Should one use an open or closed rhinoplasty approach? How appropriate is the endonasal approach in modern-day rhinoplasty? Should the tip lobule be divided or preserved? Are alloplastic implants inferior to autologous implants? Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty? Over past 5 years, how have rhinoplasty techniques and approaches evolved?
Minas Constantinides, Peter Adamson, Alyn Kim, and Steven Pearlman address questions for discussion and debate:
- 1.
Should one use an open or closed rhinoplasty approach?
- 2.
How appropriate is the endonasal approach in modern-day rhinoplasty?
- 3.
Should the tip lobule be divided or preserved?
- 4.
Are alloplastic implants inferior to autologous implants?
- 5.
- 6.
Constantinides: introduction
Theory without practice is like a one-winged bird that is incapable of flight.
Science is the father of knowledge, but opinion breeds ignorance.
I am an open rhinoplasty surgeon. Since entering practice in 1994, I have performed over 2000 primary and revision open rhinoplasties. As Director of Facial Plastic and Reconstructive Surgery in the Department of Otolaryngology at New York University School of Medicine, I teach and operate at NYU Langone Medical Center, Bellevue Hospital Center, and the Manhattan Veterans Administration Hospital. From my first day in practice I have been a rhinoplasty teacher. I have taught 19 years’ worth of residents open rhinoplasty, and many have gone on to perform rhinoplasty in their practices. In 2000 I started a fellowship in Facial Plastic Surgery. I included Drs Norman Pastorek and Philip Miller in order to give my fellows a wide array of exposure to various approaches in rhinoplasty (in addition to all other aspects of facial plastic surgery). I recognize the importance of seeing a variety of surgeons handle a variety of problems in unique ways. I could think of no one better to teach closed rhinoplasty that Dr Pastorek, probably the best closed surgeon in the world today.
The controversies discussed in this Clinics issue are well chosen to reflect how my own philosophy has changed over my years in practice. In my answers, I hope to paint a picture of how I decide to do what I do in rhinoplasty today, why I have changed what I do over the years and how even now I am looking for better ways to improve what I do. Dr Eugene Tardy has said, “the rhinoplasty student never graduates.” This complex and beautiful operation is at once rewarding and humbling. I am blessed that my practice is a rhinoplasty practice on such a large and demanding stage.
Should one use an open or closed rhinoplasty approach?
Adamson and Kim
Open septorhinoplasty (OSR) was introduced 40 years ago in North America and has since gained wide acceptance as a good approach, if not the preferred approach, for rhinoplasty. In a survey by Dayan and Kanodia of fellowship graduates of the American Academy of Facial Plastic and Reconstructive Surgery between 1997 and 2007, they found that the vast majority, 87.9%, performed open rhinoplasty as their primary approach. The open approach to rhinoplasty has been controversial since its inception, but this statistic indicates increasingly wide acceptance of this approach. In the past, open rhinoplasty was supported for difficult or revision cases only. Proponents of closed rhinoplasty initially criticized the open technique, citing potential problems such as unnecessary scarring, reduction of tip support, extended operative time, and excessive postoperative tip swelling. The issue of columellar scarring was addressed by Vuyk and Olde Kalter in a meta-analysis of 7 articles encompassing 986 patients who underwent open septorhinoplasty. Only 3 had columellar flap necrosis that led to scarring. Another argument against OSR was that the open scar was longer when, in fact, it, and the marginal incision, are shorter than the scars of a cartilage delivery technique and do not affect the internal valve, an area of potential functional compromise in closed approaches. Other potential arguments against the open approach are purportedly longer lasting supratip swelling and longer operative times. Toriumi and colleagues used cadaver studies to demonstrate that the main vasculature of the nose runs aloft the musculoaponeurotic layer, or in it and parallel to the alar margin, as opposed to vertically in the columella. Thus, it is dissection above the musculoaponeurotic layer that disrupts and perhaps prolongs postoperative tip edema, not the transcolumellar incision of OSR. Indeed, operative times may be longer with OSR because more time may be taken to deal with the asymmetries that are uncovered.
The open approach clearly offers better exposure to a small surgical field, thereby affording the opportunity to better diagnose the deformity through inspection, to better execute certain maneuvers, and to teach and to learn the operation with greater ease. Indications have expanded with widespread increasing levels of comfort and familiarity with the technique. In my experience, open rhinoplasty is the technique of choice for all cases unless a comparable improvement for a definable deformity can be obtained with the closed approach. The open approach offers clear diagnostic and therapeutic advantages for many challenging functional and cosmetic nasal deformities, primarily resulting from the broad undistorted exposure it affords and the improved opportunity for bimanual correction. This is especially true with respect to the premaxillary spine, caudal septum, dorsal and superior septum, lobule, and superior dorsum. The open approach offers an unparalleled appreciation of the underlying anatomy resulting in the external deformity. Sutures can be placed, grafts trimmed exactly, and asymmetries corrected without distortion of surrounding tissues. Scar tissue and redundant subcutaneous tissue are more easily excised. The valve region can be well protected, and the absence of incisions in the intercartilaginous region diminishes subsequent obstructive phenomena by precluding scar formation and disruption of one of the tip support mechanisms. It may also be that revision rates for primary OSR are less than those for closed rhinoplasty.
