Joseph J Rousso, MD
Chief, Dvision of Facial Plastic & Reconstructive Surgery
The New York Eye & Ear Infirmary of Mount Sinai
New York, New York
Rhinoplasty is arguably the most complex technical procedure in the field of plastic surgery. On account of its unique anatomy and required technical capabilities, the open rhinoplasty surgery is a difficult procedure to train surgical students to perform. As such, it is most important to break down the procedure in order to employ the safest methods to protect the intricate anatomy. This is a suggested guide to accessing the nose via a ‘belt and suspenders’ approach for surgical educators to utilize while training their residents and fellows.
Rhinoplasty is often considered the most complex technical procedure in the vast field of plastic surgery. It is no surprise that in a 2011 survey of plastic surgery residency program directors more than half did not feel confident in their graduating residents ability to perform a rhinoplasty .  A 2019 survey by O’brien et al highlights that otolaryngology residents are required to graduate with a minimum of 8 rhinoplasty procedures; yet it is the procedure that graduating residents identify as being one they are most uncomfortable performing after graduation. 
The surgical education of otolaryngology and plastic surgery residents and fellows should be inclusive of a comprehensive understanding of the 3-dimensional nasal anatomy. The complexity of the anatomic structures require that the trainee also understand conceptual principles, many of which are referred to as ‘theories’ but are accepted as working principles. These include an understanding of the nasal tip dynamics as explained via Anderson’s tripod theory and M-arch model described by Adamson . A comprehensive understanding of the nasal structure, not just in its anatomy but in its architectural function such as the L strut support, is paramount prior to active surgical training. Keys to distinguishing the functional roles of each anatomic component lie in the understanding of each set of cartilages unique roles, and a pre-requisite requirement is an understanding of the effect that these may have on nasal breathing. One clear example is that of the components that affect the nasal valves, both internal and external, in breathing. Although the focus of this publication is on the safe surgical techniques of opening the nose, it should be emphasized that there are several necessary topics that must be understood prior to learning these technical skills. These includes but are not limited to the following:
- Nasal tip dynamics
- Physiologic understanding of nasal physiology and the nasal airway
- The nasal valves (internal and external)
- The major and minor tip supporting mechanisms
- The nasal bony pyramid and osteotomies
- Common complications secondary to rhinoplasty surgery
- The septum and the L strut
- Graft harvesting from all relevant sources such as septum, auricular, costal, calvarial bone, temporalis fascia
- The nasal turbinates and their role in functional breathing
- The pre-operative aesthetic assessment
A step by step approach is described below and describes the procedure that is shown on the attached surgical video, with an analysis of each major tip. Bolded sentences correspond to each surgical tip pointed out in the video.
The inverted V transcolumellar gullwing incision is marked out pre-operatively, in the mid-point of the columella . These markings are the preferred incisions for open rhinoplasty based on a survey by Adamson and Doud Galli. 
Initial incisions are performed with a number 15 blade taking into account that the lateral and marginal columella incisions needs to be shallower than the central ones on account of the superficial nature of the medial crura in the former. The focus during these early incisions is for the surgical trainee to keep full attention on the surgical field, as such the number of instruments utilized should be minimized. The marginal columellar incisions are the shallowest incisions and are only performed as an entryway for the safe utility of blunt dissection, via creation of a supra-crural tunnel performed with the converse nasal tip scissors. Once this tunnel is created the skin is palpated to assure that the medial crura are not between the tines of the scissors and the skin. The tines are left in the tunnel to protect the underlying medial crura and the 15 blade is utilized to complete the inverted V incision. Using this technique, a methodical opening of the skin can be performed with direct visualization and protection of the underlying cartilaginous structure, highlighting use of the belt and suspenders safety approaches whenever possible.
After making the initial skin incisions it is not uncommon to encounter bleeding from the columellar artery, this is controlled with the bipolar cautery. It should be emphasized that bipolar cautery should be considered the only system of cautery to be used in the nose. Monopolar cautery should be avoided, if possible, on account of its unpredictability in a sensitive closed space such as the nose.
Skin Soft Tissue Envelope (SSTE) elevation
Next, one small double pronged skin hook is used to retract the skin while an additional one is used to display each medial crura respectively. This retraction allows for blunt dissection with cotton swabs as well as spreading maneuvers with the converse scissors to develop the plane immediately above the cartilage. The highest yield method of dissection in nasal opening is blunt dissection. Cutting moves are only done after defining planes completely with blunt dissection.
Once both domes are identified, a wide double pronged skin hook is placed on the underside of the domes and they are retracted caudally for counter-retraction of the SSTE. This will help to display the pitanguy’s ligament prior to dissecting it out. An additional skin hook is used to gently retract the SSTE and a third wide double pronged skin hook used to help identify the caudal margin of each lower lateral crura respectively. It should be noted that the middle and index fingers of the non-dominant hand that is holding the wide double pronged skin hook should be pressing down on the nasal skin to further expose the caudal margin. This is a technique known as three-point counter-traction that is described by Dr. Dean Toriumi , and is one of many utilized time tested techniques described by the master surgeons. With this exposure and blunt dissection exposing the caudal aspect of the LLC, the converse scissors is used to make the marginal incisions on each side respectively.
