septal deflection is located within the central portion of the cartilage,exposure can be achieved with a hemitransfixion or Killian incision. The robust blood supply of the nose allows for aseparate Killian incision to be made, even in open rhinoplasty[6].

A severely deviated anterior septum located within the anterior 2 cm of the caudal septum is typically reason enough toopen a nose[10]. A noticeable exception to a deviated deflection here would be a straight caudal deflection, which may bemore amenable to being repositioned via a swinging door technique to allow the inferior caudal septum to swing freely tothe midline and come to rest in the maxillary groove. The cartilage may be scored to liberate it from its intrinsic concavityand convexity patterns. Many anterior septal deflections can be repaired by repositioning the septal cartilage and securing it

to the periosteum of the nasal spine, whilst others may require excision and replacement [8].

Another indication for open septoplasty is the deviated dorsal septum which is often difficult to evaluate with the closedapproach. A unilateral spreader graft, placed on the concave surface, can provide sufficient strength to help straighten theseptum whilst asymmetric spreader grafts may provide further strength[4]. More severe deviations will necessitate anexcision and replacement of the deviated component. It is important to recognise a high subradix deviation as it can be acause of residual dorsal curvature if left uncorrected[9]. This may be treated by vertical shaving of the dorsal septalcartilage and careful mobilisation of the ethmoid plate to the midline, taking care not to fracture it superiorly. Even moresignificant deviations may necessitate near-total excision and disarticulation of the deviated septum with reconstructionusing extracorporeal septoplasty technique. Although the entire septum may be removed, the senior author feels thatmaintaining a small cartilaginous attachment to the bony septum is a safer and more effective means of repairing septal

deviations. Attaching cartilaginous components to bony elements is challenging and can lead to slight shifts inreapproximation, while attaching cartilage to an existing piece of cartilage can lead to improved overall stability.

Patients with short nasal septums often benefit from extension of the existing septum. The caudal extension graft maybe used to adjust septal rotation and projection to help contribute to the position of the nasal tip. In patients with a poorlyprojected nasal tip, open septoplasty is often necessary to allow for sufficient manipulation o f the tip position to adequatelyproject the nose. Some patients with poorly projected noses will have concurrent nasal ptosis and may noticeimprovement in breathing with restoration of the nose with a more obtuse nasolabial angle[10].

II) Nasal Tip Modification

Shaping of the nasal tip is the most challenging aspect of rhinoplasty surgery. Modification of lower lateral cartilages (LLCs)requires strict maintenance of their symmetry whilst factoring in the eventual effects of healing on the supportmechanisms. The tripod theory of the nasal tip describes the central leg formed by the conjo ined medial crura, and theother 2 legs by the lateral crura, each supported by ligamentous attachments. Alteration of any limb of the tripod henceaffects tip position and rotation [11].

Six factors are important in assessing the need for tip remodeling [12]. The surgeon must determine whether the tiprequires:

Reduction in the volume of the alar cartilages


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Alteration in the attitude and orientation of the alar cartilagesChange in tip projectionNarrowing of the interdomal distanceNarrowing of the domal angles andCephalic rotation with a consequent increase in the columellar inclination (nasolabial angle).

This will guide the selection of the most favorable incisions, approach and tip sculpture technique, rather than routine usageof a single method. Ultimately, the key is the symmetry and amount of cartilage retained, readily noted with the openrhinoplasty approach.

IIa) Tip projection

The goals of surgery are to achieve

Natural looking, well-defined tip to tackle a broad or bulbous noseTip rotation appropriate to gender to address a drooping nasal tip (ideal nasolabial angle is 90 to 105 degrees in malesand 100 to 115 degrees in females) andTip projection appropriate to the height of the nasal dorsum and chin.

