Successful outcomes in rhinoplasty depend more on diagnosis than on approach or technique. When the needs of each patient are assessed on multiple occasions, operative performance improves and revision rates decline. The evolutionary track from an endonasal and excisional operation to the more commonly preferred external and restructuring technique is outlined in this article. The senior author’s rationale and preference for the endonasal approach and the repositioning of cartilage in the tip using vertical dome division techniques is emphasized.
What separates rhinoplasty from other facial plastic surgery procedures?
Why do surgeons rank this operation near the top when rating degree of difficulty or desirability?
The answers rest in the combination of factors leading to successful outcomes in nasal surgery. This is an operation that embraces both the art and science of surgery. Technical expertise alone does not guarantee success. The oft-stated adage that “in rhinoplasty we do a little to achieve a lot” places the emphasis on astute diagnosis, not on prescribed techniques.
If the desirability and demands of rhinoplasty reside in long-term enhancement of facial features without surgical stigmata, then the understanding of the patient’s needs takes precedence in achieving these goals. The surgical approach is secondary to the experienced surgeon’s primary diagnosis.
There is no better time than the initial consultation to obtain valued information regarding the individual nature of the patient. At the top of the chart, in his or her own words are the patient’s stated desires; unwritten but spoken at this time are the surgeon’s goals to satisfy the patient with a natural look. The recommendation that every rhinoplasty patient deserves at least 5 operations has been made on many occasions ( Fig. 1 ). The importance of the initial diagnosis at this earliest encounter is reiterated.
At this first step, the crucial decision is not how but whether the operation should proceed. Are the patient’s requests reasonable? Are expectations and demands too high? Through conversation, a comfort zone is either established or not. Open-ended questions about the individual, rather than directed remarks about the nose, begin the dialog. The sensitive listener can distill troublesome comments or remarks.
The prospective patient’s body language, along with office staff’s observations outside the consultation room, add to the information. Too many red flags and the comfort zone is never entered. Without shared comfort, the operative contract has less chance of a successful outcome and probably should never be signed.
Unthreatening, but vitally important, are the photographs taken at the initial visit. It is the second opportunity to plan the operation. Each of the 6 basic views has a meaningful input in the decision process. There should be standardization of positioning, distance, lighting, background, and camera. Two light sources are preferred to a uni-flash arrangement.
If well taken, the frontal view reinforces impressions about the width, deviation, asymmetries, and length of the nose. The 2 light sources illuminate the presence or lack of meaningful highlights ( Fig. 2 ).
The 2 lateral views taken with the Frankfort horizontal plane (tragus to infraorbital rim) parallel to the floor, provide evidence regarding tip projection and overall dorsal height and length. Relationships between the alar rim and columella, favorable or unfavorable angles at the nasofrontal and nasolabial areas, and the appropriate position of the chin are all considered.
Additional information is afforded by the lateral smiling view. The dynamic movement on smiling may enhance the dependency of the nasal tip and length of the nose ( Fig. 3 ). The heightened prominence of the septal angle and the acuteness of the nasolabial angle together with the downward displacement of the lower alar cartilage complex defines the ptotic nasal tip. It argues for measures to disrupt the activity of the depressor septi muscle and to reposition the alar complex. The smile may also change the static position of the chin. A protruding mentalis muscle may negate the consideration of chin augmentation.
The three-quarter or oblique view helps to establish the nasal relationship to the surrounding bony and soft tissue features, such as the frontal, zygomatic, maxillary, and mandibular contours. The brow-tip aesthetic line addresses the need for a strong, smooth, dorsal line with appropriate tip position.
However, probably the most important preoperative photograph is the base view ( Fig. 4 ). This photograph needs to be taken at right angles and within 45 cm of the patient. Because rhinoplasty is basically an operation of skin redrapage, the best information relating to support and thickness of coverage is afforded by the base view.
Medial support is paramount to good tip projection. The base view evidence of the desired 2:1 relationship of columella to lobule helps the surgeon’s understanding of the need to maintain or change tip projection ( Fig. 5 ).
Two light sources readily document the distance and symmetry of the 2 lobular apices ( Fig. 6 ). Divergent medial crura and the base asymmetries created by functional septal displacement must be appreciated preoperatively. The photographic views are shared with the patient in different ways by various surgeons. In the past, a lateral view was placed against a radiographic view box and the desired profile changes sketched in with a black marker. Computers are now used to create the anticipated changes.
In an era of virtual reality, the immediate sense of personal change and gain afforded by computer imaging is a powerful tool. It has educational benefits for both patient and surgeon. However, the line drawings must be reasonable and are not guaranteed. The healing in rhinoplasty is too variable to give the patient a sense of the final result, similar to the promises of a plan presented by an architectural draftsman.