Middle and Upper 1/3 exposure
Once the marginal incisions are completed and the correct plane immediately above the cartilages are well visualized, the middle 1/3 of the nose can start to be exposed. This starts by isolating the Pitanguy midline ligament by dissecting tunnels around it to isolate it. It is very useful to isolate this structure completely, prior to cutting it, as it is a likely source of bleeding. The ligament can either be cauterized prior to releasing it or cut sharply knowing that it may be the source of bleeding. In other fields it is common to ask anesthesia providers to lower the blood pressure for an operative field to have less bleeding. Certainly if a patient is hypertensive intra-operatively this should be a consideration as well in rhinoplasty. However, as a general rule in rhinoplasty surgery the trainee should use anatomic knowledge rather than medications for hemostasis.
The middle and upper third of the nose should be exposed methodically by starting centrally all the way up and then separating soft tissue in the correct plane from medial to lateral. The aufricht retractor can be used for blunt retraction and to help expose the correct sub-nasalis muscle plane. In order to help stay immediately on the dorsal framework of cartilage and bone, nasal dorsal framewok sharp dissection should be done with the elbows up. The curved stevens scissors, cottle elevator and josephs elevator are used for this dissection.
Once the skin soft tissue envelope is elevated and the entirety of the dorsum is able to be visualized, there are a variety of methods that can be employed to retract it. Far too often these retraction methods are very traumatic on account of a good SSTE being thick and there being less concern for pressure in this area. However, it should be emphasized that the SSTE of the nose should be treated as gently as any facial soft tissue. It is on account of this concept that I feel the safest method of retraction is a soaked pledget that is suspended onto a head drape. This is very soft on the skin and less likely to cause unnecessary edema which will distort the intra-operative appearance of the nose when the skin is re-draped.
Medial Crural Separation and Septal Exposure
Now that the SSTE is completely opened, attention is focused on the separation of the medial crura from each other and identification of the anterior septal angle as well as the caudal septum. At this point in the surgery the trainees focus should be on the L strut. Identifying it by constantly re-assessing where in the 3-dimensional plane they are as well as studying it and preserving its integrity when dissecting it out. The medial crura are separated from each other by a method which should be familiar at this point in the surgery, bluntly dissecting with cotton swab and spreading with the converse scissors. Once the caudal septum and the anterior septal angle are identified, cutting can be employed to expose it further. The 15 blade is used to identify the sub-mucoperichondreal flap plane and to get directly onto the gritty septal cartilage on each side. After cutting, the edge of the blade can be used to scrape away the perichondrial layer and visualize it further. Never rush the process of finding the submucoperichondrial plane, particularly in the area that covers the L strut on both sides. If you need to replace or reconstruct the L strut you must be assured that there is strong viable tissue to protect your reconstruction. Once the plane is identified it can be elevated with any variety of elevators, but if in the correct plane it should open up smoothly even with a blunt cotton swab. While elevating the plane over the entire cartilaginous and bony septum, the belt and suspenders method employs looking directly at the flap from the underside to assure there are no tears as well as utilizing the nasal airway view to safely monitor the mucoperichondrial flap.
Elevation of the mucoperichondrial flap on the dorsal side includes exposure of the internal nasal valve, and moving the mucoperichonrium upward and laterally under the Upper lateral cartilages so it does not get exposed on the dorsum of the nose. This is a good time to display the Internal nasal valve to junior residents so that they understand the concept.
Separating the Upper Lateral Cartilages from the Dorsum
The upper lateral cartilages are then sharply released from their attachment to the dorsum by hugging the septum with the side of the 15 blade prior to incising. Furthermore the skin soft tissue envelope should be well protected from the blade with the aufricht retractor prior to incising. Once both ULC’s are separated there should be an open sky view utilizing the nasal speculum of the entire septum. Do not commit to any L strut altering moves until open sky view is achieved. Such L strut altering moves include hump reductions, caudal cephalic trims, and septal cartilage harvest among others. At this point exposure of the nose is adequate to visualize both aesthetic and functional anatomic issues and to continue on with the techniques that will correct these deformities.
Rhinoplasty surgical education is essential in advancing the art and science of our field. The safest most methodical approaches to opening and exposing the underlying structural skeleton of the nose can help trainees gain the confidence to further harness their skills in rhinoplasty surgery. The ‘belt and suspenders’ method and approach helps to eliminate possible untoward intra-operative complications and offers one method of open septorhinoplasty surgical training.
- Oni, GAhmad J, Zins JE. Et al. Cosmetic surgery training in plastic surgery residents. Aesthet Surg J 2011; 31(4): 445-55
- O’brien DC, Kellermeyer B, Chung J et al.Experience with key indicator cases among otolaryngology residents. Laryngoscope Investig Otolaryngol 2019 Aug;4(4): 387-392
- Adamson PA, Doud Galli SK. Arch Facial plast Surg. 2005;7(1):32-37
- Toriumi DM. Structural approach to primary rhinoplasty. Aesthet Surg J. 2002; 22(1):72-84