Enhancement of tip definition can be achieved with suture techniques, cartilage excision techniques or using a combinationof two techiques. The former is better suited to a patient with very thin skin, a tip requiring more limited refinement, or a

surgeon with less experience, whereas the latter is best reserved for a patient with thicker skin and a surgeon more well-versed with the nuances of excisional techniques.

1. Cephalic trim.This refers to reduction in the oveall volume of the lateral crura often used to reduce the bulbosity ofthe tip. A cephalic trim is limited to the more medial aspect of the lateral crus, as trimming the cartilage morelaterally will not improve definition more centrally in the lobule and may unnecessarily risk alar collapse by weakeningthe support that the lateral crura provide to the nasal ala. A minimum height (width) of 6 to 7 mm of the lateral crusshould be maintained to ensure adequate alar support and minimize the risk of alar collapse or retraction.An alternative to cephalic resection of the alar cartilage, for example in the case of a bulbous tip, is a turn-in flap ofthe cephalic portion of the lateral crus. This enables aesthetic corrections and reinforces the durability of the lateralcrus, reduces tip volume and permits medialization of the tip-defining points, thereby achieving a more pleasant-appearing nasal tip[13].


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2. Tip suturing.A broad or bulbous nasal tip may be narrowed by using permanent sutures to modify the lateral cruraat the tip (dome). A 5-0 monofilament permanent suture is placed as a horizontal mattress suture spanning thealar dome is the preferred option. The stitch is passed through cartilage only (superficial to the vestibular mucosaunderneath) from a point medial to the dome. It exits the cartilage lateral to the dome and is then reinserted backthrough the cartilage just below the first pass in a lateral-to-medial direction, so that the suture knot ends upbetween the two medial crura. This is known as a transdomalsuture [14]. As the suture is tightened, the domalangle is narrowed, reducing the width of the nasal tip. The same maneuver is repeated contralaterally. At the knot,one limb of the suture from each side is tied to that of the opposite side to unite the two domes from either side toone another (the interdomalsuture). This increases stability to the new tip complex, helps maintain the position oftip-defining points and minimizes the effect o f soft tissue contracture post operatively.


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3. Vertical dome division.This technique is not commonly used in modern rhinoplasty practie, but has its meritswhen excuted appropriately. Vertical dome division (VDD) describes an excisional technique where the integrity ofLLC is interrupted from their cephalic to their caudal border at or near the dome, with preservation of the underlyingvestibular mucosa [15]. A cephalic trim is carried out together with excision of a cephalically-based triangle or a

wedge of cartilage at the chosen point of division. The two medial crura are then sutured to one another severalmillimeters proximal to the cut edge with 5-0 monofilament mattress suture. This will stabilize the medial cruralcomplex as natural scar contracture develops with healing, minimising the chance of migration or twisting of thecartilage, which might otherwise lead to unsightly irregularities. It is worth noting that excision of a cephalically-based triangle of cartilage lateral to the dome will tend to increase both tip rotation and projection whileconcurrently narrowing the tip. In such cases the medial border of the excised triangle should be no more than 2 to3 mm lateral to the dome. On the other hand, a wedge of cartilage can be excised right at the dome, thusshortening the medial and lateral crura equally to effectively deproject and narrow the nasal tip. If additional tipprojection is required, strut grafts and plumping grafts may be used as required[16].

IIb) Tip rotation

The planned degree of tip rotation depends on various factors, often including facial balance and proportions, the patientsaesthetic desires and the surgeons aesthetic judgment. Tip rotation and projection are complementary and interrelated.One must also distinguish between true tip rotation and the illusion of cephalic tip rotation achieved by contoured cartilagegrafts inserted in the infratip lobule, co lumella and nasolabial angle.

Cephalic rotation results fundamentally from planned surgical modifications of LLC but might also result from adjunctiveprocedures on nasal structures adjacent to the alar cartilages. Shortening of the caudal septum, excision of overlongcaudal ULCs and septal shortening with a high transfixion incision are used regularly to enhance the effects of a planned


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degree of tip rotation, which may be facilitated through an open approach [12]. Some basic maneuvers to achieve tiprotation include:

1. Dorsal reduction. A limited reduction (2 to 3 mm) may not result in a significant change in nasal tip rotation but

reductions o f >4 mm will often result in secondary tip rotation[12].

