Open Rhinoplasty: A Personal Evolution of Technique.

Abstract

Rhinoplasty remains one of the most commonly performed aesthetic surgical procedures, and the open approach has gained more popularity.1,2 Closed rhinoplasty can address dorsal hump deformities, with minimal tip modification.1 Meanwhile, the open approach provides undistorted exposure of the nasal anatomy, allowing for greater accuracy in the diagnosis and approach to nasal obstruction or deformity.1–3 Many trainees and young plastic surgeons become accustomed to the way they were taught rhinoplasty. As an otolaryngology resident, I was taught to commence a rhinoplasty with marginal incisions. Once through the vestibular skin, the lower lateral cartilages are revealed and the nasal dorsum and sidewalls are undermined blindly with a Littler scissor. This was imprecise, often leading to out-of-plane dissections and subsequent bleeding. One reform I have made in fellowship under the direction of my program director (P.B.) is to first make the transcolumellar incision. Once the skin–soft tissue envelope is elevated, the medial crura are dissected and followed superolaterally to then dissect the lateral crura. Staying on cartilage with this technique helps the surgeon to stay in the right plane and maintain hemostasis. Next in the sequence of performing a proper rhinoplasty, the anterior septal angle needs to be identified to allow for proper mucoperichondrial dissection and cartilage release.4 It is especially important to start a septoplasty and dorsal work. The anterior septal angle represents the anteriormost projecting point of the septum, contributing to nasal tip support, projection, length, and airway function. In secondary rhinoplasty, its identification is paramount because it is usually one of the landmarks that is preserved, serving as a guide when anatomical planes have been scarred or are even missing.4 In residency, we retracted the domes laterally with single skin hooks to identify the anterior septal angle. This commonly traumatized the nasal cartilages, rendering them prone to damage or avulsion. In addition, the tactile feedback was not optimized. In fellowship, I have learned to handle cartilage delicately with Adson-Brown forceps (Fig. 1). This change has allowed me to preserve the integrity of the cartilages while maintaining proper control and feedback. Adson-Brown forceps are precise because they allow one grasp at a time from a single point.5 Another modification I have made is the process by which I identity the anterior septal angle. In residency, I would turn my Iris scissors parallel between the medial crura to find the caudal septum low as it takes off from the anterior nasal spine. In fellowship, I have transitioned to beginning my dissection superiorly under the direction of the senior author (P.B.) (Fig. 2). The septum has more stability at this position, thus making it less prone to fracture. In addition, we find this location easier to begin the mucoperichondrial dissection.Fig. 1.: Lower lateral cartilages being handled delicately with Adson-Brown forceps while maintaining tactile feedback.Fig. 2.: Dissection of the anterior nasal spine superiorly, allowing for easier identification and mucoperichondrial dissection.Although these nuances may seem subtle, they can impact the final result. Throughout one’s training and subsequent career, surgeons should be encouraged to reform their surgical technique and the use of surgical instruments accordingly. PATIENT CONSENT The patient provided written consent for use of the patient’s images. DISCLOSURE The authors report no financial disclosures or conflicts of interest. Jason E. Cohn, D.O.Sunrise Facial PlasticsLindenhurst, N.Y. Katherine Chemakin, B.S.Albert Einstein College of MedicineBronx, N.Y. Paige Bundrick, M.D.Department of Otolaryngology–Head and Neck SurgeryDivision of Facial Plastic Reconstructive SurgeryOchsner Louisiana State University of HealthShreveport, La.