Our use of the computer is limited to sharing with patients the results for other patients with similar problems ( Fig. 7 ). Establishing a problem-specific database takes time and effort, but is most rewarding. Whether the issue is one of size, width, deviation, trauma, aging, ethnicity, revision, or adjunctive procedures, cases can be provided to show patients what is possible in their specific situation. This is also another opportunity to reassess the game plan and gauge the level of comfort.
Rhinoplasty is routinely performed as an outpatient procedure. Using your own surgical facility or an ambulatory center comfortable for your needs is beneficial to the patient and the surgeon. A relaxed situation is provided by familiarity and appropriate preparation.
Anesthesia protocol depends on the repeated provision of safety and comfort. During the first 35 years in practice, we successfully used local anesthesia injections with assisted intravenous sedation. For the last 6 years, we have routinely used general endotracheal anesthesia. The operation works well in either situation. The change to general anesthesia was due primarily to the experience and background of the anesthesia providers.
Sometime before the operation, possibly in the preoperative holding area or at the scrub sink, there is again the opportunity to readdress the game plan. The preoperative analysis based on photographic review and physical examination should provide an almost x-ray assurance of what will be found and what must be done. Surprises are not the norm, and waiting until the nose is opened to decide what to do is rarely acceptable. The approach to rhinoplasty depends largely on the background and skills of the surgeon. Neither the endonasal nor the external approach is inherently superior or inferior. Both approaches have their advantages and the choice in most cases depends on the training and experience of the surgeon.
In the early 1960s and 1970s everybody approached the nose through endonasal and transfixion incisions. The senior author’s continued preference for the endonasal, marginal delivery and incisional tip techniques was strongly influenced by Irving Goldman MD during residency years at Mount Sinai Hospital in New York City.
The swing of the pendulum to the external approach occurred in the late 1970s when many surgeons became enchanted with newfound exposure, especially in the intradomal area. Visualization, mobilization, suturing, and restructuring seemed easier and training programs suffered the loss of teachers with endonasal skills. Rather than lose or have to rediscover a beautiful method for performing rhinoplasty, training programs should insist on familiarity and use of the endonasal intercartilaginous and transfixion incisions, the marginal delivery of alar cartilages, and visualizion of dorsal components. In developing a well-trained rhinoplasty surgeon, these learning steps should precede the transcolumellar incision and conversion to the external approach. A renewed appreciation for what can be seen and done through endonasal incisions will revitalize the endonasal approach or at least eliminate the illogical differentiating terminology of “closed.”
With the patient on the operating table, supine, sedated, and infiltrated with local anesthesia, preoperative areas of nasal concern become less distinct. This is further rationale for arriving in the operating room (OR) with the game plan in hand before incision ( Fig. 8 ).
In more than 95% of primary cases and 90% of revision cases our approach to the surgery is endonasal. With complete transfixion and marginal incisions, the endonasal approach affords excellent visualization of all areas except the lateral osteotomy site, allows variation of technique, permits delicate touch evaluation, limits pocket size for grafts, and avoids any external scar. Final profile adjustments and the appropriate relationship of tip to dorsum are made easier with the skin envelope intact.
The external approach is used in unique situations of extreme scarring, tissue deficiency, or marked curvature of the dorsum. Usually the placement of spreader grafts or the need for high septal repositioning is more easily approached and controlled from above.
In most instances the operation begins with the transfixion of the nose. Separation of caudal septum from columella, combined with elevation of dorsal skin through intracartilaginous incisions, is as old as the text of Jacques Joseph, but it remains effective and utilitarian. Planes of elevation hugging the perichondrium or periosteum lessen bleeding and aid healing.
The extent of the transfixion incisions at the base of the columella may vary from partial to full with the latter preferred in cases where the caudal septum must be shortened or straightened, where the depressor septi muscle attachment to pre-maxilla is transected, or where over projection of the tip may benefit from medial crural feet retro-displacement. A retrograde dissection into the columella to remove soft tissue from between the medial crura to help narrow a widened columella, is most easily performed at this time.
Beyond initial transfixion or uncovering of the dorsum there is no universal sequence of steps in rhinoplasty. In cases where dorsal height and central length is excessive it makes sense to start with an initial paring down of these elements. Shortening the caudal septum along with overhanging mucoperichondrium must be judicious and limited to situations presenting with columellar hang, nasal crowding of the upper lip, or the desirability of more tip rotation.
Similarly, the lowering of the dorsal profile must be conservative. One of the major mistakes of earlier days was the excessive lowering of the cartilaginous and bony dorsum to achieve the illusion of projection for a dependent or inadequately projected nasal tip.
In most cases, dorsal reduction is accomplished by removal of more cartilage than bone ( Fig. 9 ). If the nose is generally wide, dividing the upper laterals just lateral to their septal attachment makes the careful lowering of the septal angle a bit easier. This maneuver will also help later in narrowing the wide middle third when lateral osteotomies are performed.