2. Shortening the caudal septum.In patients w ith excessive columellar show (>4 mm on lateral view), shortening

the overly long caudal septum will promote tip rotation.

3. Transdomal/interdomal sutures.Transdomal and interdomal sutures will provide a conservative increase in tiprotation.

4. Vertical dome division.When division of the lateral crura is undertaken 2 to 3 mm lateral to the dome VDD, will

increase rotation [15]. The medial crura are thus lengthened at the expense of the lateral crura, thereby increasingprojection and rotation simultaneously.

5. Lateral crural overlay.Vertical division of the lateral crura is performed midway along the lateral crus, and the twosegments are then overlapped and suture-fixated. A lateral crural overlay procedure will rotate the tip upward whilesimultaneously deprojecting the tip (as the lateral crura are effectively shortened) [17]. When tip deprojection isdesired together with tip rotation andthe nasal tip itself is already narrow and well-defined, maneuvers further outon the lateral crura are preferable to maneuvers executed at the dome itself so that already agreeable tip featuresare not disrupted.

III) Grafting Techniques

The open approach is most favorable for reconstructing major framework deficiencies and performing precise graft

placement, especially in revision and reconstructive rhinoplasty. The grafts can be easily sculpted and secured under directvision as desired.

Septal cartilage is the most commonly used grafting material in primary rhinoplasty, due to its straightforward harvest, lackof functional or cosmetic donor site morbidity and reliable long-term results[18]. Septal cartilage can be crushed to providevolume augmentation or soften contour transitions. When harvesting septal cartilage, it is important to maintain a 1.0- to1.5-cm L-shaped caudal and dorsal strut. Septal cartilage is however often limited in revision rhinoplasty, therefore, thecartilage may be harvested using an open rhinoplasty approach whereby bilateral submucoperiosteal andsubmucoperichondrial flap elevation is combined with division of the ULCs. Here, the septum and nasal dorsum are laid wideopen with unparalleled exposure for diagnosis, harvest of residual structural material and treatment of structural


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deformities.

Other grafting materials used include auricular cartilage, costochondral (rib) grafts, used for building framework, temporalisfascia and fibroadipose tissue used mainly to camouflage cartilage grafts by softening the frameworksoft tissue interfaceor to correct minor contour irregularities, reducing the risk for graft extrusion, bossae formation and improving the overallquality of the skin envelope[11].

Alloplasts have become increasingly popular due to their ease of use, limitless supply, adaptiability and lack of donor sitemorbidity. Most alloplasts are polymers and include expanded-porous polytetrafluoroethylene (e-PTFE; Gore-Tex) [19]and silicone, which is used primarily in Asian patients who have thick skin [18].

Specific grafting techniques suitable for each nasal region will be discussed below.

Grafts in the Nasal Tip:

These may be broadly classified into columellar struts, onlay tip grafts and shield grafts.

i) Columellar struts

The columellar strut is one of the workhorse grafts in rhinoplasty, providing structural support to the nasal tip andimproving tip projection. The graft is placed between the paired intermediate and medial crura, through a small vertical

incision between the medial crura or through the skin of the nasal vestibule and medial crura on one side. A strongcolumellar strut is indicated in noses with short, weak, or flared medial and intermediate crura[16]. When using an openrhinoplasty approach, the graft is sutured to the medial crura. Care should be taken to avoid unintentional distortion of thenasal tip contour or the infratip lobule. The graft must be placed short of the domes to avoid excessive prominence with a

unidome outline. Preserving a small amount of soft tissue over the nasal spine prevents clicking and displacement of thegraft with lip movement. For greater stability, the columellar strut may be secured to the nasal spine or premaxilla.

