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Basic Open Rhinoplasty

Updated: Jun 04, 2017
Author: Jugpal S Arneja, MD, MBA, FRCSC; Chief Editor: Mark S Granick, MD, FACS more...

OVERVIEW

Background
Rhinoplasty modifies the functional properties and aesthetic appearance of the nose through
operative manipulation of the skin, underlying cartilage, bone, and lining. The incision type that the
surgeon uses classifies the rhinoplasty as open or closed. In open rhinoplasty, the surgeon makes
a small incision in the columella between the nostrils and then makes additional incisions inside the
nose. Closed rhinoplasty involves incisions only in the interior of the nose.

History of the Procedure

The Ebers Papyrus from Egypt (dating from ~3500 BCE) included a discussion of nasal
reconstruction secondary to rhinectomy for punishment. In 800 BCE, Sushruta performed nasal
reconstruction with a pedicled forehead flap. In the 1500s, Tagliacozzi introduced delayed arm-
based flaps for nasal reconstruction. In the 1750s, Quelmatz advocated daily digital pressure for
septal deformities. In 1845, Diffenbach made external skin incisions to change the shape of the
nose. In 1887, Roe performed the first cosmetic rhinoplasty secondary to a pug nose deformity.

In the early 1900s, Killian and Freer pioneered submucous resection septoplasty. Peer and
Metzenbaum performed the first manipulation of the caudal septum in 1929. In 1947, Cottle
performed a hemitransfixion incision with conservation of the septum and became a strong
advocate of the closed approach. In the 1990s, Sheen advanced their early teachings and also
advocated the closed approach.

With respect specifically to open rhinoplasty, Rethi first introduced the columellar incision for open
rhinoplasty for tip modification in 1921. [1] In 1957, Sercer advocated the open approach to the
nasal cavity and nasal septum with the use of a columellar incision, calling the procedure "nasal
decortication." For the next 15 years, open rhinoplasty fell out of favor until Padovan presented his
series in the early 1970s, advocating open rhinoplasty. Also in the 1970s, Goodman further
promoted the case for the open approach. [2] In the 1990s, Gunter became an advocate of the
open approach. [3]

The debate continues today over the advantages and disadvantages of an open versus closed
approach to rhinoplasty. [4, 3, 5, 6, 7]

Problem
Rhinoplasty may be performed to correct various problems, including (1) intrinsic and extrinsic
nasal pathology, (2) unsatisfactory aesthetic appearance, (3) abnormalities resulting from previous
rhinoplasties, (4) airway obstruction, and (5) congenital nasal anomalies.

Etiology
Conditions that may necessitate rhinoplasty can be divided into congenital and acquired etiologies.

Congenital etiologies include the following:

Cleft lip or palate nasal deformity

Congenital nasal anomalies
Ethnic or genetic characteristics

Acquired etiologies include the following:

Traumatic deformities
Nasal fractures
Nasoorbitoethmoidal fractures
Septal hematomas
Bites
Burns
Infections (eg, syphilis)
Malignancies
Allergic and vasomotor rhinitis
Toxins (eg, cocaine)
Inflammatory conditions
Connective-tissue diseases
Autoimmune diseases

Presentation
History
A complete history must be obtained from the patient as part of the clinical evaluation. The patient
must explain the functional and aesthetic problems for which they present. Important questions
include symptoms and duration, past interventions, allergies, substance use or abuse,
medications, and a complete general medical history. Patient motivation for rhinoplasty is a critical
portion of the preoperative evaluation. Male patients with the personality traits summarized as
SIMON (single, immature, male, overly expectant, narcissistic) should be identified during the
patient history.

Physical

A complete physical examination is also essential. A complete head-to-toe cursory examination is

performed, and any problems are noted. Preoperative consultation with an anesthesiologist is
arranged, if warranted. A specific facial and nasal evaluation follows, with the facial analysis
including skin type, surgical scars, symmetry, and balance of facial aesthetic units.

An external examination is performed of the superior, middle and inferior thirds of the nose.
Specifically, the structure, external nasal angles, and bony and soft tissue characteristics are
noted. An internal examination follows, during which the nasal septum, internal and external nasal
valves, turbinates, and lining are evaluated. Additional attention is directed to the structure and
form of the nasal tip and dorsum. Specific tests, when warranted, include the Cottle maneuver, the
mirror test, and examinations with vasoconstriction.

Photography
For the benefit of patients and physicians, the authors advocate photographic documentation
during the preoperative consultation, during the procedure, and after the procedure is complete.
Specifically, the authors photograph the nose in the anteroposterior, lateral, worm's eye, bird's eye,
and three-quarter profile views.
Indications
Indications for open rhinoplasty include the following:

Nasal tip modification

Internal nasal valve dysfunction
Thick nasal skin
Repair of septal perforations
Patient is a member of certain non-Caucasian ethnic groups
Posttraumatic nasal deformity with a deviated septum or dorsum
Major augmentation with tip, columellar, spreader, and/or shield grafts
Cleft lip and palate nasal deformity
Nasal tumor excision
Educational tool for trainees
Secondary rhinoplasty [8, 9]
Thin skin where accurate sculpting is important

Advantages of open rhinoplasty include (1) direct exposure, inspection, and assessment of the
osseocartilaginous framework; (2) precise modification and stabilization of the abnormality (tip and
dorsum modification, graft placement, osteotomies); and (3) excellent tool for training purposes. [10,
11]

Disadvantages of open rhinoplasty include (1) transcolumellar scar and potential for columellar flap
necrosis, (2) extensive dissection of skin off the osseocartilaginous framework with increased
scarring, (3) increased operative time (compared with closed rhinoplasty), and (4) postoperative
nasal tip edema and numbness.

