Most surgeons recognize the broad utility of both endonasal and external rhinoplasty approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. In this article, the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.
Key points
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Most surgeons now recognize the broad utility of both endonasal and external rhinoplasty approaches. In this chapter the pros and cons are discussed and further thoughts on the decision-making process are provided.
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Based on an analysis of the individual patient’s anatomy, appropriate incisions, approaches and tip-sculpting techniques may be selected.
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Much can be gained from considering the experiences of surgeons who have had the opportunity to see the consequences over time. The important philosophic concept is not open or closed, but instead, the emphasis on anatomical diagnosis and preservation of structural support.
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There is no ideal approach. Each surgeon will develop a unique approach based on the concepts outlined and based on the techniques and experiences he or she has developed in the course of an eclectic training.
Introduction
In the modern era of rhinoplasty, the introduction of external rhinoplasty was greeted by enthusiastic advocates and also met with spirited opposition. Over time, however, the tenor of this debate has become more ecumenical. Most surgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. Most also agree that there is a large “gray area,” where either the endonasal or the external approach would be appropriate, and the choice may be considered a toss-up. Most surgeons readily acknowledge that surgeon comfort with a procedure is an appropriately important factor.
In this article the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.
Introduction
In the modern era of rhinoplasty, the introduction of external rhinoplasty was greeted by enthusiastic advocates and also met with spirited opposition. Over time, however, the tenor of this debate has become more ecumenical. Most surgeons now recognize the broad utility of both endonasal and external approaches. Most understand that there are situations when a given approach offers advantages and may be considered preferable. Most also agree that there is a large “gray area,” where either the endonasal or the external approach would be appropriate, and the choice may be considered a toss-up. Most surgeons readily acknowledge that surgeon comfort with a procedure is an appropriately important factor.
In this article the anatomy, incisions, and approaches that are available to the surgeon are reviewed. General indications are discussed for the external and endonasal approaches. The pros and cons of each approach are discussed, and further thoughts on the decision-making process are provided.
Anatomy, incisions, and approaches
Nasal Anatomy
Although the anatomy of the nose has been fundamentally understood for many years, only relatively recently has there been an increased understanding of the long-term effects of surgical changes on the function and appearance of the nose. A detailed understanding of nasal anatomy is critical for successful rhinoplasty. Accurate assessment of the anatomic variations presented by a patient allows the surgeon to develop a rational and realistic surgical plan. Furthermore, recognizing variant or aberrant anatomy is critical to preventing functional compromise or untoward esthetic results. This section presents a limited diagrammatic overview of nasal anatomy ( Figs. 1–4 ). More detailed study of nasal and facial anatomy is recommended.
Incisions and approaches
Incisions are methods of gaining access to the bony and cartilaginous structures of the nose and include transcartilaginous, intercartilaginous, marginal, and transcolumellar incisions. Approaches provide surgical exposure of the nasal structures such as the nasal tip and dorsum. The main rhinoplasty approaches include cartilage-splitting (transcartilaginous incision), retrograde (intercartilaginous incision with retrograde dissection), delivery approach (intercartilaginous + marginal incisions), and external (transcolumellar and marginal incisions) ( Box 1 ). Based on an analysis of the individual patient’s anatomy, appropriate incisions, approaches, and tip-sculpturing techniques may be selected ( Fig. 5 ).
Major tip support mechanisms
- 1.
Size, shape, and strength of lower lateral cartilages
- 2.
Medial crural footplate attachment to caudal septum
- 3.
Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages
(Nasal septum is also considered a major support mechanism of the nose.)
Minor tip support mechanisms
- 1.
Ligamentous sling spanning the domes of the lower lateral cartilages (ie interdomal ligament)
- 2.
Cartilaginous dorsal septum
- 3.
Sesamoid complex of lower lateral cartilages
- 4.
Attachment of lower lateral cartilages to overlying skin-soft tissue envelope
- 5.
Nasal spine
- 6.
Membranous septum
Incisions: methods of gaining access
Intercartilaginous
Transcartilaginous
Marginal (NOT to be confused with rim incision)
Transcolumellar
Approaches: provide surgical exposure
Cartilage-splitting
Retrograde
Delivery: Marginal + intercartilaginous incision
External approach: marginal + trans-columellar incision
Sculpting techniques: surgical modifications
Complete strip: that is, cephalic resection, or volume reduction of lateral crura
Incomplete strip (dome division)
Transdomal/domal sutures
Augmentation grafting
Tip graft
Other
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