Open Rhinoplasty

Anatomy and Physiology

Key Rhinoplasty Terminology:

• Ala – the lower lateral surface of the nare formed by the lower lateral cartilages
• Alar groove – the surface depression between the lower lateral crus (medially) and the ala (laterally)
• Anterior septal angle – the angle formed by the dorsal and caudal septum
• Columella – the skin between the nasal tip and the base, lying between the nares
• Dome – the anterior projection of the nose where the intermediate and lateral crura meet
• Dorsum – the external midline ridge of the nose between the tip and the nasion
• External nasal valve – the opening of the nare including the rim, columella, and nasal sill
• Internal nasal valve – the point of maximal airway resistance in the nose formed by the upper lateral cartilage (caudal edge), the head of the inferior turbinate, and the nasal septum
• Keystone – the location where the perpendicular plate of the ethmoid and the cartilaginous septum join at the dorsum of the nose
• Lower lateral cartilage (LLC) – the paired alar cartilages including the medial, intermediate, and lateral crura
• Nasion – the depression marked by the nasofrontal suture
• Nasolabial angle – the angle between the long axis of the nostril and a line perpendicular to the Frankfort horizontal line. Ideal angles vary, though have been defined as 90–115 degrees, with more acute angles preferred for males.
• Radix – the junction of the nasal and frontal bone, with the deepest portion ideally located at the level of the supratarsal crease
• Rhinion – the superficial location of the bony-cartilaginous junction along the nasal dorsum. Note: the nasal skin is thinnest at this area.
• Scroll area – the juncture of the cephalic lateral crus caudal upper lateral cartilage
• Supratip area – the region cephalad to where the caudal nasal dorsum meets the tip 
• Tip-defining point (TDP) – the most anterior projection of the tip which produces an external light reflex as seen on frontal view
• Tip projection – the anterior-posterior distance from the TDP to the alar-facial groove. Several methods exist to measure tip projection (e.g., Goode ratio).
• Tip rotation – the cephalad or caudad movement of the TDP with a pivot at the alar base 
• Upper lateral cartilages (ULC) – the paired cephalad cartilages of the nose situated below the caudal aspect of the nasal bone, forming the lateral walls of the middle vault

For a more comprehensive review of nasal anatomy and physiology, which is beyond the scope of this paper, the reader should engage in further reading.[2][3][4][5]

Facial Analysis:

Only after obtaining a thorough understanding of the underlying nasal anatomy and physiology can a comprehensive nasal analysis be performed, allowing a customized rhinoplasty treatment plan with attention to both aesthetic and functional concerns.[6] It merits noting that while various objective measurements (e.g., Goode ratio) have been used to describe ideal facial/nasal proportions[7], additional factors such as cultural differences and ethnic preferences should take preference when performing facial/nasal analysis.[8][9][10][11]

At a minimum, assessment of frontal, lateral, and basal views is necessary. The nose then gets divided into thirds (i.e., upper, middle, and lower third), and each area analyzed individually for issues related to symmetry, width (e.g., wide nasal bones) contour irregularities (e.g., dorsal hump), tip shape (e.g., boxy, bulbous), tip location (e.g., low tip-defining point), projection, rotation (cephalad/caudad), length (short/long), columellar/alar relationships (e.g., hanging columella), as well as shape/size of the nostrils.

The surgeon should document the nasal skin thickness, as this has practical implications not only for surgery (e.g., thicker skin requires more extensive alteration of the underlying framework to maximize definition) but also for recovery (e.g., thicker skin is associated with prolonged postoperative edema).[12] 

Nasal palpation is mandatory to determine tip support, the integrity of the caudal septum, and the size and position of the nasal bones.

Lastly, the nasal cavity should be inspected to evaluate the septum, inferior turbinates, and nasal valves (external and internal), as deficits may dictate what type of surgical techniques are required (e.g., septoplasty, turbinate reduction, spreader grafts, etc.)

