Regardless of your preferred technique, a thorough knowledge of nasal anatomy and understanding of nasal airflow and physiology are the foundations for successful aesthetic and functional rhinoplasty.

Proponents of open rhinoplasty argue that closed rhinoplasty is difficult because the surgeon does not have good binocular vision through small incisions, the dissection is blind, the anatomy is complex, and the operation is technically difficult.

Proponents of endonasal or closed rhinoplasty techniques point to two common considerations:

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  First, by separating columellar skin from the medial crura, the surgeon loses an important component of tip stability and projection, which therefore requires some method (suture fixation or columellar strut) to support the medial crura so that a new nasal tip can be made. The strut can impart rigidity to the columella and increases graft requirements.

  
  
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  In primary patients, this consideration may be unimportant, but in secondary patients whose donor sites are already depleted, every bit of graft material counts.

  
  
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  Though incisions are limited, endonasal rhinoplasty is not a blind operation. Most procedures are performed under direct vision with greater access than endoscopic surgery permits.

  
  
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  The operative strategy, making skeletal changes through limited incisions and judging progress by feeling the surface, is precisely the same discipline required by suction-assisted lipectomy.

  
  
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  Limited pocket dissection minimizes the need for graft fixation and simplifies some procedures.

  
  
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  Solid or crushed grafts can be used in ways that would be tedious or impossible by the open approach, although some solutions have been described.

In rhinoplasty, there are four common anatomic variants that predispose to unfavorable results:

Low radix or low dorsum:

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  Low radix or low dorsum begins caudal to the level of the upper lash margin with the patient’s eyes in primary gaze.

  
  
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  The low radix is one of several primary causes of nasal imbalance: an upper nose that seems too small for its lower nasal component.

  
  
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  When the radix begins lower than the upper lash margin, dorsal length is therefore shorter, and so nasal base size appears larger.

  
  
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  If the surgeon reduces the nasal dorsum, the patient’s preoperative skeletal and skin sleeve maldistribution will worsen, and the lower nose will appear even larger.

  
  
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  The surgeon should instead either limit tip reduction or raise the dorsum segmentally or entirely to balance the nasal base.

A narrow middle vault:

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  Arbitrarily defined as any upper cartilaginous vault that is at least 25% narrower than the upper or lower nasal third. This variant is a trait that places the patient at special risk for internal valvular obstruction, which can exist preoperatively or may be produced by dorsal resection.

  
  
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  Inadequate tip projection is defined as any tip that does not project to the level of the anterior septal angle.

  
  
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  Alar cartilages sufficiently strong to support the tip to the level of the septal angle are “adequately projecting”; alar cartilages too weak to do so are “inadequately projecting”.

  
  
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  The practical value of this definition lies in its ability to define treatment: adequately projecting tips do not need increased support, whereas inadequately projecting tips do.

  
  
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  “Alar cartilage malposition” describes cephalically rotated lateral crura whose long axes run on an axis toward the medial canthi instead of toward the lateral canthi, the position of orthotopic lateral crura.

  
  
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  This anatomic variation was first recognized by Sheen as an aesthetic deformity that produced a round or boxy tip lobule with characteristic “parentheses” on frontal view.

  
  
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  Malposition also has two additional ramifications that are not aesthetic:

  
  
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  First, the abnormal cephalic position of the lateral crura places them at special risk if an intercartilaginous incision is made at its normal intranasal location.

  
  
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  Second, most malpositioned lateral crura do not provide adequate external valvular support, and so malposition is not only associated with boxy or ball tips but also the leading cause of external valvular incompetence.

  
  
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  None of these four anatomical variants (low radix or low dorsum, narrow middle vault, inadequate tip projection, and alar cartilage malposition) always require treatment, but they do supply cautionary notes.

  
  
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  The most common grouping in both primary and secondary patients was the triad of low radix, narrow middle vault, and inadequate tip projection.

  
  
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  The second most common grouping was the association of all four anatomic traits.

For many years, the following concepts provided the basis for analysis of the obstructed nose:

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  The bony and cartilaginous septal partition, deformed by congenital or traumatic causes, may obstruct the nasal airway.

  
  
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  Compensatory hypertrophy of the contralateral inferior turbinate frequently occurs so that both airways eventually become obstructed.

These concepts are more understandable if the reader considers airway size to be the product of at least four factors: (1) mucosal sensitivity to the environment or hereditary factors, (2) inferior turbinate hypertrophy from many causes, (3) septal deviation, and (4) position and stability of the lateral nasal wall during the dynamic process of ventilation.

Obtain information on the patient’s medical and emotional suitability to undergo rhinoplasty.

Feelings of inadequacy, immaturity, family conflicts, divorce, and other major life changes may be unhealthy motivating factors behind the patient seeking aesthetic surgery.

Poor postoperative patient satisfaction is often based on emotional dissatisfaction as opposed to technical failure, and this can be avoided by the preoperative identification of these unhealthy motivating factors.

Review past medical history and specifically note a history of allergic disorders, including hay fever, asthma, and other problems, including vasomotor rhinitis and sinusitis. These conditions should be controlled prior to rhinoplasty; however, patients should be informed that they may be exacerbated in the postoperative period and can persist for weeks to months.

Nasal obstruction is usually found in patients with a long history of allergic rhinitis secondary to inferior turbinate hypertrophy. Engorgement of the inferior turbinates causes these symptoms to be worse at night. Patients may also complain of headache because of the inadequacy of the inferior turbinate to warm inspired air.

