Surgical Approaches and Techniques in Rhinoplasty
Rhinoplasty surgeries are one of the most frequently performed aesthetic operations. Though the duration of the operation varies according to the type of the malformation in the nose, concurrent pathologies like intranasal deviation, nasal turbinate hypertrophy, chronic sinusitis, that need intervention in the same session and to the surgical technique that will be applied, it usually lasts for 1.5-2 hours. However, in special situations in which tissues are required to be taken from other regions like the ear and the ribs, this duration can be longer.
Surgical Approaches
There are two main surgical approaches to access the bony and/or cartilaginous deformities of the nasal anatomy in rhinoplasty surgery. These are;
- Open approach
- Closed approach
In closed approach the bony and cartilaginous structures of the nose are approached through the incisions all located in the nose, performed through the nostrils. The only difference in open approach is an extra horizontal cut in the skin bridge between the nostrils which frees the nasal skin and provides full exposure of nasal structures.
Figure: The incision line performed in open rhinoplasty surgery
Surgical Techniques and Technologies in Rhinoplasty
In recent years different surgical techniques and technologies have been introduced in aesthetic nasal surgery and all of them can be performed through open or closed approach. Most popular of them are;
- Tip-rhinoplasty
- Structural rhinoplasty
- Preservation rhinoplasty
- Ultrasonic piezosurgery
- Micro-rhinoplasty
Operations that are performed just to correct the malformation of the anterior cartilaginous part (tip) of the nose without intervening the bony structures is called tip-rhinoplasty or tipplasty. In these operations, except for very limited problems, usually open approach is preferred. Correction of the projection problems and asymmetries of the tip of the nose, reducing the stuffed nose tip or correcting the cartilage angulations that narrow the entry of the nose is performed with this surgery. Since bony structures are not intervened during the operation, swelling and bruising around the eyes are generally not observed. After the tipplasty operation patients return to their normal daily life in around a week time.
When the bony and cartilaginous parts of the nasal dorsum is modified with resection of the excessive parts and reconstructed seperately by using open or closed approach the operation is regarded as structural rhinoplasty.
For patients having malformation or asymmetry on the tip of the nose besides the upper bony part, patients who have undergone nasal surgery previously and/or patients who have to be operated due to intranasal septum deviation with rhinoplasty in the same session the most ideal approach is open rhinoplasty. Since in most of the rhinoplasty patients there is a need for modification of the nasal tip, open rhinoplasty is the mostly preferred surgical approach.
In the open rhinoplasty surgery, the operation starts by making a horizontal incision in the middle of the region between the two nostrils (columella) and after the skin of the nose is lifted by this way, all cartilage tissues that form the tip of the nose are exposed and the surgery can be performed under direct vision which helps providing complete symmetry. Also as additional cartilage supports can be placed and fixed with sutures to the stable structures, the risk of changing the nasal shape, dropping of the nasal tip and shifting of the septum after the surgery is minimized in this operation.
In the open technique, since septum can be controlled entirely, the high deviations located near the dorsum of the nose can be completely corrected with the addition of cartilage pieces with appropriate methods and cartilage deficiencies that formed in previous surgeries can be repaired completely and symmetrically. In open technique surgeries, since the incision made to the tip of the nose is closed with appropriate technique and materials, it recovers within 1.5-2 months and become invisible in most cases.
In patients who do not have a significant problems on the tip, framework or septum of the nose and having the main complaint as bone and cartilage protuberance on the dorsum of the nose (dorsal hump) or having simple superficial irregularities on the dorsum of the nose following a previous surgery, closed rhinoplasty technique is preferred.
In this technique, the dorsum of the nose is reached through the incisions made through the nostrils and the required interventions are made to the malformations. Closed technique provides short duration of the operation in selected patients, since a small amount of edema is formed at the tip of the nose, recovery takes a shorter time.
In the operations, after the removal of the bony and cartilaginous protuberance at the dorsum of the nose (dorsal hump), the bones of the nose are brought together by cutting them with different instruments in order to give a natural appearance to the nose. Due to these fractures, some amount of bruising and swelling occurs in around the eyes after the surgery. These color change and swellings disappear within 7-12 days completely.
After application of ultrasonic piezosurgery technology, which prevents soft tissue damage while shaping or cutting the bones, the bleeding related bruising around the eyes became significantly less in rhinoplasty operations.
In selected patients with limited dorsal deformities without external asymmetries and or severe intranasal septal deviations “preservation rhinoplasty” can be an alternative technique to preserve the integrity of the nasal dorsal bony and cartilaginous structures. In this technique the bump in the dorsum of the nose is pushed down after preparing a space just under it in order to create a straight and natural profile.
Piezoelectric surgery is a relatively new technology which provides cutting, rasping and shaping of the bony structures of the nose with minimal soft tissue trauma which provides more control during the bone interventions and facilitates faster healing.
In patients having a small amount of malformation at the dorsum of the nose without having a wide upper bone, micro-rhinoplasty technique may be preferred. In this technique, the dorsum of the nose is reached through the intranasal incisions (closed rhinoplasty approach) and the small bump (hump) on the bony dorsum of the nose is shaped (rasped) by using small rasps or micro motors. Since the intervention is quite limited, fractures of the side bones in order to give the dorsum of the nose its natural round shape are not required and the intervention to the tip of the nose is very limited, recovery is usually completed within a very short period without the occurrence of bruising and swelling around the eyes. The most important condition in being successful in micro-rhinoplasty technique is the selection of the appropriate patient and realistic clarification of the expectations from the surgery.
