Rhinoplasty remains among the most challenging procedures to master, requiring a sound understanding of nasal anatomy and surgical maneuvers with a focus on improving both nasal appearance and/or function. While much has been written about the different rhinoplasty approaches (open vs. closed), the more commonly performed open rhinoplasty technique certainly has its advantages, namely improved visualization. This activity outlines the foundation for executing a successful rhinoplasty using the basic open technique, including proper patient evaluation and execution of a thorough, anatomic-based surgical plan.
Key Rhinoplasty Terminology:
Only after obtaining a thorough understanding of the underlying nasal anatomy and physiology can a comprehensive nasal analysis be performed, allowing a customized rhinoplasty treatment plan with attention to both aesthetic and functional concerns. It merits noting that while various objective measurements (e.g., Goode ratio) have been used to describe ideal facial/nasal proportions, additional factors such as cultural differences and ethnic preferences should take preference when performing facial/nasal analysis.
At a minimum, assessment of frontal, lateral, and basal views is necessary. The nose then gets divided into thirds (i.e., upper, middle, and lower third), and each area analyzed individually for issues related to symmetry, width (e.g., wide nasal bones) contour irregularities (e.g., dorsal hump), tip shape (e.g., boxy, bulbous), tip location (e.g., low tip-defining point), projection, rotation (cephalad/caudad), length (short/long), columellar/alar relationships (e.g., hanging columella), as well as shape/size of the nostrils.
The surgeon should document the nasal skin thickness, as this has practical implications not only for surgery (e.g., thicker skin requires more extensive alteration of the underlying framework to maximize definition) but also for recovery (e.g., thicker skin is associated with prolonged postoperative edema).
Nasal palpation is mandatory to determine tip support, the integrity of the caudal septum, and the size and position of the nasal bones.
Lastly, the nasal cavity should be inspected to evaluate the septum, inferior turbinates, and nasal valves (external and internal), as deficits may dictate what type of surgical techniques are required (e.g., septoplasty, turbinate reduction, spreader grafts, etc.)
Rhinoplasty is indicated for the correction of any functional or cosmetic deficits of the nose. The debate continues as to whether closed (endonasal) vs. open rhinoplasty is superior; however, the widely accepted opinion is that the open approach (the more common approach) has numerous advantages, namely improved visualization. The ability to directly visualize the surgical maneuvers underway not only enhances diagnostic accuracy and correction of deformities but also facilitates education and participation of team members.
Disadvantages of the open approach:
Certain components of the patient’s history require attention and/or resolution before performing a rhinoplasty, including:
Use of illicit intranasal drugs (e.g., cocaine) complicates the procedure and may compromise the postoperative result.
Patients at increased risk of developing post-operative bleeding and/or septal hematoma:
Body Dysmorphic Disorder (BDD):
Medical clearance must be obtained, including pre-operative risk stratification and medical optimization.
Pre-operative photography with static and dynamic images in frontal, three-quarter, lateral, base (worm’s eye), and dorsal (bird’s eye) views should adequately document position and shape of the nose, facial asymmetries, and the effect of the smile on the nose. Digital imaging software can demonstrate proposed surgical outcomes that are otherwise difficult to verbalize, thus improving communication between the patient/surgeon and setting realistic expectations of surgery.
Incisions are marked in narrowest portion of the columella with an inverted-v pattern which results in better scar formation and less notching than transverse incisions. Osteotomy pathway, if planned, is marked out as well. Marking incisions for an alar base reduction are typically reserved for the end of the procedure.
Though not routine, specific nasal landmarks may be marked, including the rhinion (keystone), upper lateral and lower lateral cartilages.
General anesthesia or intravenous techniques (e.g., propofol) are advisable during the open rhinoplasty. If general anesthesia is employed, muscle relaxants are an option.
A single dose of intravenous antibiotics covering skin flora requires pre-operative administration.
A single dose of an intravenous steroid injection (.e.g., 8 mg of dexamethasone) may help with swelling.
