Rhinoplasty 101

The author describes in depth but in a very accessible way the importance and technical facts of one of the most popular plastic surgery procedures: Rhinoplasty. Two techniques are available: open and close. Know which one is more suitable for your case.

Rhinoplasty, also known as Nose Job, is the Plastic and Cosmetic Surgery Procedure intended to improve the nose appearance. The upper 25-50% of the nose is constituted by nasal bones. The remaining component of the skeletal structure is cartilage. This basic structure is covered by muscles, tissue and finally skin. Rhinoplasty Surgery is designed to change underlying structural elements to obtain a more aesthetically pleasing nose.

First of all I want to explain the basic aesthetics of the face so that the reader can place the proper aesthetic importance to the nose. According to my "Palmer Beauty Principles" the top three aesthetic beauty features are the Cheeks, the Eyes and the Lips which account respectively for 75%, 10% and 7% of facial beauty. Have you noticed that the nose is not mentioned here? That's correct. However, because the nose does make you more attractive, your beauty may be diminished by the nose having characteristics that call attention to it and away from the top 3 beauty features.

Rhinoplasty or a Nose Job is designed to remove those characteristics of the nose that may cause the observer to look at the nose instead of the Cheeks, Eyes and Lips. Ideally, Rhinoplasty should make the nose look more sleek and streamlined without tell tale signs that a surgery has been performed. Rhinoplasty Procedures should not leave the nose looking scooped out or show pinched tips. Rhinoplasty should leave the nose looking natural.

There are two basic types of Rhinoplasty Techniques, Closed and Open. Have you ever wonder how we perform Rhinoplasty through the nostrils? The space seems too small to perform surgery doesn't it? Obviously it's not too small and that's exactly how a Closed Rhinoplasty is performed. And as the name Closed infers there must be an Open Rhinoplasty. and yes, that is the case.

What is the difference? Closed Rhinoplasty refers to the fact that all the incisions made to perform the Surgery are plced inside the nose.through the nostrils to be specific. An Open Rhinoplasty, on the other hand, involves incisions that mostly are within the nostrils but also across the skin of the Columella. The Columella is the part of your nose that goes horizontally from the nasal tip to the upper lip. An Open Rhinoplasty will have an inverted V incision placed midway in the columella from where communicates with the rest of the incisions within the nostril.

Now that the differences between open and close rhinoplasty has been established, let's continue with the description of each one of these procedures. Offhand, you may assume that this wouldn't make any difference when doing a Rhinoplasty, but that would be a false assumption.

Don't let a Plastic and Cosmetic Surgeon tell you that he/she only does one or the other in every case. You need a Plastic and Cosmetic Surgeon that can and does frequently use both Closed Rhinoplasty and Open Rhinoplasty in order to get the best possible aesthetic result from your nasal surgery.

Let's start with Closed Rhinoplasty, the Procedure that has all of its incisions within the nostrils. In my opinion, it is limited in certain clinical situations because of the fact that the central part of the skin of the nasal tip is not dissected and remains attached. This means that the cartilages of the nasal tip can not possibly be viewed within the nose, as they normally exist, nor can they be manipulated or sutured in place. These nose tip cartilages must be drawn down through one of the nostrils in order to access the center of them during a Closed Rhinoplasty.

So, what's the big deal you may ask? If you hasn't had previous Rhinoplasty performed on the tip, or don't have a nasal tip that is asymmetric, wide or boxy, ..it doesn't matter because the chances are that the nasal tip cartilages will not require extensive correction and manipulation within this central cartilage region of the nasal tip.and that's excatly the type of case I treat with a Closed Rhinoplasty. The noses that don't require extensive and complicated sewing, shaping and/or placement of tip cartilage grafts (which require direct visualization and sewing in position) can have a Closed Rhinoplasty. Oh, and certainly in Revision Rhinoplasty cases also, where the nasal tip will require anything other than the most minor modifications along the superior aspect of the nasal tip and upper lateral cartilage junction. In any other situations, in my honest opinion, an Open Rhinoplasty is required.

Now, you'll see that so far I haven't mentioned removing a large hump, bump or otherwise manipulating the rest of the nose framework in my determination of when to perform an Open Rhinoplasty versus a Closed Rhinoplasty. That's because the cartilages and bone of the nose out of the tip can be correctly changed, augmented or refined using either a Closed Rhinoplasty or an Open one. And since the Closed Rhinoplasty has fewer incisions, is easier to perform (by quite a bit.even for someone like myself with the experience of doing thousands of cases over 16 years), takes less time to be performed (arrround 2 hours for an Open Rhinoplasty versus 1 hour for a Closed one), and has quicker healing time (a fair amount faster for a Closed Rhinoplasty versus an Open one because less nasal tip skin is dissected).I would use a Closed Rhinoplasty for any of the manipulations of the nose.

The rub comes when the nasal tip is wide and broad (looks bulbous), one or more previous Rhinoplasties have been performed, the tip is really uneven and asymmetric.In my honest opinion, anything gives me the ability and the power to correct these things like an Open Rhinoplasty. By making that seemingly insignificant inverted V incision along the the Columella and connecting that with incisions hidden within the nostrils, I can look at the nasal tip structures as they exist at rest. No twisting, no distortion.just the way they are. More importantly, I can manipulate, sew and modify these nose structures under direct visulaization. That's great!

When I combine the curved portion of the ear as a graft for the tip, I have the ability to do or redo seemingly impossible nasal tips that are large, asymmetric, twisted or in some other way distorted. Combine that ability with an onlay silicone graft to the nasal bridge and I have the right tools to tackle even the most challenging of noses.and believe me, I have seen my share of those.

So, my take home message is simple: both Open Rhinoplasty and Closed Rhinoplasty are valuable techniques and neither is perfect for all of the cases.

SOURCE: Author: Dr.Francis R Palmer, III MD

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