Notes about rhinoplasty (work in progress)#

First version: 2020-03-20
Last update: 2022-03-02
Persistent link to latest version:

1 Overview

Rhinoplasty is any surgery performed on the nose. Several specific procedures are part of rhinoplasty. They can be performed for purely cosmetic purposes or to fix an anatomical defect that causes difficulty in breathing.

When performed for cosmetic purposes the goals can include any of the following:

  • Removal of a dorsal hump (the characteristic of so-called Greek/Roman/Jewish nose)
  • Increased projection of the tip
  • Rotating the tip so that it is higher or lower
  • Narrowing a boxy tip
  • Narrowing the base of the nose
  • Correction of deviation of the nose to one side
  • Correction of asymmetric nostrils
  • Adding material to the dorsum, especially to correct an overly aggressive previous rhinoplasty
  • Reduction of alar flare

For an overview of the surgical techniques used in rhinoplasty see Rohrich et al. (2014), Tasman (2008). Adamson, Gantous (2019) describe the historical development of rhinoplasty.

In current practice use of unpowered tools is the norm more common. Powered tools can be used instead to perform the osteotomies. See section Videos for an example of a rhinoplasty with powered tools.

Current trend is to avoid removal of tissue as much as possible in favor of remodelling existing tissue. The maxim “resect and regret” embodies this philosophy. For a short paper arguing in favor of this philosophy see Daniel (2018).

1.1 Overview of procedure

Rhinoplasty is not an invariant sequence of steps. The techniques used vary depending on the goal and personal choice. Rhinoplasty involves work in at least one of the following: Lower alar cartilages, upper alar cartilages, nasal bone, frontal protrusion of the maxillary bone, septum and nasal turbinates.

Most rhinoplasties involve access to the nose from the lower alar cartilages to the nasal bone. There are 2 main ways to achieve this:

  • Open rhinoplasty. Access is through an incision made through or below the columella and continued by the interior of the nose through the nostrils.
  • Closed rhinoplasty. Access is through one incision in the interior of each nostril. The skin of the columella is unperturbed.

When rhinoplasty is limited to work in and around the lower alar cartilages, a closed approach is usual. There is a choice between:

  • Delivery approach. The lower alar cartilages are partially removed from their anatomical position and pulled through the nostrils.
  • Non-delivery approach. The lower alar cartilages are worked in situ.

Conceptually, the location and orientation of the tip of the nose is given by a tripod. 2 legs of the tripod are the lateral crura of the lower alar cartilages and the other leg is the central crura of both alar cartilages.

To increase pointyness of the tip a columellar strut can be used. This consists of a long and narrow piece of grafted cartilage.

2 Instruments

Rhinoplasty usually employs the following special instruments. Instruments used in virtually any surgery (scalpel, needle holder, etc.) are not listed.

  • Hook with 2 prongs
  • Chisel-type osteotome
  • Guarded osteotome
  • Bone rasp
  • Mallet
  • Tenotomy scissors
  • Aufricht elevator
  • Cottle elevator
  • Joseph elevator
  • Takahashi forceps
  • Vacuum aspirator

For percutaneous lateral osteotomy, the osteotome must necessarily be non-guarded; good practice is to have the width of the tip be 2 mm.

3 Opening the nose

The “open” in “open rhinoplasty” referes to opening the nose itself with an incision in the columella and dissection that exposes the nasal cartilages and nasal bones.

3.1 Columellar incision

Open rhinoplasty starts with an incision in the columella. There are 2 options:

  • Incision at the middle of the columella. Also called “Réthi incision” by Abbou et al. (2014). This is the most common option. An incision is made in the middle of the columella ending at the nostrils. A simple line is avoided because of inferior cosmetic results after healing. Usual shapes for the columellar incision include stair-step and inverted-V. Ivhan et al. (2017) compared an inverted-W shape with an inverted-V shape and found them to be similar; subjectively-rated results did not reach statistical significance.
  • Columellar-transalar incision. An incision is made at the lowest of the columella where it joins the nasolabial skin.

Abbou et al. (2014) found that open rhinoplasty with the mid-columella incision resulted in a difference average increase the nasolabial angle of 4.2° and columellar-transalar incision resuled in a average decrease of 6.4°. Aksu et al (2008) found that a straight line columellar incision results in more scar formation than an inverted-V columellar incision; strangely, they did not publish the difference in ratings, only p-values.

Rohrich et al. (1995) examined the arrangement of the blood vessels of the nasal tip and around it and concluded that the columellar incision in rhinoplasty is not a risk to the blood supply of the nose.

After the columellar incision, an incision is performed inside each nostril below the inferior alar cartilages. The intra-nostril incisions meets the transcolumellar incision to make a single opening. This opening is the main access to the nose during the surgery. See Rohrich et al. (2014) p. 1429-1430 for a description of the opening of the nose.

3.2 Dissection

After the columellar incision, the cartilages and nasal bone are mostly inaccessible. Only the lower part of the lower alar cartilage and the septum is exposed. The nose has to be dissected (separated) between the perichondium and the cartilages and between the periostium and the nasal bone, thus making a tunnel that allows access to the nasal cartilages, septum and nasal bone. This dissection is usually performed by inserting closed scissors and opening them to separate the tissue and by using a scalpel wih blade type 15 to directly cut the tissue that joins the perichondium and periostium with the cartilages and bone.

