Put the Nose First, Not the Incision

Posted Tuesday, September 11, 2007 to PROCEDURES > Face

Posted by The Original Anti-Aging & Cosmetic Surgery Magazine

New York plastic surgeon Norman V Godfrey MD explains why both the open and closed techniques of rhinoplasty have benefits depending on the result desired and the anatomical structure of the individual nose.

In browsing the Web for rhinoplasty information, I was struck by the profusion of hype masquerading as valid, useful data for the patient interested in rhinoplasty. For this article I have chosen the issue of rhinoplasty incisions for detailed clarification. I see a growing number of surgeons who tout themselves as the surgeon-of-choice because they ALWAYS use open rhinoplasty approach. Still others suggest they are to be preferred because they NEVER use open rhinoplasty approach. Both of these 'philosophies' have the potential to mislead the patient into faulty thinking and subsequently to a rhinoplasty result that is less than the best possible result. At the core of the problem is the failure to recognize that the ultimate objective of the patient is not one incisional approach or another. Rather, the objective is the best possible esthetic result. Codifying one incisional approach as the supreme for all patients ignores this all-important truth and fails to capitalize on the strengths and weaknesses of each approach.

First described in the US in 1887, closed (or endonasal) rhinoplasty has been the standard approach in the Western world for over a century Although the external (or open) approach incision was first described in Eastern Europe in 1921, it did not enjoy any recognition in the Western world until its introduction in the 1970's. It did not enjoy any widespread use until the last 20 years. In the author's opinion, it has offered a significant improvement in the quality of rhinoplastic surgical results for a significant subset of patients. Unfortunately, it has also engendered the kind of surgeon-centered marketing hype to which I referred above. A short tutorial on rhinoplasty incisions should help patients see past this type of misinformation to the important core concepts.

Today, virtually every cosmetic rhinoplasty is performed via one of two basic incisional approaches. Endonasal rhinoplasty is performed entirely through incisions that are confined to the interior aspects of the nose.As a result, all resulting scars are confined to the interior of the nose.Open rhinoplasty combines similar internal incisions with an external incision across the columella. The columella is the little central pillar between the nostrils.This external incision connects between the internal incisions in the nostrils and results in a scar across the external surface of the columella.

With the endonasal approach, the external nasal skin is left intact and in place. As a result, the surgeon can only visualize the underlying nasal tip cartilages incompletely. The surgeon sees them best by buckling them down into their respective nostrils. Structures of the profile of the bridge and the bony width are seen through the nostrils or are assessed and corrected by feel alone. Endonasal approach offers the experienced surgeon excellent ability to correct the bridge profile, the width of the nose and to make precise changes in the position and angle of the tip of the nose as a whole. However, the surgeon may be restricted in the ability to correct deformities of the shape and symmetry of the tip cartilages because of the inability to see and adjust the cartilages directly in their undistorted position.

With the open rhinoplasty approach, the addition of the transcolumellar incision permits lifting of the nasal skin off the tip cartilages. This is done in a manner not unlike lifting the hood of a car.This permits not just a better view of the tip cartilages, but a view of those cartilages in their undistorted, undisplaced position. Accessing the intact and undisplaced structures of the nasal tip gives the surgeon an unequalled opportunity to achieve pleasing, stable, reversible, nondestructive changes to the shape, size, and relationships of the nasal tip cartilages. For this reason, the surgeon is better able to correct many esthetic tip deformities. Many of these types of changes are difficult or impossible to create through endonasal approach. While the open rhinoplasty approach also offers somewhat better visualization of the lower bridge profile, in most cases it does not confer significantly greater ability to carefully refine the profile. Furthermore, alteration of the bony width is equally well performed through both approaches because separate incisions and a reliance on feel are utilized. In addition, open rhinoplasty approach results in a scar on the external surface of the columellla. Although its location and characteristic good healing mean that the scar is typically unobtrusive, it must be acknowledged as a DISADVANTAGE of open rhinoplasty.

Because of this trade-off, open rhinoplasty is only desirable when the enhanced ability to create a better looking nose compensates the patient for the scar.

Since each patient's nose is unique in the details of its shape, it is inappropriate to suggest that either incisional approach is universally best.

Many patients that I see in consultation for rhinoplasty have esthetic problems with the profile and width of their nasal bridge, and the position and attitude of their nasal tip, and not with the shape of the individual tip cartilages themselves. These patients can be beautifully corrected endonasally and without the creation of an external scar. On the other hand, there are also many patients who manifest esthetic difficulties with the dimension, Shape and relationship of their tip cartilages and nasal septum. These patients can usually be better corrected with suture techniques that can only be performed via the open approach, and the scar is a small price to pay for a much more attractive correction. To summarize: I advise prospective patients to consider 1) the esthetic problems 2) the anatomic basis of the problems 3) the surgical techniques appropriate to correct the anatomy and 4) the incisional approach dictated by those techniques. In other words, put the NOSE first, not the incision.

Add Comment

To discourage SPAM, we ask that you type your code (displayed below) in the text box.

Your Code:
Enter Code:	*