Prior nasal trauma and surgeries, including rhinoplasty, septal reconstruction/septoplasty, and sinus surgery, should be noted.

Smoking, alcohol consumption, and use of illicit drugs, in particular cocaine, can compromise outcomes. Medications including acetylsalicylic acid, nonsteroidal anti-inflammatory drugs, fish oil, and certain herbal supplements may cause increased risk of bleeding and postoperative ecchymosis.

Anatomic examination includes both external nasal analysis ( Table 4.1 ) and internal nasal examination ( Table 4.2 ). In addition, facial analysis plays a key role in achieving facial harmony after rhinoplasty.

Standardized photography is obtained for every patient presenting for rhinoplasty and includes frontal, lateral, oblique, and basal views of the patient.

It is useful to review photographs with the patient to identify areas of concern that can be addressed with surgery and deformities that may persist after surgery, including notches, grooves, and irregularities. Facial disproportions and asymmetries should be pointed out to the patient as these may require orthognathic surgery to address.

Identifying the patient’s expectations preoperatively is a key component to postoperative patient satisfaction and successful rhinoplasty.

Common concerns include asymmetry, tip deformities, dorsum irregularities, and nasal airway obstruction.

The patient should attempt to rank these concerns in order of importance.

A patient who focuses on minor or uncorrectable problems or who has unrealistic expectations despite extensive discussion will likely be disappointed following surgery regardless of the aesthetic improvement; it is better to avoid operating on these patients.

In general, the ideal candidate for surgery has legitimate concerns and realistic expectations and is secure and well-informed and understands the limitations of surgery.

The acronym SYLVIA has been used to describe the ideal patient: secure, young, listens, verbal, intelligent, and attractive.

The poor candidate for surgery has excessive concerns about minimal deformities and unrealistic expectations, and is insecure, poorly informed, and fails to recognize the limitations of surgery. These patients are likely to be unsatisfied following surgery regardless of the aesthetic improvement. They should be approached with caution and, in most cases, should not be operated on.

The acronym SIMON has been used to describe this patient: single, immature, male, overly expectant, and has narcissistic traits.

Proper identification of causative factors of nasal airway obstruction is key to successful treatment. Nasal airway obstruction can have both medically and surgically correctable causes.

Common surgically correctable causes include nasoseptal deviation, internal or external valve dysfunction, and inferior turbinate hypertrophy.

Primary and secondary rhinoplasty patients differ in three characteristic ways.

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  First, the secondary patient’s scarred, contracted soft tissues will not tolerate aggressive dissection, multiple incisions, or tight dressings.

  
  
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  Second, graft donor sites may have already been harvested, necessitating the use of more difficult (distorted septum or concha), painful (costal), or frightening (calvarial) donor sources.

  
  
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  Third, the secondary rhinoplasty patient’s morale is often more fragile. Having already invested money, time, discomfort, and emotion in one or more unsuccessful procedures, what secondary rhinoplasty patients fear most and need least are additional disappointments.

For secondary rhinoplasty patients, the surgeon should be careful to construct a plan that is based on a clear understanding of what is possible and founded on sound surgical and biologic principles that maximize the airway and respect the patient’s aesthetic goals.

Before agreeing to operate on a patient, the surgeon must be able to answer each of the following questions affirmatively:

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  Can I see the deformity? This question eliminates delusional patients or those with minimal defects that may not be surgically correctable.

  
  
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  Can I personally fix it? This criterion will vary from surgeon to surgeon and must be based on operative experience and ease in correcting specific problems.

  
  
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  Can I manage the patient? A patient who is unacceptably nervous, impossible to examine, or unwilling to comply with preoperative and postoperative instructions is a poor candidate, even if all other conditions are met.

  
  
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  If there is a complication, will the patient remain controlled and cooperate with treatment? No patient enjoys a complication, but there are those who, although disappointed, quietly understand and will await the proper time for revision. There are others who become hysterical, angry, disruptive, or accusatory and want an immediate correction.

  
  
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  Does the patient accept the margin of error inherent in surgery? This is the most important criterion. The patient’s willingness to accept the imperfection that is inherent in surgery is a willingness to accept the imperfection that is inherent in being human.

It is helpful to conceptualize the nose as a system of two interrelated layers ( Fig. 4.1 ) .

The structural layers of the nose, which separate those anatomical units that move together. The investing soft tissues and alar cartilages (A) glide over the inner, fixed, semirigid layer, which contains the bony vault, the upper cartilaginous vault, and the nasal septum (B) .

The outer layer, like a soft, elastic sleeve, slides over the inner semirigid layer and contains the entire investing nasal soft tissues plus the alar cartilages and their associated lining.

The inner layer contains everything else (the bony and upper cartilaginous vaults, the nasal septum, and their associated linings).

This two-layer concept associates those structures that behave together anatomically and functionally, and provides an explanation for the “global” manifestations of some surgical changes (e.g., the effect of dorsal reduction or augmentation on nasal length).

The internal nasal valve is formed by the articulation of the caudal and anterior (or dorsal) edges of the upper lateral cartilages with the anterior septal edge ( Fig. 4.2 ) .

The nasal valves. The internal valves are formed by the articulation of the upper lateral cartilages with the anterior (dorsal) septal edge; the external valves are formed by the alar cartilage lateral crura and their associated investing soft tissue cover.

The external nasal valve is composed of the cutaneous and skeletal support of the mobile alar wall (the alar cartilage lateral crura with their associated external and vestibular skin coverings).