Indications

Rhinoplasty is indicated for the correction of any functional or cosmetic deficits of the nose. The debate continues as to whether closed (endonasal) vs. open rhinoplasty is superior; however, the widely accepted opinion is that the open approach (the more common approach) has numerous advantages, namely improved visualization. The ability to directly visualize the surgical maneuvers underway not only enhances diagnostic accuracy and correction of deformities but also facilitates education and participation of team members.[13] 

Contraindications

Disadvantages of the open approach[14]:

• Potentially increased edema
• Extended surgical time
• Destabilized cartilaginous framework
• External transcolumellar scar. Note: the majority of patients (98%) are not “disturbed” by their external rhinoplasty scar, with 90% considering them to be invisible or barely perceptible. Furthermore, for the patient with anxiety regarding suture removal, the surgeon can use rapid resorbable sutures to lessen discomfort.[15] 

Certain components of the patient’s history require attention and/or resolution before performing a rhinoplasty, including[1]:

• Preexisting allergic disorders
• Vasomotor rhinitis
• Nasal trauma
• Prior nasal procedures
• Airway problems (e.g., asthma or cystic fibrosis)
• Sinus pathology.

Use of illicit intranasal drugs (e.g., cocaine) complicates the procedure and may compromise the postoperative result.[16] 

Patients at increased risk of developing post-operative bleeding and/or septal hematoma:

• Patients taking anticoagulants, antiplatelet agents, and nonsteroidal anti-inflammatory drugs
• Patients taking herbal medications and supplements such as chondroitin, ephedra, echinacea, glucosamine, Ginkgo biloba, goldenseal, milk thistle, ginseng, kava, and garlic
• Poorly controlled hypertension, both pre-operatively and intra-operatively

Body Dysmorphic Disorder (BDD):

• A psychiatric disorder characterized by an obsessive preoccupation with self-perceived defects in one's appearance that are either minute or absent to the casual observer
• Patients who have BDD tend to be less satisfied after surgery and exhibit higher aggression and litigation rates toward surgeons.
• The prevalence of BDD may be as high as 13% for all patients seeking facial plastic surgery,[17] and up to 43% in patients who present for a cosmetic rhinoplasty consultation.[18] 

Equipment

Preoperatively:

• Local anesthesia, such as 1 to 1 mix of 1% lidocaine with 1 per 100000 epinephrine, with 0.5% bupivacaine with 1 per 200000 epinephrine.
• Nasal pledgets soaked in nasal decongestant (e.g., oxymetazoline)
• Topical antiseptic, such as povidone-iodine paint
• Shoulder roll (patient placement should be in the “sniffing” position)

Intraoperatively:

• Headlight
• Scalpel (No. 11 and 15 blade)
• Fine Scissors (Iris and Converse)
• Heavy scissors (Metzenbaum, Fomon, Mayo)
• Forceps (Adson-Brown, Adson, bayonet, Takahashi)
• Septum morselizer and cartilage crusher
• Nasal retractors (Converse, Aufricht)
• Skin hooks (5 mm and 10 mm)
• Mallet and Osteotomes (2 mm, 3 mm, 4 mm, and Rubin)
• Elevators (Cottle, Freer, Joseph, Goldman)
• Nasal speculum
• Rasps (push and pull)
• Frazier suction (8Fr and 10Fr)
• Caliper
• Sutures columellar and marginal incision closure, septal coapting, graft fixation, tip/supra-tip contouring, and septal splint placement (materials vary depending on surgeon preference)

Postoperatively:

• Antibiotic ointment
• Adhesive tape (e.g., paper tape)
• Nasal cast (e.g., thermoplastic splint)
• Septal splints (e.g., custom silicone sheets)
• “Mustache” dressing of rolled 4x4 gauze
• Nasal packing (e.g., rolled non-adherent gauze)

Personnel

• Anesthesiologist
• Surgical scrub technician
• Operating room nurse (circulator)
• A surgical assistant is useful to help retract, manage intraoperative bleeding, and cut suture

Preparation

Medical clearance must be obtained, including pre-operative risk stratification and medical optimization.[19] 

Pre-operative photography with static and dynamic images in frontal, three-quarter, lateral, base (worm’s eye), and dorsal (bird’s eye) views should adequately document position and shape of the nose, facial asymmetries, and the effect of the smile on the nose. Digital imaging software can demonstrate proposed surgical outcomes that are otherwise difficult to verbalize, thus improving communication between the patient/surgeon and setting realistic expectations of surgery.[20] 

Incisions are marked in narrowest portion of the columella with an inverted-v pattern which results in better scar formation and less notching than transverse incisions.[21] Osteotomy pathway, if planned, is marked out as well. Marking incisions for an alar base reduction are typically reserved for the end of the procedure.

