OPEN-TIP RHINOPLASTY: EXPOSURE, STEP BY STEP.

PRATAS R., MARÇAL N.

1. INTRODUCTION

History of rhinoplasty comes from many centuries ago, most probably from ancient cultures in Egypt. One of the most important steps in modern open-tip rhinoplasty history was taken in 1921 by Rethi, from Budapest, which described an external approach to expose alar cartilages and nasal dorsum only through a unique high columellar skin incision, connected with bilateral endonasal skin incisions along the caudal border of the alar cartilages.⁽¹⁾ The Rethi incision became the dictum for transcolumellar approach.

Later on, Haubenrisser⁽²⁾ in 1956 modified the Rethi incision with propose of facilitating the flap elevation. He described the extension of the incision laterally to the alar facial junction, curving it in the crease of the alar facial junction over the external skin.

Jacob D. Steiger, MD
Private Practice
Boca Raton, FL

Patients seeking rhinoplasty span a wide range of ages and ethnicities.  In addition, they may have an equally wide range of desired outcomes from the procedure.  The initial rhinoplasty consultation is an opportunity for the surgeon to assess the patient.   This assessment includes both that of the physical and psychological condition of the individual.  In doing so, the surgeon can determine if the patient is an appropriate surgical candidate. Once this is determined the surgeon can proceed to further prepare the patient for surgery and manage expectations.

Daniel G. Becker, MD FACS
Becker Nose and Sinus Center, LLC
400 Medical Center Drive, Suite B
Sewell and Princeton, New Jersey USA
856 589-6673
856 589-3443 fax
drbecker@therhinoplastycenter.com

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Pennsylvania Medical Center
Philadephia, Pennsylvania

Clinical Professor
Department of Otolaryngology-Head and Neck Surgery
University of Virginia Medical Center
Charlottesville, Virginia

Proper local anesthesia is critical to allow atraumatic dissection with minimal bleed­ing and edema. A total volume of less than 3 ml of 1% lidocaine with 1:100,000 epinephrine is typically used to attain anesthesia for rhinoplasty alone. When performing septorhinoplasty, as much as 10 nil of local anesthetic may be used. The anesthetic is al- lowed to take effect for at least 15 minutes to maximize the vasoconstrictive effect of the epinephrine.

To become familiar with a method of injection of local anesthetic agent, saline can be injected with a 5-ml syringe and 27 gauge (1.5 cm) needle along the site of injection in a cadaver specimen. Injection varies in some respects, based on the surgical approach se­lected; for example, the subdermal columellar injection may be omitted in an endonasal approach. A generalized approach to injection is described below. For a septoplasty, multiple 0.5-m1 to 1.0 ml injections are made in the subperichondrial and subperiosteal plane along the entire area of anticipated dissection. Injections also should be placed along the site of the proposed incision (Killian, hemitransfixion, etc.). Both sides of the septum should be in­jected if the surgeon plans to elevate mucosa bilaterally. The injection will aid in the dis­section if placed in the subperichondrial plane. It is helpful to place an injection on the posterosuperior septum bilaterally to minimize bleeding from the sphenopalatine blood vessels.

Annabelle C. Leong and Alwyn R. D’Souza

Abstract

The tenets of rhinoplasty focus on restoring or maintaining the strength and support of the nasal skeleton while altering the contour to achieve the desired aesthetic result.  The debate continues unabated over the advantages and disadvantages of an open versus a closed endonasal approach. The open technique offers the obvious benefit of direct observation, which often outweighs the commonly-cited disadvantage of transcolumellar incision and scar.  The enhanced exposure is especially beneficial for work on the nasal tip, dorsum and septum and additionally, offers the best possible teaching tool for the trainee.  The goal of this chapter is to provide the reader a logical and systematic road map upon which to manage the surgical correction of nasal deformities with the open rhinoplasty approach.