Septal or costal cartilage is recommended, although double-layered auricular cartilage will often provide sufficient strength.Using the perpendicular plate of the ethmoid or other bone grafts may be effective but requires perforation before suturing.In the patient who has a dependent caudal septum requiring increased projection, establishing a tongue-in-grooverelationship between the medial crura and the nasal septum will achieve stability similar to a columellar strut without the

need for graft placement [20].

ii) Onlay tip grafts

Onlay tip grafts are positioned over the alar domes as single or multilayer grafts. They are used to camouflage irregularitiesor achieve subtle increases in tip projection. Beveling or morselization of the edges minimizes the likelihood of visibility orpalpability. An umbrella graft is the use of an onlay tip graft in conjunction with a columellar strut where the columellarstrut is the umbrella shaft and the onlay tip graft secured to it forms the umbrella top [18]. Placement of tip grafts overthe tip-defining points will increase tip projection and definition, whereas placement at and below the tip-defining points willincrease projection and add volume to the infratip lobule. It is desirable to secure the grafts within a well-defined pocket.


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iii) Shield grafts

These are shield-shaped grafts which are placed over the medial crura, extending from the medial crural footplates to thenasal tip [18]. They are useful in increasing tip projection, defining the nasal tip and enhancing the contour of the infratipregion but may leave a visible tombstone impression on the overlying skin. They are hence best reserved for patients

with thick skin, with edges extensively bevelled or morselized to minimize visibility. The extended shield graft is anextended columellar strut-tip graft which extends anteriorly beyond the domes to provide added tip projection[12].Shield grafts provide the added benefit of derotation of the overrotated nose. The use of conchal cartilage for this graftimproves its pliability and confers a softer contour, decreasing the risk for a visible graft silhouette after resolution of

oedema.

Grafts of the Alar Region:

Alar batten grafts, alar rim grafts and lateral crural strut grafts are used to increase structural support in cases ofoverresection or inversion of alar concavities, contour irregularities and rim retractions.

i) Alar batten grafts

These curved cartilaginous grafts of septal or conchal origin used to support areas of maximal lateral wall weakness, usuallyposterior to the lateral crura. The curvature of the graft is oriented to lateralize the supra-alar area. The grafts may extendbeyond the pyriform aperture to add maximal support. When lateral recurvature of the native lateral crura impinges on thenostril width, the lateral crura may be sutured to the alar batten grafts for stabilization laterally. An extended lateral cruralstrut graft may be used as an alternative when there is significant alar collapse.

ii) Alar rim grafts

These grafts are useful in the prevention or correction of alar retraction and also provide the alae with sufficient rigidity toresist collapse, such as in cases of cephalic malposition of LLC [12]. Additional uses include correction of alar flare andtreatment o f alar contour irregularity.

iii) Lateral crural struts and lateral crural grafts

These grafts are used when the overall geometry of the nose is projecting, narrow, and thin, with weak cartilaginoussupport. They provide structural reinforcement of the native lateral crura.

Two types of grafts may be used to achieve this [17]. The lateral crural strut is an underlay graft placed between thevestibular lining and undersurface of the lateral crus whilst the lateral crural graft is an overlay graft placed superficial to thelateral crus.

Grafts of the Nasal Dorsum and Middle Vault

In most cases, the middle vault, the ULCs and the internal valve proper angle between the ULC and dorsal septum have


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less functional airway implications than the lateral wall of the nose but airway obstruction can be significant in noses with anarrow middle vault, a projecting dorsum or inferomedial collapse of the ULC and inverted-V deformity (typically iatrogeniccomplications from primary rhinoplasty cartilaginous dorsal reduction). Two commonly used grafts of the nasal dorsumand middle vault are described.

i) Spreader grafts (and extended spreader grafts)