Though not routine, specific nasal landmarks may be marked, including the rhinion (keystone), upper lateral and lower lateral cartilages.

General anesthesia or intravenous techniques (e.g., propofol) are advisable during the open rhinoplasty. If general anesthesia is employed, muscle relaxants are an option.

A single dose of intravenous antibiotics covering skin flora requires pre-operative administration.

A single dose of an intravenous steroid injection (.e.g., 8 mg of dexamethasone) may help with swelling.

A single dose of intravenous tranexamic acid (10 mg/kg) may help reduce intra-operative bleeding.

Local anesthesia is infiltrated along the septum, columella, margin, soft tissue triangle, sidewalls, and dorsum with care not to distort the appearance of the nose with excess injection.

Nasal pledgets soaked in nasal decongestant are applied to the bilateral nasal cavity

Vibrissae are trimmed to help with visualization and decrease crusting post-operatively.

Technique or Treatment

Open rhinoplasty encompasses a uniquely difficult procedure in that many different means may exist for achieving the same objective, all of which have their own nuances which require incorporation into the overall result. The M-arch model, which builds on Anderson’s tripod theory, can be used to help the surgeon understand the dynamic interplay between the maneuvers performed, particularly regarding their effect on tip aesthetics.[22]

The modern approach to open rhinoplasty focuses on cartilage preservation and incremental changes to the cartilage and bony framework.[23] While a detailed list of every reported technique associated with open rhinoplasty is beyond the scope of this paper, the following briefly summarizes several essential components required in performing a successful open rhinoplasty.[24][14][1][25][13] These key maneuvers include:

