16 The Closed Rhinoplasty

Mark G. Albert

Abstract

Closed rhinoplasty, or endonasal rhinoplasty, was the first approach used to surgically modify the nose in the 19th century. Since the open approach gained popularity in the 1970s, trainees have generally considered this technique easier to visualize anatomy and observe surgical maneuvers. Once a surgeon understands the basics of closed rhinoplasty, the unique benefits of this approach can be seen. This chapter provides a concise guide to the fundamentals of closed rhinoplasty.

Endonasal – closed – rhinoplasty – delivery – cartilage

16 The Closed Rhinoplasty

Key Points

Closed rhinoplasty involves surgical maneuvers to alter the surface anatomy of the nose. By leaving the skin and soft tissue envelope down, the surgeon can see the immediate effect of these maneuvers.
By leaving nasal soft tissue undisturbed, and avoiding external incisions, the risk of deformity and complications is minimized.
Variations in closed techniques allow surgeons to make decisions based on the goals of each patient. Some closed rhinoplasty surgeons prefer to leave the cartilage within the nose and add grafts, others routinely perform intracartilaginous incisions to access the lower lateral cartilage, and others favor tip delivery.

16.1 Preoperative Steps

Establish the primary concerns of the patient. Understand why the patient is seeking rhinoplasty. Determine whether he or she has breathing concerns.
Inquire about prior surgery or trauma to the nose as well as medical history, smoking history, medications, and recreational drug use (i.e., cocaine).
Perform an intranasal speculum examination and assess the septum, turbinates, and the internal and external nasal valves.
Palpate the nose to determine the length of the nasal bones and stability of the upper and lower lateral cartilage.
Assess for body dysmorphic disorder. If there is suspicion of the condition, one should use a screening questionnaire such as the Body Dysmorphic Disorder Questionnaire (BDDQ).

16.1.1 Analysis

Begin by asking the patient what he would specifically like addressed during the rhinoplasty. Provide a mirror for patients to point out exactly their concerns and document this conversation thoroughly. Photo-editing software can be a useful tool to communicate with patients in the preoperative period as long as patient’s expectations are appropriately managed.
Tell the patient the maneuvers you plan to do and consider explaining step-by-step how you will achieve the goals. Not only does this satisfy part of the informed consent process, many patients appreciate having a thorough understanding of what will be happening on the day of surgery.
While analyzing the nose in front, oblique, profile, and base views, examine the nose top-down by upper, middle, and lower one-thirds. This order is based on surgeon’s preference. Rohrich’s 10–7-5 rule provides guidelines for a thorough evaluation of anatomic features of each nose.
Contact the patient by phone the day before surgery to summarize the plan, review nil per os (NPO) requirements, answer questions, and provide reassurance.

16.2 Operative Steps

See Video 16.1.

16.2.1 Opening the Nose

Following skin prep and placement of a head drape, vibrissae are cut and collected with an ointment-coated cotton-tip applicator.
The nose is infiltrated with 6 to 8 cc of 1% lidocaine with epinephrine 1:100,000 and 10 minutes are allowed for vasoconstriction. Afrin-soaked pledgets are then inserted until the procedure begins.
A #15 blade is used to make an intercartilaginous incision on the left and right sides sequentially. The incisions are carried to the mucosa on the medial aspect of the nares (Fig. 16.1).
Using a double hook for counter-traction, a full transfixion incision is made and is often connected with the intercartilaginous incisions for tip delivery.
The depressor septi nasi muscle can be freed from the incisive foramen of the maxilla using a Joseph elevator as indicated.

Fig. 16.1 Intercartilaginous and infracartilaginous incisions. Intercartilaginous incisions are made on the cephalic aspect of the lower lateral cartilages to avoid scarring and stricture of the internal valve. These incisions are often lengthened to join the full transfixion incision to allow for cartilage delivery. Infracartilaginous incisions closely follow the caudal margin of the lower lateral cartilages.

16.2.2 Dorsum

A periosteal elevator is then used to elevate periosteum and other soft tissue from the dorsum.
A lighted Aufricht retractor and angled septal scissors are used remove excess cartilaginous septum and upper lateral cartilage. A headlight can be used if a lighted Aufricht is unavailable.
The upper lateral cartilage does not need to be preserved for spreader flaps in closed rhinoplasty. Constantian demonstrated the important effect of spreader grafts on airflow in his 160 consecutive patient rhinomanometry series in 1996.
A rasp is then used to lower the nasal bones to match the height of the septal cartilage. It is important to perform this step before harvesting septal cartilage in order to ensure at least 15 mm of strut is left behind.