Spreader grafts are long rectangular cartilaginous grafts placed between the dorsal cartilaginous septum and ULC to correctproblems related to a narrow or asymmetric middle vault. They may be used to reconstruct an "open roof" deformity andto smooth the aesthetic brow-tip line[18]. These grafts may also be used in primary rhinoplasty to prevent ULC collapse,such as when reduction of a cartilaginous dorsal hump leads to excision o f the horizontal articulation of the dorsal septumand ULCs. Spreader grafts prevent or correct midvault collapse by stenting open the internal nasal valve, thereby avoidingmedial displacement of the ULCs. They therefore stabilize the middle vault and help restore appropriate horizontal width.

ii) Dorsal onlay graft

These grafts are designed to span the entire length of the nasal dorsum, from the radix to the septal angle, to minimize therisk for palpable irregularities. Although septal or conchal cartilage is usually sufficient for refinement of the nasal dorsum,costal cartilage is indicated in those cases where major augmentation is required, for example in severe saddle nosedeformity, traumatic compressive fractures, or o ther major structural deficits.

IV) Dorsal Refinement

The open approach greatly enhances the performance of techniques for dorsal hump refinement. The soft tissue envelopeis elevated from the bony-cartilaginous framework up to the level of the nasofrontal angle, taking care to undermine justenough to permit adequate hump reduction and subsequent skin redraping. The authors' preference is to use an osteotomefor larger humps and a rasp for smaller reductions and subtle refinements. Slight undercorrection is preferred, followed byfinal smoothing with a fine sharp nasal rasp.

Reduction of the septal and ULC components of the dorsal hump may then be done with a no. 11 blade or angled scissors,with or without first separating the ULCs from their attachment to the dorsal septum. If reduction o f > 3 mm is desired,submucosal separation of the ULCs before dorsal reduction will preserve the support provided by the nasal mucosa below

them. When a lesser reduction is planned, it may generally be performed extramucosally without separating the ULCs fromtheir septal attachment, keeping the nasal mucosa intact. Once the cartilaginous hump is removed, the height of the ULCsrelative to the dorsal septum is examined and its medial borders lowered with a no. 11 blade until they lie level with thedorsal septum or the medial part of the cartilage is folded to for an auto-spreader flap.

V) Osteotomies


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Broken line in midline represents medial osteotomy. Dotted black line represents intermediate (transverseosteotomy).

The potential functional effects of osteotomies on the patients nasal airway should always be considered, with the aim topreserve the periosteum and lateral suspensory ligaments o f the LLCs.

Osteotomies are indicated:

To close an open nasal vaultTo straighten a deviated nasal dorsum;To narrow the nasal sidewalls.

In general, osteotomies should be limited to the thinner aspect of the nasal sidewall [21] . Commonly used osteotomytechniques include the lateral osteotomy performed either with a perforation or linear technique , the medial osteotomy


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and the intermediate osteotomy [22].

Va) The lateral osteotomy

The lateral osteotomies are performed to close an open roo f deformity or to narrow the nasal pyramid. This may beperformed with either the linear (single-cut) or the perforating technique [9]. With the former, the osteotome is used tomake a bony cut along the nasal facial groove. The most widely accepted path of the osteotomy follows a high, low, highpathway [21]. The course of the lateral osteotomy begins at the level of the attachment of the inferior turbinate. A smalltriangle of bone at the pyriform aperture is left intact to preserve the lateral attachments of the suspensory ligaments.Next, the osteotomy is continued along the nasal facial groove until it curves superiorly and anteriorly into the thinneraspect of the nasal bone at the level of the inferior orbit. The cut is then terminated around the level of the medial canthus[23].

With the perforating technique, a series of perforations using a sharp 2-mm straight osteotome are made along the desiredfracture site using a transnasal or transcutaneous approach. With the transcutaneous technique, one or two osteotomysites are marked on the skin and postage stamptype perforations are created through these sites along the desiredosteotomy route[9]. Alternatively, the perforations can be placed intranasally, such that the perforating intranasalosteotomy can also be used to push out the nasal bones which have been medially displaced by previous trauma orsurgery [24] .