1. Opening the nose: The open approach to the nose involves making a mid-columellar inverted-V incision, placement of which should be where the underlying cartilage is closest to the skin to avoid scar visibility and contracture. With the help of skin hooks and sharp dissection (e.g., Converse scissors), the mid-columellar incision is transitioned to the marginal incisions, taking care to avoid injury to the medial and lateral crura. The soft tissue envelope is further reflected superiorly in a relatively avascular supra-perichondrial plane to expose the upper lateral cartilages (ULC). At this point, dissection over the ULC is transitioned to a sub-perichondrial plane using sharp dissection. A periosteal elevator (e.g., Joseph elevator) is then used elevate the periosteum over the nasal bones up to the nasofrontal angle. The lower lateral cartilages are then separated in the midline to expose the anterior septal angle (ASA) in preparation for septoplasty and/or septal cartilage harvesting.
2. Septoplasty: The ASA is sharply exposed, and a sub-mucoperichondrial pocket is created caudally to the nasal spine and posteriorly beyond the septal bony-cartilaginous junction bilaterally. If the surgeon anticipates spreader grafts, the upper lateral cartilages may undergo sharp release from the dorsal septum up to the nasal bones. At this point, septal cartilage may be harvested with attention to leave a 1.5 cm L-strut to preserve adequate structural support. Bony deviations and/or spurs are removed using basic septoplasty principles. Additionally, a “swinging-door” maneuver with excision of redundant inferior-caudal septal cartilage can be performed to correct any existing caudal septal deviations.[26]
3. Dorsal hump reduction: A prominent bony hump is addressed using a combination of osteotomes (e.g., Rubin) and rasps. The cartilaginous dorsum is reduced sharply with a scalpel and/or scissors under direct vision, taking care not to violate the upper lateral cartilages (trimmed later, or used as spreader flaps) or nasal mucosa. Note: To obtain a straight dorsum, the hump at the level of the rhinion should be left slightly higher than the rest of the dorsal skeleton, owing to the thin skin overlying this area. Additionally, the surgeon should be aware that nasal dorsal reduction provides an optical illusion of cephalad tip rotation.[27]
4. Spreader grafts or flaps: Spreader grafts are placed to reconstruct disrupted dorsal aesthetic lines and address middle vault (internal nasal valve) collapse; this is done typically with previously harvested septal cartilage grafts which get sewn in a sub-mucoperichondrial pocket between the native cartilaginous septum and ULC using a series of horizontal mattress sutures. Alternatively, spreader flaps (auto-spreaders) is an option if adequate ULC height remains after performing the cartilaginous dorsal hump reduction.[28]
5. Nasal base stabilization: In theory, stabilizing the nasal base should be performed before nasal tip contouring is carried out. If the projection, rotation, and nasolabial angle do not require modification, a columellar strut (cartilage placed end-to-end with the caudal septum into a pocket between the medial crura) can be used to add support to the tip without altering the tip position. Alternatively, a tongue-in-groove technique or caudal septal extension graft (cartilage placed side-to-side or end-to-end with the septum) may be used to address projection and rotation.[29]
6. Nasal tip contouring: the nasal tip remains the most challenging anatomic region to diagnose and treat. Though a detailed review of each available technique is beyond the scope of this paper, the astute rhinoplasty surgeon should be familiar with the various suture-based tip-plasty techniques—transdomal sutures, interdomal sutures, lateral crural mattress sutures, and columella-septal sutures—all of which have their own variations and subtleties. In addition to suture-based techniques, a softened cartilage graft (e.g., CAP tip graft) and/or cartilage perichondrium may be sutured over the domes to add projection or camouflage to the tip.  Other techniques used to address tip/supra-tip shape include the cephalic trim, cephalic turnover flaps, and lateral crural strut grafts,  which are particularly useful in correcting lateral crural convexity or malposition. Cartilage excising techniques (e.g., vertical dome division, lateral crural overlay, and medial crural overlay) provides a powerful tool for contouring the nasal tip as well, though these maneuvers are generally reserved when more conservative techniques are not useful. [30][31]
7. Dorsal augmentation: Upon setting the tip projection/rotation, the surgeon should make refinements to the dorsum. If augmentation is needed, a radix graft using soft tissue (e.g., temporalis fascia) or diced cartilage in fibrin glue may be used to elevate the nasal starting point. If only a small dorsal augmentation is needed, septal cartilage onlay grafts (single or stacked) typically suffice. Performing large augmentations is best with diced cartilage wrapped in either surgical or temporalis fascia (preferable). Of note, if any further dorsal reduction is desired, this can be done using gentle push rasping and/or precise dorsal cartilage excision.[24]
8. Alar rim grafts: Small onlay grafts are placed into pockets along the caudal aspect of the marginal incision to create an elevated ridge along the alar margin and prevent alar retraction. Alar rim grafts also increase the nostril length and width, improving the function of the external valve.[31]
9. Alar base reduction: Skin confined to the area between the nasal sill and the ala is excised to create desired nostril size and base width. Alar base reductions are typically necessary when a reduction of tip projection creates a widened alar base appearance.[32]
10. Osteotomies: Precise cuts in the bone are used to (1) close an open book deformity (caused by a previously excised hump) and (2) straighten deviated nasal bones and (3) narrow the width of the bony dorsum and sidewalls. This can be done with a combination of various osteotomy techniques (e.g., medial, intermediate, and lateral) based on the existing bony abnormality and desired outcome.[33][27]
11. Closure: A septal splint (e.g., trimmed silicone sheet) may be sewn in place, though this is optional as long as a sufficient coapting of the septum was performed. The transcolumellar incision is then closed with either interrupted permanent (6-0 or 7-0 nylon) or fast-absorbing sutures, the latter of which offers similar aesthetic outcomes without the discomfort associated with suture removal. The marginal incisions are closed with interrupted absorbable sutures (5-0 fast).
12. Taping and casting: Adhesive flesh-colored tape is gently applied from the nasofrontal angle to the supratip to help reduce postoperative edema. A longer strip gets placed around the infratip lobule, acting as a sling to support the tip in its intended level of rotation. A nasal cast is then applied with a thermoplastic splint material that becomes soft and pliable when exposed to hot water and hardens when it cools. Antibiotic ointment is applied to both nares, and a mustache dressing is placed. Nasal packing, which is typically avoided, may be reserved for cases with excessive bleeding.[19] 