OSR provides an opportunity for greater surgical exposure for the operating surgeon and the assistants, and thereby provides an excellent teaching tool. As this approach is used in didactic teaching sessions, more surgeons in training are exposed to the approach and may be more apt to continue with this approach in their later practices. In general, surgeons with the greatest experience (more than 100 rhinoplasties per year) tend to use the closed approach more often, but, nonetheless, even they still perform a notable amount of OSR. There is still some trend to increasing use of the OSR approach: the only group using it slightly less are those in practice 16 to 25 years—older surgeons who were less exposed to the OSR approach in their training and continue to practice in the manner in which they were trained. Younger surgeons perform open rhinoplasty more frequently compared with older surgeons for all indications. The movement toward open rhinoplasty seems to be plateauing with possibly a slight upward trend in its use. Except for “simple” cases, OSR may be indicated for rhinoplasty by a large proportion of surgeons, especially for rhinoplasties that are “difficult” or revisions or those requiring grafting. When all is said and done, each surgeon will assess the patient’s deformity and their own ability to correct it, and will utilize the approach that works best for them. There will always be room for differing opinions and different approaches.
Constantinides
Note: Constantinides here discusses open versus closed approach jointly with the next discussion of endonasal approach.
When discussing open and closed approaches, the terms themselves engender controversy. “Open” is also called “external” while “closed” is called “endonasal.” Should one set of terms be abandoned for another? There are good arguments on both sides. In favor of keeping “open” and “closed” are the arguments that:
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“Closed” correctly characterizes the approach as obscured, with inferior visualization and poor ability to exactly manipulate cartilages in their native position.
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“External” correctly characterizes the trivial columellar incision as being of consequence. It is not.
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It is simpler for a patient to say and to remember “open” and “closed.”
In favor of using “external” and “endonasal”:
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“Closed” was called “closed” only when the “open” approach was introduced.
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“Closed” implies without incisions, as in “closed reduction of a nasal fracture.”
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“Endonasal” correctly refers to an approach with incisions only inside the nose.
Historical perspective is important. The open approach was used in Germany by Johann Friedrich Diffenbach who described a dorsal midline vertical incision in his “Die Operative Chirurgie” in 1845. Jacques Joseph’s first case in 1898 used the same approach, but he later switched to an endonasal approach to avoid the scar. He thought he was first to perform an endonasal rhinoplasty, but had been beaten by two New York surgeons. John Orlando Roe reported the first endonasal rhinoplasty in 1887 and Robert F. Weir reported his first in 1892 (although he claimed he had performed it in 1885 in order to beat Roe).
What does a Google search reveal on “Open versus Closed Rhinoplasty”? The #1 position is held by Dr Steven M. Denenberg, who lists a number of conditions that must exist for him to use the closed approach. He summarizes by saying: “I use the closed technique only about 5% of the time.” Other positions by other surgeons (some well-known, others not) essentially summarize the arguments that I have listed in often colorful (and sometimes misleading) language that captures each surgeon’s individual sentiments on the subject. On the Web, the “open versus closed” argument is used as a publicity tool to scare patients away from one approach or the other, depending upon each surgeon’s bias. Is there any wonder there is so much disinformation and confusion on this topic in the public’s eye?
Since this issue of Clinics is to capture each expert’s description of his particular approach, I will limit myself to a description of my open approach. I only use the closed approach in very minor revisions and never in primary rhinoplasty. Unlike Dr Denenberg, I have never found a primary rhinoplasty in which I do not want to fully visualize the entire nose. Even for relatively simple changes, the open approach allows me the possibility of hitting a home run. With the closed approach, I am worried that I will not have accounted for some unnoticed issue (cephalic excision releasing the lateral crus to become convex postop; minor dorsal reduction causing asymmetric upper lateral cartilage (ULC) weakness and postop irregularity) that could lead to a postoperative problem.
The incisions and the columellar scar
I use the same incision Goodman used when he introduced open rhinoplasty in Canada in 1979, the inverted “V” incision. The alternate incision, the stair-step incision, I long thought was equivalent until I started having to revise it. There are several real problems with the stair-step. One is that the lateral limbs of the incision should be at the narrowest part of the columella. This is so that the incision is placed where the medial crura are closest to the skin. The underlying cartilage provides support against contraction, insuring the best possible resultant scar. Indeed, in columellas with thicker skin, I make sure that I reinforce the underlying cartilaginous support to insure a strong platform that resists contraction. The stair-step incision’s lateral limbs are not ideally placed.
With the stair-step incision one limb is higher on one side of the columella than the other. If scar revision is required, excising the incision can leave one side of the resultant scar too close to the top of the columella, creating the potential for notching and nostril asymmetry. The inverted “V” incision forces the resultant limbs lower on the columella, so any subsequent scar revision is simpler and the chance for asymmetry is less ( Fig. 1 ).