The superior backfracture is created by turning the osteotome, applying digital pressure, or using a percutaneoustransverse superior osteotomy. In the latter technique, a small cutaneous puncture is created with a 2-mm osteotome

midway between the nasal dorsum and the medial canthal region. Through this site, the same osteotome is used to create3 or 4 small perforations, allowing the nasal bone to be mobilized without disrupting the overlying periosteal support[9].

Vb) The medial osteotomy

Medial osteotomies are used when the nasal sidewalls have to be mobilised, for example when correcting the deviatednose or narrowing the wide nose without a hump. Medial osteotomies are performed in an angulated manner between thenasal bone and septum and are extended superiorly to meet the superior osteotomy site or back-fractured site. In theseverely deviated or wide nose, the medial osteotomies are considered essential. When less correction is required, cautionis advised as they may actually cause bony irregularities[25].

Vc) The intermediate osteotomy

The main indications are:

To narrow an extremely wide nose that has good nasal height (bilateral osteotomies)To correct a deviated nose with one sidewall much longer than the other,To straighten a markedly convex nasal bone[25].

The intermediate osteotomy is made parallel to the lateral osteotomy along the midportion of the nasal sidewall and can be


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performed more precisely through the open rhinoplasty approach. It is performed before the lateral osteotomy, becausethe intermediate cut cannot be made easily after the bone is mobilized.

Osteotomies in specific clinical scenarios [25]

1. The extremely deviated nose

The above osteotomies may be used in combination to correct any given anatomic deformity of the bony nasal pyramid.These are performed sequentially beginning on the concave side of the deviation, to allow creation of a space in which torealign the deviation. Camouflage graft techniques are also often essential.

2. Short nasal bones

Palpation of the dorsal nasal hump will often reveal a primarily cartilaginous hump in patients who have short nasal bones.The surgeon must avoid both overmobilization of the nasal bones with osteotomies and overresection of the dorsal nasalbones with a rasp or osteotome. The dorsal hump can sometimes be lowered without performing osteotomies. Aperforating osteotomy may be used to preserve maximal soft tissue support. Making a greenstick fracture superiorly isdesirable because it also avoids overmobilization of the delicate, short nasal bones.

3. Wide nose

Removal of a significant hump from the wide nose may result in a wide-open dorsum. Standard osteotomies may allow thenasal bones to be moved medially to close the open roof. Debris or residual wedges of bone or cartilage at the junction ofthe nasal bone and septum must be removed before closure. Bilateral intermediate osteotomies may be necessary toobtain adequate narrowing [25].

VI) Alar Base Narrowing

Wedge and Sill excision


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Excessive alar width due to lateral insertion of ala, repositioning using V-Y advancement with stem of the Yaliened with nasolabial fold

Alar base reduction is best completed as the final step of rhinoplasty often after closure of all incisions. It narrows nasalwidth, reduces nostril size and alters the nostril axis. A prominent alar flare may be created or worsened by alterations to

the lower third of the nose during surgery. Specifically, reduction procedures that decrease tip projection may increase theamount of alar flaring. If there is any doubt at the completion of rhinoplasty that alar reduction is needed, then theprocedure should be deferred [26]. The authors feel that reduction of nasal base width should be considered when theinteralar distance exceeds the intercanthal distance in the Caucasian patient but ethnic differences and personal preferencesshould be considered.

The three basic techniques to effect this change are alar base excision, nasal sill excision and V-Y advancement [9, 27].The goals of alar base excision are to avoid overstraightening the ala, preserve the natural curvature of the ala and avoidtelltale incisions into the nostril opening. A wedge resection along the rounded caudal margin of the alar lobule decreasesthe amount of alar flare. This maneuver may be used together with nasal sill excision, for correction of the excessive flarewith enlarged nasal sill width [28]. A relative indication for sill reduction is when the nostril is enlarged and has a horizontalaxis [26]. If the lateral insertion of the ala is responsible for excessive nasal base width, then it may be repositioned with a

V-Y advancement [29].