A single dose of intravenous tranexamic acid (10 mg/kg) may help reduce intra-operative bleeding.
Local anesthesia is infiltrated along the septum, columella, margin, soft tissue triangle, sidewalls, and dorsum with care not to distort the appearance of the nose with excess injection.
Nasal pledgets soaked in nasal decongestant are applied to the bilateral nasal cavity
Vibrissae are trimmed to help with visualization and decrease crusting post-operatively.
Open rhinoplasty encompasses a uniquely difficult procedure in that many different means may exist for achieving the same objective, all of which have their own nuances which require incorporation into the overall result. The M-arch model, which builds on Anderson’s tripod theory, can be used to help the surgeon understand the dynamic interplay between the maneuvers performed, particularly regarding their effect on tip aesthetics.
The modern approach to open rhinoplasty focuses on cartilage preservation and incremental changes to the cartilage and bony framework. While a detailed list of every reported technique associated with open rhinoplasty is beyond the scope of this paper, the following briefly summarizes several essential components required in performing a successful open rhinoplasty. These key maneuvers include:
Major complications after rhinoplasty (hematoma, infection, pulmonary complications, venous thromboembolism) are rare, affecting less than 0.7% of patients. More common postoperative complications after rhinoplasty include epistaxis, ecchymosis, edema, and patient dissatisfaction secondary to persistent or new functional and/or cosmetic deficits.
Specific cosmetic complications include:
The need for revision rhinoplasty in a primary open rhinoplasty is low (3%).
Open rhinoplasty is a powerful tool to enhance the form and function of the nose. When performing an open rhinoplasty, proper patient evaluation, and execution of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.
It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing an open rhinoplasty. A team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done:
an interprofessional team of an experienced surgeon, anesthesiologist, and surgical assistants and operative nurses should be involved during the open rhinoplasty to maximize outcomes. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of the open rhinoplasty, should monitor the patient for possible complications including a septal hematoma. It is also crucial to provide patient education on proper care for the surgical wounds, and avoiding nose-blowing, strenuous activity, heavy lifting, or bending over during the first several days post-operatively to mitigate complications.[Level V]
Nursing will play a significant role in both perioperative and intraoperative settings; their duties are outlined below. They must inform the surgeon of any concerns they may have, including postoperative issues, adverse medication effects, or lack of patient compliance. Pharmacists do not have a significant role in rhinoplasty cases, but their expertise for postoperative pain control is helpful, and as with any patient, they should perform medication reconciliation to head off any potential drug-drug interactions, reporting to the surgeon if they see anything noteworthy. Only through collaborative interprofessional teamwork can rhinoplasty cases achieve their optimal result with minimal adverse events. [Level V]
The surgeon can prescribe adequate pain medication, as patients often report mild pain for about 3 days post-operatively. To minimize edema and ecchymosis, the patient should intermittently ice the bridge of the nose and eyes for the first 24 hours, sleep with the head elevated for 1 week, and avoid rigorous activity for 2 weeks. The patient may be given a low-dose corticosteroid taper and/or Arnica montana to help lessen bruising and swelling. Patients are asked to return at 7 days for cast and suture removal, at which time they may be given “nasal massage exercises” to help resolve swelling. The patient may be instructed to continue nasal taping if residual supra-tip fullness, external deviation, tip edema, and nostril deformities are present. The patient should avoid putting direct pressure on the bridge (e.g., with glasses) until 6 weeks postoperatively. Return visits occur at 6 weeks and 6 months for further wound assessment. Photographic documentation should occur at around 12 months postoperatively.
Patients should understand that it may require several weeks for the majority of edema to resolve postoperatively, particularly in thick-skinned patients and/or patients where the surgeon performed excessive tip manipulation. Moreover, incremental nasal refinement occurs for up to 1 to 2 years after surgery. The patient may benefit from steroid injections to the tip if significant swelling lingers post-operatively.
Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of the open rhinoplasty, should monitor the patient for possible complications including septal hematoma formation and epistaxis.
|||Momeni A,Gruber RP, Primary Open Rhinoplasty. Aesthetic surgery journal. 2016 Oct; [PubMed PMID: 27651480]|
|||Lessard ML,Daniel RK, Surgical anatomy of septorhinoplasty. Archives of otolaryngology (Chicago, Ill. : 1960). 1985 Jan; [PubMed PMID: 3966894]|
|||Lam SM,Williams EF 3rd, Anatomic considerations in aesthetic rhinoplasty. Facial plastic surgery : FPS. 2002 Nov; [PubMed PMID: 12524592]|
|||Goodman WS,Gilbert RW, The anatomy of external rhinoplasty. Otolaryngologic clinics of North America. 1987 Nov; [PubMed PMID: 3320862]|
|||Lane AP, Nasal anatomy and physiology. Facial plastic surgery clinics of North America. 2004 Nov; [PubMed PMID: 15337106]|
|||Woodard CR,Park SS, Nasal and facial analysis. Clinics in plastic surgery. 2010 Apr; [PubMed PMID: 20206737]|
|||Chait LA,Widgerow AD, In search of the ideal nose. Plastic and reconstructive surgery. 2000 Jun; [PubMed PMID: 10845313]|
|||Leong SC,Eccles R, Race and ethnicity in nasal plastic surgery: a need for science. Facial plastic surgery : FPS. 2010 May; [PubMed PMID: 20446199]|
|||Nassif PS,Lee KJ, Asian rhinoplasty. Facial plastic surgery clinics of North America. 2010 Feb; [PubMed PMID: 20206098]|
|||Azizzadeh B,Mashkevich G, Middle Eastern rhinoplasty. Facial plastic surgery clinics of North America. 2010 Feb; [PubMed PMID: 20206101]|
|||Harris MO, Rhinoplasty in the patient of African descent. Facial plastic surgery clinics of North America. 2010 Feb; [PubMed PMID: 20206100]|
|||Chauhan N,Sardesai MG,Burchard AE,Ellis DA, Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness. Aesthetic surgery journal. 2010 Jan; [PubMed PMID: 20442073]|
|||Rohrich RJ,Afrooz PN, Rhinoplasty Refinements: The Role of the Open Approach. Plastic and reconstructive surgery. 2017 Oct; [PubMed PMID: 28953724]|
|||Cafferty A,Becker DG, Open and Closed Rhinoplasty. Clinics in plastic surgery. 2016 Jan; [PubMed PMID: 26616691]|
|||Alinasab B,Haraldsson PO, Rapid Resorbable Sutures Are a Favourable Alternative to Non-resorbable Sutures in Closing Transcolumellar Incision in Rhinoplasty. Aesthetic plastic surgery. 2016 Aug; [PubMed PMID: 27251749]|
|||Guyuron B,Afrooz PN, Correction of cocaine-related nasal defects. Plastic and reconstructive surgery. 2008 Mar; [PubMed PMID: 18317151]|
|||Joseph AW,Ishii L,Joseph SS,Smith JI,Su P,Bater K,Byrne P,Boahene K,Papel I,Kontis T,Douglas R,Nelson CC,Ishii M, Prevalence of Body Dysmorphic Disorder and Surgeon Diagnostic Accuracy in Facial Plastic and Oculoplastic Surgery Clinics. JAMA facial plastic surgery. 2017 Jul 1; [PubMed PMID: 27930752]|
|||Picavet VA,Prokopakis EP,Gabriëls L,Jorissen M,Hellings PW, High prevalence of body dysmorphic disorder symptoms in patients seeking rhinoplasty. Plastic and reconstructive surgery. 2011 Aug; [PubMed PMID: 21788842]|
