Incisions and Approaches

4 Incisions and Approaches


Image Terminology

Incisions, Approaches, and Techniques

There is often confusion about the terms “incision,” “approach,” and “technique.”

  • An incision is an opening made in the skin or mucosa that allows us to gain access to a certain area or anatomical structure. For instance, the caudal septal incision gives access to the septum, or the intercartilaginous incision serves as an entrance to the nasal dorsum.
  • An approach is a surgical method used to arrive at a certain structure so that it may be modified. For instance, an anterosuperior septal tunnel is used as an approach to the cartilaginous septum, or undermining of the skin of the nasal dorsum is a means to approach a bony hump.
  • A technique is a surgical procedure or method by which an anatomical structure is mobilized, repositioned, or modified. For instance, the let-down technique is used to lower a prominent pyramid, or the inversion technique is used to narrow the nasal tip. Generally speaking, a technique is a method by which tissues are repositioned, modified or resected.


From an anatomical or a linguistic point of view, the names of the following incisions are incorrect.

Hemitransfixion: anatomically incorrect. This incision is not a half transfixion but an incision of the skin overlying the caudal end of the cartilaginous septum. We use “caudal septal incision.”

Transfixion incision: linguistic misnomer. The word “transfixion” already implies that the tissues are cut through (Latin: transfigo, -fixi, -fixum = to stab).

Hemitransfixion incision: anatomically as well as linguistically incorrect (see previous text).

Marginal incision: causes confusion when used to denote the incision that follows the caudal border of the lobular cartilage (see Fig. 4.8). We use “infracartilaginous incision.” The term “rim incision” is reserved for an incision at the rim of the nostril (see Fig. 4.18).

Glabellar incision: anatomically incorrect. This incision is not made at the glabella. It is made in a horizontal wrinkle at the depth of the frontonasal angle.

Image External vs Internal Incisions

Internal incisions are preferable to external incisions. External incisions are often said to become “almost invisible” when the tissues are handled delicately and sutured precisely. This may be true, but a completely invisible internal scar is always preferable to an almost invisible external one.

Therefore, external incisions are avoided unless they are inevitable. For instance, the columellar inverted-V incision is inevitable in the external approach.

Image Basic Principles

When making an incision, we apply the following basic principles:

Main Incisions

Image Caudal Septal Incision (Hemitransfixion)

The caudal septal incision (CSI), also known as the hemitransfixion, is made about 2mm above and parallel to the caudal margin of the cartilaginous septum. It provides access to the septum, premaxilla and anterior nasal spine, nasal dorsum, columella, and floor of the nasal cavity.

A right-handed surgeon makes the CSI on the right side, even if the caudal septal end is dislocated to the left. Since the surgeon is standing on the right side of the patient, a right-sided approach means that the instruments can be introduced and maneuvered from the right.



The CSI is closed by two or three 4–0 atraumatic sutures or by two or three 2–0 or 3–0 septocolumellar (SC) sutures.


The caudal septal incision provides access to the following areas:1) septum; 2) premaxilla and anterior nasal spine; 3) nasal dorsum; 4) columella; and 5) floor of the nasal cavity.

Septum: Depending on the pathology, the septum is approached by elevating the mucoperichondrium and the mucoperiosteum as discussed in Chapter 5 (p. 141 ff).

Premaxilla and anterior nasal spine: The premaxilla and the anterior nasal spine may be exposed by the MP approach as illustrated in Figures 5.17 and 5.18.

Nasal dorsum: The dorsum may be approached by undermining the skin as illustrated in Figure 4.5.

Columella: Access to the columella, in particular the intercrural space, may be obtained by creating a columellar pocket as discussed in Chapter 7 (see Fig. 7.49).

Floor of nasal cavity: The floor of the nasal cavity may be approached by elevating its mucoperiosteum using the MP approach (see Figs. 5.17, 5.18).


Fig. 4.1 CSI (hemitransfixion) is the universal approach to the septum, dorsum, columella, and nasal floor.


Fig. 4.2 The caudal end of the septum is exposed by scraping aside the last perichondrial fibers with a Cottle knife or a pointed, slightly curved scissors.


Fig. 4.3 IC incision used as an approach to the nasal dorsum and the lobule.

Image Intercartilaginous Incision

The intercartilaginous (IC) incision is a cut made in the vestibular skin just cranial to the caudal margin of the triangular cartilage. The IC incision gives access to the cartilaginous and bony dorsum and allows retrograde undermining of the lobule.


  • The ala is retracted in a lateral and cranial direction with the left hand using an uneven 4-pronged hook. The middle finger is used to provide counterpressure, stabilization, and exposure of the valve area (Fig. 4.3).
  • The caudal margin of the triangular cartilage is identified with the back of the knife handle. The medial part of the caudal margin is examined for the presence of returning.
  • An incision is made from lateral to medial just above the caudal border of the triangular cartilage using a No. 11 or a No.15 blade. The incision starts halfway along the lower end of the cartilage and continues just past the valve angle.
  • If a No. 11 blade is used, the loose intercartilaginous connective tissue is cut at the same time. The blade is moved like a saw, cutting parallel to the triangular cartilage. Usually, only the skin is incised if a No. 15 blade is used.
  • The incision does not join with the CSI. A small tongue of tissue is kept intact between the ends of the two incisions (Fig. 4.4). The IC and the SC incision are only joined when wide access to the dorsum is required, for example in surgery of the cartilaginous vault and the nasal valve, for removal of a hump, and when inserting a large dorsal transplant.
  • The ala is lifted by the four-pronged hook to open the incision. Blunt, slightly curved scissors are introduced with the points downward. The skin of the dorsum may now be undermined using gentle spreading movements in the plane between the subcutis and the perichondrium (Fig. 4.5).


Fig. 4.4 The IC incision is not joined with the CS incision except for special purposes. A small tongue of skin is kept intact between the two incisions.


The length of the IC incision depends on the kind of surgery to be performed. A (bilateral) incision of about 10mm is long enough to undermine the dorsal skin for repositioning the bony pyramid. A 10-mm incision also suffices for inserting crushed cartilage or a small cartilaginous transplant. If the transplant is large, the approach has to be made wider, while the skin has to be undermined over a broader area. For transplants in the supratip and tip area, a very small cut just above the valve angle may be sufficient.


The IC incision is generally closed by two or three 4–0 atraumatic, slowly resorbable sutures. After valve surgery, more stitches may be required. If upward rotation of the tip is desired, suturing may be done in an oblique fashion by “advancing sutures.” This means pulling the tissues above the incision in a medial and cranial direction.


The intercartilaginous incision provides access to: 1) the nasal dorsum and the cartilaginous and bony vault; 2) the valve; and 3) the lobule.

Nasal dorsum and cartilaginous and bony vault: The dorsum (cartilaginous and bony vault) may be approached by undermining the dorsal skin according to the technique shown in Chapter 6 (p. 192 and p. 192, Figs. 6.2 and 6.44).

Valve: The valve may be exposed as shown in Chapter 6 (p. 229 Figs. 6.65, 6.66).

Lobule: Access to the lobular structures may be gained by retrograde undermining of the lobular skin as illustrated in Figure 7.3.


Fig. 4.5 Access to the dorsum is gained by supraperichondrial undermining in cranial direction.

Image Vestibular Incision

The vestibular incision is a slightly curved cut made in the vestibular skin just lateral to the margin of the piriform aperture. It is used as an approach to the paranasal area, the piriform aperture, and the lateral wall of the nasal cavity.


Mar 6, 2016 | Posted by in Reconstructive surgery | Comments Off on Incisions and Approaches

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