Closure


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Closure involves careful skin redraping, external contouring, and shaping. The septal mucosal flaps are closed with quilted 4-0 absorbable Vicryl sutures. To avo id a step deformity of the columella, meticulous closure of the transcolumellar incisionwith 6-0 Prolene interrupted sutures is vital. As the incision heals, there may be a trapdoor effect of the flap which is mostprominent at the junction of the vertical and transverse incision. This can be avoided effectively by undermining the inferiorcolumellar flap.

In cases of reduced nasal projection, there may be excess tissue in the columellar flap, which may lead to columellarhanging. Equally, where the tip has been projected, excessive tension may result due to lack of skin. To reduce this, thevertical margin incision can be bilaterally extended inferiorly to allow the inferior flap to be advanced.

The nasal dorsum is splinted with cheek-to-cheek Steri-strips. A thermoplastic splint is fabricated for additional externalsupport in the perioperative period. No other packing is usually used. The patient is advised to use Fucidin ointment daily tokeep the external incision moist.

Followup

Patients are seen at 1 week for suture removal and 1 month postoperatively. Further follow-up visits are scheduled asneeded thereafter. At each visit photography is performed.

COMPLICATIONS

Compared to the closed approach, an open approach rhinoplasty carries virtually the same risks, apart from an externalscar which usually heals well and remains hidden from view [7]. The risk of complications is higher in revision casesbecause of scarring and tissue manipulation as summarised below [30] .Intraoperative complications

Excessive bleedingTears of mucoperichondrial flapsButtonholing of skinCollapse of bony pyramidDisarticulation of ULCOsteotomy complications

"Rocker" deformityOpen roof deformity

Early postoperative complications

HemorrhageSeptal hematomaInfectionPersistent oedemaSkin necrosis


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Sequestra formationOlfactory disturbances

Late postoperative complications

Scar hypertrophyPolly beak nasal deformitySynechiae formationSeptal perforationNasal valve collapseVestibular stenosisRevision rhinoplasty

CONCLUSION

The open rhinoplasty approach offers unparalleled exposure of nasal anatomy, structural nasal deformities and is also aninvaluable educational tool for the trainee. It allows for precise diagnosis and correction of deformities. These advantagesmake it a greatly valued technique in the armamentarium of the facial plastic surgeon and ensure its continued usage in thefuture.

References

1. Rethi, A., Operation to shorten an excessively long nose.Rev Chir Plast, 1934(2): p. 85-7.2. Sercer, A., [Nasal decortication and its value in cosmetic surgery].Rev Laryngol Otol Rhinol (Bord), 1957. 78(3-4): p.161-8.3. Padovan, T., External approach in rhinoplasty (decortication).Symp ORL, 1966(4): p. 354.4. Anderson, J.R., C.M. Johnson, Jr., and P. Adamson, Open rhinoplasty: an assessment.Oto laryngol Head Neck Surg,1982. 90(2): p. 272-4.5. Wright, W.K. and R.W. Kridel, External septorhinoplasty: a tool for teaching and for improved results.Laryngoscope,1981. 91(6): p. 945-51.6. Gunter, J.P., The merits of the open approach in rhinoplasty.Plast Reconstr Surg, 1997. 99(3): p. 863-7.7. Sheen, J.H., Closed versus open rhinoplasty--and the debate goes on.Plast Reconstr Surg, 1997. 99(3): p. 859-62.

