Procedures & Techniques

Exploring surgical approaches, non-surgical alternatives, and the latest advancements in rhinoplasty

Surgical Approaches

There are two primary surgical approaches to rhinoplasty: open and closed. Each has distinct advantages and considerations that surgeons weigh when determining the best approach for a particular patient.

Open Rhinoplasty

Open rhinoplasty involves making a small external incision on the columella (the tissue between the nostrils) in addition to internal incisions. This approach offers several advantages:

● Enhanced Visibility: Provides direct visualization of nasal structures, allowing for precise modifications
● Better Access: Facilitates more complex procedures, especially those involving the nasal tip
● Educational Value: Ideal for teaching purposes and documentation
● Precise Grafting: Allows for more accurate placement of cartilage grafts

However, open rhinoplasty does have some drawbacks:

● External scar (though typically very small and fades over time)
● Potentially longer operative time
● Possibly more postoperative swelling and a longer recovery period

Closed (Endonasal) Rhinoplasty

Closed rhinoplasty involves making all incisions inside the nose, with no external incisions. This approach offers:

● No Visible Scarring: All incisions are hidden inside the nose
● Potentially Less Swelling: May result in less postoperative edema
● Shorter Operating Time: Can be quicker for straightforward cases
● Preservation of Support Structures: May better maintain certain anatomical relationships

Limitations of closed rhinoplasty include:

● Limited visibility of nasal structures
● More challenging for complex cases
● Steeper learning curve for surgeons
● Potentially less precise for certain tip modifications

Choosing Between Approaches

The decision between open and closed approaches depends on several factors:

Complexity of the case
Specific anatomical concerns
Need for grafting
Surgeon's experience and preference
Patient's goals and preferences

Many surgeons use both approaches, selecting the most appropriate one for each individual case. Some may also employ a "hybrid" approach that combines elements of both techniques.

Common Techniques

Rhinoplasty encompasses a variety of techniques that surgeons employ to address specific nasal concerns:

CARTILAGE GRAFTING

Cartilage grafts are pieces of cartilage harvested from various donor sites and used to augment, support, or reshape nasal structures. Common donor sites include:

● Septal Cartilage: From the nasal septum (preferred source when available)
● Auricular Cartilage: From the ear (conchal bowl)
● Costal Cartilage: From the ribs (used for major reconstructions or revision cases)

Common types of grafts include:

● Spreader Grafts: Placed between the upper lateral cartilages and septum to widen the middle vault and improve airflow
● Shield Grafts: Used to define and project the nasal tip
● Columellar Strut: Provides support and projection to the nasal tip
● Dorsal Onlay Grafts: Used to augment or smooth the nasal bridge
● Alar Contour Grafts: Provide definition to the alar rim and prevent collapse

OSTEOTOMIES

Osteotomies are controlled fractures of the nasal bones used to:

● Narrow a wide nasal bridge
● Close an open roof deformity after hump removal
● Straighten a crooked nose
● Correct asymmetries of the bony pyramid

Types of osteotomies include:

● Lateral Osteotomies: Most common, used to narrow the nasal bones
● Medial Osteotomies: Used to mobilize the nasal bones from the midline
● Intermediate Osteotomies: Additional cuts made between lateral and medial osteotomies for better control
● Percutaneous Osteotomies: Performed through small skin punctures

TIP MODIFICATION

Nasal tip surgery (tip plasty) is often considered the most challenging aspect of rhinoplasty. Techniques include:

● Suture Techniques: Used to refine and shape the tip cartilages without excision
● Cephalic Trim: Removal of the upper portion of the lower lateral cartilages to refine the tip
● Tip Grafts: Various grafts used to add definition, projection, or support
● Tongue-in-Groove: Technique to set the relationship between the septum and columella
● Lateral Crural Spanning Sutures: Used to control the convexity of the lower lateral cartilages

PRESERVATION RHINOPLASTY

A relatively recent advancement in rhinoplasty, preservation techniques focus on preserving the natural structures of the nose rather than resecting and reconstructing them. Key concepts include:

● Dorsal Preservation: Maintains the dorsal aesthetic lines by lowering the entire dorsum as a unit rather than resecting the hump
● Septal Preservation: Maintains the integrity of the septal L-strut
● Tip Preservation: Preserves the natural tip support mechanisms

Advantages include potentially more natural results, better preservation of function, and possibly less postoperative edema.

Non-Surgical Alternatives

For patients seeking nasal improvements without surgery, several non-surgical options have emerged:

INJECTABLE FILLERS (LIQUID RHINOPLASTY)

Non-surgical rhinoplasty using injectable fillers has gained popularity for its immediate results and minimal downtime. This procedure involves:

● Using hyaluronic acid fillers (such as Juvederm or Restylane) or calcium hydroxylapatite (Radiesse)
● Strategic injection to camouflage bumps, improve symmetry, or enhance tip projection
● 15-30 minute office procedure with immediate results
● Results lasting 6-18 months, depending on the filler used

Limitations include:

● Cannot reduce the size of the nose
● Not suitable for major structural changes
● Temporary results requiring maintenance
● Potential risks including vascular complications

THREAD LIFTS

Thread lifts use dissolvable sutures to provide subtle lifting and support to the nasal tip. Benefits include:

● Minimally invasive procedure
● Can provide modest tip elevation
● Results lasting 1-2 years

NASAL RESHAPING DEVICES

Various external devices claim to reshape the nose without surgery:

● Nose shapers and clips
● Nasal exercises

However, scientific evidence supporting the effectiveness of these devices is limited.

Latest Advancements

The field of rhinoplasty continues to evolve with several notable advancements:

These advancements continue to improve outcomes, reduce complications, and expand the possibilities of what can be achieved through rhinoplasty.

3D Imaging and Planning

Three-dimensional imaging technology has revolutionized rhinoplasty planning:

● Allows for precise preoperative analysis
● Facilitates communication between surgeon and patient
● Enables virtual simulation of potential outcomes
● Can be used to create custom-designed implants or guides

Ultrasonic Rhinoplasty

Ultrasonic instruments (piezosurgery) offer several advantages for bone work:

● Precise bone cutting without damaging surrounding soft tissues
● Reduced trauma and bleeding
● Potentially less postoperative swelling and ecchymosis
● Ability to perform precise sculptural work on nasal bones

Structural Rhinoplasty

The structural approach emphasizes:

● Maintaining or enhancing nasal function
● Preserving or reconstructing key support mechanisms
● Using grafts to reinforce rather than just reshape
● Long-term stability of results

Ethnic-Specific Approaches

There is increasing recognition of the importance of ethnicity-specific approaches:

● Respecting cultural and ethnic aesthetic ideals
● Understanding anatomical variations among different ethnic groups
● Tailoring techniques to address specific concerns while preserving ethnic identity