Contraindications
See the list below:

Intranasal substance abuse (eg, cocaine)

Psychological or psychiatric instability
SIMON (single, immature, male, overly expectant, narcissistic) personality traits
Comorbid medical conditions that preclude surgical clearance
Preoperative diagnosis of nasal dysfunction (with or without aesthetic deformity) that may be
better treated with a closed approach (ie, septoplasty for airway obstruction) or medical
management
Patient refusal of external scar
Very thick nasal skin in which postoperative edema can be permanent

Workup

References

1. Rethi A. Operation to shorten an excessively long nose. Rev Chir Plast. 1934. 2:85.

2. Goodman WS, Charles DA. Technique of external rhinoplasty. J Otolaryngol. 1978 Feb.
7(1):13-7. [Medline].

3. Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr Surg. 1997 Mar.
99(3):863-7. [Medline].

4. Aiach G. Atlas of Rhinoplasty: Open and Endonasal Approaches, Second Edition. Plast
Reconstr Surg. 2005 May. 115(6):1778-9.
 5. Sheen JH. Closed versus open rhinoplasty--and the debate goes on. Plast Reconstr Surg.
1997 Mar. 99(3):859-62. [Medline].

6. DeFatta RJ, Ducic Y, Adelson RT, Sabatini PR. Comparison of closed reduction alone versus
primary open repair of acute nasoseptal fractures. J Otolaryngol Head Neck Surg. 2008 Aug.
37(4):502-6. [Medline].

7. Anderson JR. The future of open rhinoplasty. Facial Plast Surg. 1988 Winter. 5(2):189-90.
[Medline].

8. Daniel RK. Secondary rhinoplasty following open rhinoplasty. Plast Reconstr Surg. 1995 Dec.
96(7):1539-46. [Medline].

9. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg.
1987 Aug. 80(2):161-74. [Medline].

10. Friedman GD, Gruber RP. A fresh look at the open rhinoplasty technique. Plast Reconstr
Surg. 1988 Dec. 82(6):973-82. [Medline].

11. Gruber RP. Open rhinoplasty. Clin Plast Surg. 1988 Jan. 15(1):95-114. [Medline].

12. Bitik O, Uzun H, Kamburoglu HO, et al. Revisiting the role of columellar strut graft in primary
open approach rhinoplasty. Plast Reconstr Surg. 2015 Apr. 135(4):987-97. [Medline].

13. Bertossi D, Walter C, Nocini PF. The pull-up spreader high (PUSH) technique for nasal tip
support. Aesthet Surg J. 2014 Nov. 34(8):1153-61. [Medline].

14. Crosara PF, Nunes FB, Rodrigues DS, et al. Rhinoplasty Complications and Reoperations:
Systematic Review. Int Arch Otorhinolaryngol. 2017 Jan. 21 (1):97-101. [Medline]. [Full Text].

15. Teichgraeber JF, Russo RC, Riley WR. External rhinoplasty technique. Ann Plast Surg. 1990
Nov. 25(5):388-96. [Medline].

Media Gallery

Local infiltration of anesthesia.

Endonasal 4% cocaine packings.
Iodine preparation of the operative field.
Location of incision.
Incision.
Exposure.
Septoplasty.
Septoplasty.
Alar cartilage resection.
Alar cartilage resection.
Nasal tip modification.
Nasal tip.
Osteotomies.
Nasal dorsum.
Nasal dorsum.
Graft harvest.
Graft harvest.
Graft harvest.
Cartilage crushing.
Crushed cartilage.
Graft placement.
Closure.
Closure.
Packing and splinting.
of 24

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Contributor Information and Disclosures

Author

Jugpal S Arneja, MD, MBA, FRCSC Professor (Clinical), Division of Plastic Surgery, University of
British Columbia Faculty of Medicine, Canada

Jugpal S Arneja, MD, MBA, FRCSC is a member of the following medical societies: American
Academy of Pediatrics, American Burn Association, American Cleft Palate-Craniofacial
Association, American College of Surgeons, American Society of Maxillofacial Surgeons, American
Society of Plastic Surgeons, Canadian Medical Association, Canadian Society of Plastic Surgeons,
Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Coauthor(s)

G Balbir Singh, MD, FRCS Head, Section of Plastic Surgery, St Boniface Hospital; Associate
Professor, Department of Surgery, University of Manitoba Faculty of Medicine, Canada

G Balbir Singh, MD, FRCS is a member of the following medical societies: American College of
Surgeons, Canadian Medical Association, International College of Surgeons

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Mark S Granick, MD, FACS Professor of Surgery, Chief, Division of Plastic Surgery, Rutgers New
Jersey Medical School

Mark S Granick, MD, FACS is a member of the following medical societies: American College of
Surgeons, American Society of Plastic Surgeons, New Jersey Society of Plastic Surgeons,
Northeastern Society of Plastic Surgeons, Phi Beta Kappa, Wound Healing Society

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Novadaq<br/> for:

Misonix, Inc, medical consultant; Dermasciences, medical consultant; Convatec, medical
consultant; Cytori, medical consultant.

Additional Contributors
Frederick J Menick, MD Clinical Associate Professor, Department of Surgery, Division of Plastic
Surgery, University of Arizona College of Medicine; Facial and Nasal Reconstructive Surgeon,
Tucson, Arizona

Frederick J Menick, MD is a member of the following medical societies: American Society of

Maxillofacial Surgeons, Canadian Society of Plastic Surgeons, American Society for Aesthetic
Plastic Surgery, American Society of Plastic Surgeons

Disclosure: Nothing to disclose.