|||Ishii LE,Tollefson TT,Basura GJ,Rosenfeld RM,Abramson PJ,Chaiet SR,Davis KS,Doghramji K,Farrior EH,Finestone SA,Ishman SL,Murphy RX Jr,Park JG,Setzen M,Strike DJ,Walsh SA,Warner JP,Nnacheta LC, Clinical Practice Guideline: Improving Nasal Form and Function after Rhinoplasty Executive Summary. Otolaryngology--head and neck surgery : official journal of American Academy of Otolaryngology-Head and Neck Surgery. 2017 Feb; [PubMed PMID: 28145848]|
|||Swamy RS,Sykes JM,Most SP, Principles of photography in rhinoplasty for the digital photographer. Clinics in plastic surgery. 2010 Apr; [PubMed PMID: 20206739]|
|||Aksu I,Alim H,Tellioğlu AT, Comparative columellar scar analysis between transverse and inverted-V incision in open rhinoplasty. Aesthetic plastic surgery. 2008 Jul [PubMed PMID: 18458998]|
|||Adamson PA,Litner JA, Applications of the M-arch model in nasal tip refinement. Facial plastic surgery : FPS. 2006 Feb; [PubMed PMID: 16732503]|
|||Daniel RK, The Preservation Rhinoplasty: A New Rhinoplasty Revolution. Aesthetic surgery journal. 2018 Feb 17; [PubMed PMID: 29319790]|
|||Swartout B,Toriumi DM, Rhinoplasty. Current opinion in otolaryngology [PubMed PMID: 17620894]|
|||Adamson PA, Open rhinoplasty. Otolaryngologic clinics of North America. 1987 Nov; [PubMed PMID: 3320871]|
|||Heppt W,Gubisch W, Septal surgery in rhinoplasty. Facial plastic surgery : FPS. 2011 Apr; [PubMed PMID: 21404159]|
|||Azizzadeh B,Reilly M, Dorsal Hump Reduction and Osteotomies. Clinics in plastic surgery. 2016 Jan; [PubMed PMID: 26616694]|
|||Sheen JH, Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plastic and reconstructive surgery. 1984 Feb; [PubMed PMID: 6695022]|
|||Kridel RW,Scott BA,Foda HM, The tongue-in-groove technique in septorhinoplasty. A 10-year experience. Archives of facial plastic surgery. 1999 Oct-Dec; [PubMed PMID: 10937111]|
|||Toriumi DM,Checcone MA, New concepts in nasal tip contouring. Facial plastic surgery clinics of North America. 2009 Feb; [PubMed PMID: 19181281]|
|||Gunter JP,Landecker A,Cochran CS, Frequently used grafts in rhinoplasty: nomenclature and analysis. Plastic and reconstructive surgery. 2006 Jul; [PubMed PMID: 16816668]|
|||Rohrich RJ,Raniere J Jr,Ha RY, The alar contour graft: correction and prevention of alar rim deformities in rhinoplasty. Plastic and reconstructive surgery. 2002 Jun; [PubMed PMID: 12045582]|
|||Gruber R,Chang TN,Kahn D,Sullivan P, Broad nasal bone reduction: an algorithm for osteotomies. Plastic and reconstructive surgery. 2007 Mar; [PubMed PMID: 17312512]|
|||Layliev J,Gupta V,Kaoutzanis C,Ganesh Kumar N,Winocour J,Grotting JC,Higdon KK, Incidence and Preoperative Risk Factors for Major Complications in Aesthetic Rhinoplasty: Analysis of 4978 Patients. Aesthetic surgery journal. 2017 Jul 1 [PubMed PMID: 28472446]|
|||Holt GR,Garner ET,McLarey D, Postoperative sequelae and complications of rhinoplasty. Otolaryngologic clinics of North America. 1987 Nov; [PubMed PMID: 3320872]|
|||Spataro E,Piccirillo JF,Kallogjeri D,Branham GH,Desai SC, Revision Rates and Risk Factors of 175 842 Patients Undergoing Septorhinoplasty. JAMA facial plastic surgery. 2016 May 1; [PubMed PMID: 26967651]|