Rohrich et al. (2014) p. 199-201 describes briefly the dissection between the perichondium and cartilage. Toriumi et al. (1996) describe dissection along the areolar tissue with more detail; they used Converse scissors, opening them to dissect.

4 Removal of a dorsal hump

Structurally, a dorsal hump consists of an excess of the projection of the nasal bone, septum and upper alar cartilages towards the front.

Removal of a dorsal hump to transform a Greek nose into a straight or concave nose is usually accomplished with the open method. It consists of the following basic steps.

  1. Removal of the excess projection of the septum. The lower nasal cartilages are separated from the septum with a scalpel. The septum is reduced by cutting vertically with scissors or a scalpel.
  2. Removal of a central section of both lateral cartilages.
  3. Reduction of the frontal bone that underlies the top of the nose. At this point there exists a gap along the middle of the nose, called “open roof”.
  4. Lateral osteotomy to allow movement of the nasal bone and the part of the frontal bone that underlies the nose.
  5. Moving the upper cartilages close together to close the open roof.
  6. External fixation to allow the bones and soft tissue to heal in the desired position in the span of days to weeks after the surgery.

4.1 Lateral osteotomy

Interrupted (a.k.a. perforating) lateral osteotomy. In practice this method is always performed percutaneous. It is performed with a non-guarded 2 mm wide osteotome.[1] For each side a small incision is made in the skin covering the malar, near the nose. The osteotome is introduced through this hole. A series of holes are made in the piriform protrusion and nasal bone, leaving intact roughly 2 mm of bone between them. A single incision is used to introduce the osteotome; the tip is moved under the skin. Care should be taken to not to damage the maxillary nerve. After both sides are perforated the bones of the nose are fractured in one step by crushing the nose between the index and thumb fingers with one hand.

Continuous osteotomy. This method is nearly always performed intranasally. There is more margin for different types of osteotomes. Intranasal osteotomy consists of a continuous cut on each side of the piriform protrusion and nasal bone. It can be performed with a 4 mm wide guarded osteotome.[1]

5 Reduction of alar flares

A small slice of skin of the nasal alae is excised in each side just frontal to where it joins the skin above the maxilla, then it is sutured. See Rohrich et al. (2014). This procedure is rarely required and rarely performed (author’s observation).

6 Closing the nose

The final surgical step in open rhinoplasty is suturing the columellar incision. Berghaus (2016) writes: “This incision is closed accurately with five stitches utilizing 6-0 monofilament suture material.”.

7 Comparison of open with closed techniques

For a prose comparison of open with closed rhinoplasty see Berghaus (2016).

8 Other sources of information

Hwang (2019) describes a good way to hold the osteotome.

8.1 Videos

9 Footnotes

  1. Chen et al. (2017) write “Perforating percutaneous nosteotomies were performed with 2-mm straight osteotomes; continuous intranasal osteotomies were performed with 4-mm curved guarded osteotomes.”.
  2. For each side a small incision is made in the skin covering the malar, near the nose. The osteotome is introduced through this hole. A series of holes are made in the piriform protrusion and nasal bone, leaving intact roughly 2 mm of bone between them. A single incision is used to introduce the osteotome; the tip is moved under the skin. Care should be taken to not to damage the maxillary nerve. After both sides are perforated the bones of the nose are fractured in one step by crushing the nose between the index and thumb fingers with one hand.

10 References

  • R. Abbou (2014) “Open Rhinoplasty: Influence of Incisions, Alar Resection, and Columellar Strut on Final Appearance of the Tip”. DOI: 10.1007/s00266-014-0395-2.
  • P. A. Adamson, A. Gantous (2019) “Once Upon a Rhinoplasty: The History of the “Queen” of Facial Plastic Surgery”. DOI: 10.1055/s-0039-1693443.
  • A. Berghaus (2016) “Modern Rhinoplasty: Is There a Place for the Closed Approach?”. DOI: 10.1055/s-0036-1585422.
  • J. X. Chen et al. (2017) “Educational Cadaveric Module for Teaching Percutaneous and Intranasal Osteotomies in Rhinoplasty”. DOI: 10.1177/0194599817706328.
  • I. Aksu et al. (2008) “Comparative Columellar Scar Analysis Between Transverse and Inverted-V Incision in Open Rhinoplasty”. DOI: 10.1007/s00266-008-9170-6.
  • R. K. Daniel (2018) “The Preservation Rhinoplasty: A New Rhinoplasty Revolution”. DOI: 10.1093/asj/sjx258.
  • K. Hwang (2019) “How to Hold an Osteotome? Michelangelo Grip”. DOI: 10.1097/SCS.0000000000005247.
  • O. Ivhan et al. (2017) “Comparative Columellar Scar Analysis Between W Incisions and Inverted-V Incision in Open Technique Nasal Surgery”. DOI: 10.1007/s12070-017-1096-3.
  • R. J. Rohrich et al. (1995) “Nasal Tip Blood Supply: An Anatomic Study Validating the Safety of the Transcolumellar Incision in Rhinoplasty”. DOI: 10.1097/00006534-199504001-00004.
  • R. J. Rohrich et al. (editor) (2014) “Dallas Rhinoplasty”, 3rd ed.
  • A. Tasman (2008) “Rhinoplasty – indications and techniques”. No DOI found. Full text in PMC.
  • D. M. Toriumi et al. (1996) “Vascular Anatomy of the Nose and the External Rhinoplasty Approach”. DOI: 10.1001/archotol.1996.01890130020003.