The following post is an article from the Plastic and Reconstructive Surgery Journal.
This article has most influenced my approach to rhinoplasty and is the quintessential open rhinoplasty article. I encourage everyone to read it to get an understanding of my passion.
The open approach was first described in 1934 by Rethi but did not gain support in North America until the early 1970s, when Wilford Goodman, a Canadian otolaryngologist, started publishing and making presentations about the technique. Even then the value of the approach was slow to be recognized, due to the fact that those advocating the open approach were not getting any better results than the leaders in the field were getting with the endonasal approach. However in the early 1980s, some of the premier rhinoplastic surgeons in otolaryngology, namely, Anderson and Wright, began to recognize the value of the open approach and wrote favorable articles about it. The stimulated more interest in the approach, and since that time, it has continues to gain popularity and momentum.
I became interested in the open approach in 1980 after hearing Anderson present a paper entitled, “100 Consecutive Rhinoplasty Cases Using the Open Approach.” From his presentation, it seemed that the exposure afforded by the open approach would offer a great advantage, especially in secondary Rhinoplasty patients. After trying it on several patients, I started performing all major secondary rhinoplasties and primary rhinoplasties with major tip problems through the open approach. Over time, I have found that it offers me more options and control of the operation, and I am now using it in over 95 percent of my primary Rhinoplasty cases.
Why the Open Approach Has Gained Popularity
There are four main reasons for the increased popularity of the open approach. All are related to the increases exposure it affords.
- It gives the surgeon the ability to inspect the osseocartilaginous framework in its natural state (without tension or distortion) and allows him or her to make a more accurate diagnosis of the cause of the external deformity. This is true in both primary and secondary cases.
- The increased exposure makes it easier to perform certain technical maneuvers.
- It gives the surgeon more options in altering the osseocartilaginous framework.
- It is easier to teach and learn the operation with both the teacher and student observing by direct visualization.
The open approach allows remodeling the cartilaginous framework while maintaining the integrity of the framework. This reshaping is performed primarily with sutures and repositioning, as opposed to transection and resection, which are an integral part of the endonasal approach. In addition to being able to reshape and reposition the cartilaginous framework with sutures, it allows better stabilization of the framework and grafts. Grafts can be placed and sutured so that they can be sutured to surrounding structures for further stabilization. It also allows the operator to continually assess his or her results on the osseocartilaginous framework without guesswork. If the surgeon understands the effect the osseocartilaginous framework has on the external appearance, when he or she achieves the desired shape for the framework, he or she can close with a confident feeling of having accomplished what he or she set out to do.
The more I work with the open approach, the more I find there are things I can do through it that I cannot do through the endonasal approach (or can do a lot easier). A few specific examples are as follows.
- Securing a columellar strut to the nasal spine area either by placing a notched base of a strut over the spine or by using a K-wire in the base of the strut that can be seated into a frill hole in the maxilla. (Fig. 1)
- Advancing and suturing the medial crura to a secured columellar strut to increase tip projection as much as 5 to 6 mm.
- Controlling the columellar-lobular angle with a shaped columellar strut.
- Suturing tip grafts in place (Fig. 2)
- Placing and suturing alar spreader grafts for the correction of alar collapse. (Fig. 3)
- Placing and suturing lateral crural struts to reinforce or straighten the lateral crura. (Fig. 4)
- Suturing stabilizing dorsal spreader grafts. (Fig. 5)
- Suturing stabilizing dorsal on onlay grafts. (Fig. 6)
- Performing hump precision medial osteotomies with a power-driven saw.
- Deepening the nasofrontal angle with a power-driven drill.
A disadvantage of the open approach is the transcolumellar scar. Those opposed to the open approach always mention the possibility of skin loss of the columellar flap and the ‘awful” scarring they have seen from transcolumellar incision. I am certain both have occurred. However, in the close to a thousand open rhinoplasties I have performed since 1981, I have had to revise only one transcolumellar scar and have never seen any loss of columellar skin. This is not to say that all scars are invisible, but with use of the proper technique (placing a staggered incision across the columellar just anterior to the flare of the feet of the medial crura and suturing in meticulously under loop magnification), the scar is seldom noticed at conversational distances, completely accepted by the patient, and a small price to pay for the added exposure.
On the other hand, close to 50 percent of the rhinoplasties I perform are secondary, and almost all have been performed by the endonasal approach (as would be expected, since it has been in use much longer than the open approach). I have seen some severe deformities, but I have always assumed that they were due to complication or the inexperience of the surgeon, not to the endonasal approach. I also have seen loss of tip skin following endonasal rhinoplasties but again felt this was due to a fault (improper undermining, applying the tape too tight around the tip, etc.) other than the approach. Likewise, most of the problems I have seen following use of the open approach were caused by the “approacher” rather than the approach itself.
Another disadvantage of the open approach is that it requires a more extensive dissection of the skin off the osseocartilaginous framework. This results in more scar tissue contraction, which may distort the reconstructed osseocartilaginous framework if it is not well stabilized. This is the reason that tissue resection is kept to a minimum and suture repositioning and shaping are the primary methods of constructing the new framework. This makes the open approach more labor-intensive than the endonasal approach. In either approach, undermining should be performed only where necessary.
The more extensive dissection, along with meticulous closure of the transcolumellar incision and the suturing of grafts, requires more operating time than the endonasal approach. This is a disadvantage, but it should not deter one from using the open approach when a better result can be obtained.
The open approach basically accomplished three things:
- The exposure it gives allows a more accurate assessment of the problem
- It makes modification of the osseocartilaginous framework technically easier.
- It allows more options for altering the framework.
There are some people who can build a ship inside a bottle. I admire that. If the surgeon can obtain equal or better results in difficult cases with the endonasal approach, I admire that also and recommend it be used because it ill save time and eliminate any possibility of a visible columellar scar. However, if a better result can be obtained with the open approach, the extra time spent and the 5- to 6-mm scar placed on the undersurface of the nose, which is usually unnoticeable to the casual observer, are a small price to pay for a better aesthetic result.