14 Approaches to the Nasal Tip and Dorsum
14.1 Closed or Open Approach?
The first aesthetic rhinoplasty was performed by John Orlando Roe in 1887 using an endonasal approach. 1 Jacques Joseph performed the first reduction rhinoplasty through an external approach in 1898. Then, in 1904, Joseph was the first to report on the simultaneous intranasal correction of the anterior septum and a dorsal hump. 2 He continued to use the endonasal approach thereafter and systematically advanced it despite the staunch resistance of some leading contemporary surgeons such as Erich Lexer. 3 – 5 He passed his experience on to many later pioneers of rhinoplasty, such as Safian, Aufricht, and Maliniak, and thus laid the groundwork for the worldwide popularity of the closed technique. Proponents of the open approach, such as Rethi and Padovan, remained outsiders for many years. 6 , 7
For decades the closed approach was used mainly for alar cartilage resections or reducing cartilage tension. These techniques relied on the “dynamics of rhinoplasty,” or the cumulative effects of multiple surgical alterations. 8 For example, cephalic volume reduction of the alar cartilages combined with shortening and beveling of the dorsal septal border combine to produce a cephalic rotation of the nasal tip. Tip suture techniques were introduced only in recent decades. Although the proponents of the closed technique had long ago proven what could be accomplished through an endonasal approach, the booming and prospering field of facial plastic surgery, especially in the U.S., engendered a growing desire in the 1980s for a simple approach that would afford maximum visibility. 9 It was concluded that the open approach would shorten the learning curve for many surgeons inexperienced in rhinoplasties. Maximum exposure was seen as a rapid substitute for surgical experience. The open technique has evolved swiftly during the past 30 years and has prompted the development of new trends and techniques, giving rise to new suture techniques and many new and unexpected ways of applying and fixing cartilage grafts. 10 , 11 At present, ~ 88% of rhinoplasties in the U.S. are performed through an open approach. 12
Meanwhile, the disadvantages of the open technique have become apparent and have sparked a critical discussion on the relative merits of the open and closed approaches ( Fig. 14.1 ). 13 – 17 For example, controversy surrounds the fact that open rhinoplasties initially destabilize several structures that must later be repaired with grafts and sutures. 9 Typically, the surgeon must touch, dissect, repair, and reconstruct several structures for which the patient did not request treatment. The operating times are longer, and the larger wound area carries a greater risk of protracted wound healing and complications. The open approach itself may cause asymmetry due to edema, impaired nasal tip sensation, and problems with columellar closure. There is also a risk of unnatural nasal rigidity. 3
For these reasons, a new version of the old closed rhinoplasty technique is experiencing a renaissance. This trend has benefited from the techniques devised for open approaches, which can also be applied and refined for endonasal use.
14.2 Endoscopic Approach
To avoid the problem of limited access and visibility in the closed approach, a fiberoptic Aufricht retractor and miniaturized instruments have been developed for endoscopic dissection of the nasal dorsum and nasal pyramid. This technique allows surgical maneuvers to be performed under optical control that were previously done blindly or controlled by audible feedback. This principle is illustrated by endoscopic dissection of the periosteum using specialized instruments.
The return to an advanced closed technique meets the desires of many of today′s patients for a more efficient, goal-directed operation that is minimally invasive, takes less time, requires less down time, and eliminates external scars. Rhinoplasty is returning from an all-round operation in the mainstream of plastic surgery to a specialized field, and this should have positive effects. A good rule to follow in selecting an approach and operating technique is this: Preserve the functionality of the natural structure of the nose. You can rebuild form with grafts, but you cannot rebuild the natural functional elasticity of the nose.
14.3 Closed Approaches
14.3.1 Cartilage-Splitting Approach
The selection of an approach for revision rhinoplasty depends on the priorities of the patient, the degree of tissue scarring that has occurred in specific areas, and the patient′s skin and connective-tissue type. The approach should be as invasive as necessary and as atraumatic as possible. The smaller the new raw surfaces, the better.
The cartilage-splitting approach is excellent for cephalic volume reduction of the alar cartilages in patients with a bulbous nasal tip. 3 It is less suitable for correcting asymmetries. It cannot alter the interdomal distance or the position of the tip defining points but can be used to harmonize the brow–tip aesthetic line, which is impaired by a bulbous tip and is significantly improved by smoothing the transition from the middle vault to the supratip area. Cephalic rotation follows the principles of rhinoplasty dynamics. Scar contracture will occur due to scarring between the caudal edge of the upper lateral cartilage and the intact alar cartilage. The level of the resection determines whether the tip defining points should be repositioned or preserved.
Cases 1–5 illustrate how specific approaches are chosen.
Case 1
Introduction
A 24-year-old woman presented 2 years after septal surgery with the concern of a drooping nasal tip that accentuated a preexisting hump ( Fig. 14.2 ). She also complained of an intermittent whistling sound during nasal breathing. She desired a profile correction that would harmonize the junction of the nasal tip and dorsum in addition to repairing a septal perforation.
Findings
Frontal view ( Fig. 14.2a ) shows a broad, somewhat bulbous nasal tip with a disharmonious transition from the middle vault to the tip. Profile view ( Fig. 14.2b ) documents loss of tip protection and projection with a bony and cartilaginous hump. Basal view ( Fig. 14.2c ) shows a symmetrical, somewhat broad tip. Internal examination showed an ~ 1-cm septal perforation with residual deviation to the right.
Surgical Procedure
The septal perforation was closed with autologous tragal cartilage using the Schulz-Coulon bridge flap technique ( Fig. 14.2g ). 18
For cephalic volume reduction of the alar cartilage, the dome was exposed and the dome area weakened by tailored compression with a broad, blunt Adson forceps. This was followed by en bloc resection of the bony and cartilaginous nasal hump plus medial and lateral curved osteotomies ( Fig. 14.2h–j ).
Psychology, Motivation, Personal Background
The patient, who worked as a hairdresser in Berlin, was bothered by her perforated septum. She sought consultation for that problem and also desired an aesthetic correction of her nasal tip and profile in the same sitting. Her motivation for the surgery was clear and understandable.
Discussion
A preoperative computer simulation was conducted with the patient to review possible profile adjustments, with and without a supratip break, and discuss how the nasal tip could be narrowed by reducing the interdomal distance with sutures. The patient elected to have the junction of the nasal dorsum and tip harmonized through a cartilage-splitting approach. An alternative would have been a suture technique with a delivery approach. The cartilage-splitting approach is effective for reducing tip volume but cannot be used to approximate the tip defining points or decrease the interdomal angle ( Fig. 14.3h–j ). Ultimately the choice depends on the wish of the patient, provided it is medically and aesthetically sound and technically feasible.
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