8. Adamson, P.A. and S.K. Galli, Rhinoplasty approaches: current state of the art.Arch Facial Plast Surg, 2005. 7(1): p.32-7.9. Adamson, P.a.L., J., Open rhinoplasty, in Facial Plastic and Reconstructive Surgery, I. Papel, Editor. 2009, Thieme. p.529-47.10. Mangat, D.S. and B.J. Smith, Septoplasty via the open approach.Facial Plast Surg, 1988. 5(2): p. 161-6.11. Whitaker, E.G. and C.M. Johnson, Jr., The evolution of open structure rhinoplasty.Arch Facial Plast Surg, 2003. 5(4):p. 291-300.12. Smith, T.W., Thoughtful nasal tip surgery.Arch Otolaryngol, 1973. 97(3): p. 244-6.13. Murakami, C.S., J.E. Barrera, and S.P. Most, Preserving structural integrity of the alar cartilage in aesthetic rhinoplasty


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using a cephalic turn-in flap.Arch Facial Plast Surg, 2009. 11(2): p. 126-8.14. Tardy, M.E., Jr., B.S. Patt, and M.A. Walter, Transdomal suture refinement of the nasal tip: long-term outcomes.FacialPlast Surg, 1993. 9(4): p. 275-84.15. Simons, R.L., Vertical dome division in rhinoplasty.Otolaryngol Clin North Am, 1987. 20(4): p. 785-96.16. Tardy, M.E., Jr., J. Denneny, 3rd, and M.H. Fritsch, The versatile cartilage autograft in reconstruction of the nose andface.Laryngoscope, 1985. 95(5): p. 523-33.17. Kridel, R.W. and R.J. Konior, Controlled nasal tip rotation via the lateral crural overlay technique.Arch Otolaryngol HeadNeck Surg, 1991. 117(4): p. 411-5.18. Brenner, M.J. and P.A. Hilger, Grafting in rhinoplasty.Facial Plast Surg Clin North Am, 2009. 17(1): p. 91-113, vii.

19. Conrad, K., C.S. Torgerson, and G.S. Gillman,Applications of Gore-Tex implants in rhinoplasty reexamined after 17years.Arch Facial Plast Surg, 2008. 10(4): p. 224-31.20. Johnson, C.M., Jr. and Toriumi, DM, Open Structure Rhinoplasty. 1990: WB Saunders. 516.21. Larrabee, W.F., Jr. and C. Murakami, Osteotomy techniques to correct posttraumatic deviation of the nasal pyramid: atechnical note.J Craniomaxillofac Trauma, 2000. 6(1): p. 43-7.22. Aufricht, G.,Joseph's rhinoplasty with some modifications.Surg Clin North Am, 1971. 51(2): p. 299-316.23. Anderson, J.R.,A new approach to rhinoplasty.Trans Am Acad Ophthalmol Otolaryngol, 1966. 70(2): p. 183-92.24. Rohrich, R.J., et al., The lateral nasal osteotomy in rhinoplasty: an anatomic endoscopic comparison of the externalversus the internal approach.Plast Reconstr Surg, 1997. 99(5): p. 1309-12; discussion 1313.25. Larrabee, W., Open rhinoplasty and the upper third of the nose.Facial Plast Surg Clin North Amer, 1993(1): p. 23-38.26. Kridel, R.W. and R.D. Castellano,A simplified approach to alar base reduction: a review of 124 patients over 20 years.

Arch Facial Plast Surg, 2005. 7(2): p. 81-93.27. Weir, R.F., On restoring sunken noses without scarring the face. 1892.Aesthetic Plast Surg, 1988. 12(4): p. 203-6.28. Aufricht, G., Rhinoplasty and the face.Plast Reconstr Surg, 1969. 43(3): p. 219-30.29. Bernstein, L., Esthetic anatomy of the nose.Laryngoscope, 1972. 82(7): p. 1323-30.30. Cochran, C.S. and A. Landecker, Prevention and management of rhinoplasty complications.Plast Reconstr Surg, 2008.122(2): p. 60e-7e.

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