Complications

Major complications after rhinoplasty (hematoma, infection, pulmonary complications, venous thromboembolism) are rare, affecting less than 0.7% of patients. More common postoperative complications after rhinoplasty include epistaxis, ecchymosis, edema, and patient dissatisfaction secondary to persistent or new functional and/or cosmetic deficits.[34]

Specific cosmetic complications include[35]:

• Tombstone deformity: occurs if a shield tip graft is too rigid, creating a noticeable graft under the nasal soft tissue envelope
• Rocker deformity: occurs when lateral osteotomies proceed too far superiorly into the nasofrontal angle, causing the superior nasal bone to be pushed outward when the inferior nasal bones are medialized.
• Inverted-V deformity: occurs following hump reduction due to a lack of continuity between the upper lateral cartilages and the nasal bones, creating a visible triangular (inverted-V) shadowing. Routine placement of spreader grafts after hump removal should mitigate this complication.
• Polly beak deformity: occurs from either over-resection of the bony dorsum, under-resection of the cartilaginous dorsum, or relative deprojection of the lower nasal third, creating tip/supra-tip fullness with no discernible supra-tip break
• Ski slope deformity: occurs from excessive hump reduction, creating an overly “scooped” nose. This complication can be prevented by using cold compresses and frequently palpating of the soft tissue envelope during surgery, allowing for a more accurate evaluation during the dorsal hump resection.
• Saddle nose deformity: occurs from loss of septal support, creating middle vault depression, columellar retrusion, tip overrotation, tip deprojection, and nasal shortening. A saddle nose deformity is preventable by preserving the 1.5 cm septal L-strut (dorsal and caudal septum). Treatment varies depending on the degree of deformity, varying from straightforward dorsal inlay grafts to complete nasal reconstruction using rib grafts.
• Nasal bossae: occurs from asymmetries in the cartilaginous framework creating a knoblike protuberance of the alar cartilages.
• Open roof deformity: occurs from greenstick/incomplete lateral osteotomies (prevents complete closure of the open roof), creating a palpable or visible separation of the nasal bones over the dorsum

The need for revision rhinoplasty in a primary open rhinoplasty is low (3%).[36] 

Clinical Significance

Open rhinoplasty is a powerful tool to enhance the form and function of the nose. When performing an open rhinoplasty, proper patient evaluation, and execution of a thorough, anatomic-based treatment plan can produce safe, reliable, and satisfactory outcomes.[36] 

Enhancing Healthcare Team Outcomes

It remains imperative to identify the risk factors and perform a thorough assessment of the patient before performing an open rhinoplasty. A team approach is an ideal way to limit the complications of this procedure. Prior to surgery, the patient should have the following done:

• Evaluation by a surgeon experienced in selecting the appropriate patient for the open rhinoplasty surgery.
• Evaluation by a family physician and/or anesthesiologist/nurse anesthetist to ensure that the patient is fit for anesthesia.
• Perioperative nurse to coordinate care, monitor the patient, and assist the clinicians with pre- and post-operative patient and family education.

an interprofessional team of an experienced surgeon, anesthesiologist, and surgical assistants and operative nurses should be involved during the open rhinoplasty to maximize outcomes. Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of the open rhinoplasty, should monitor the patient for possible complications including a septal hematoma. It is also crucial to provide patient education on proper care for the surgical wounds, and avoiding nose-blowing, strenuous activity, heavy lifting, or bending over during the first several days post-operatively to mitigate complications.[19][Level V]

Nursing will play a significant role in both perioperative and intraoperative settings; their duties are outlined below. They must inform the surgeon of any concerns they may have, including postoperative issues, adverse medication effects, or lack of patient compliance. Pharmacists do not have a significant role in rhinoplasty cases, but their expertise for postoperative pain control is helpful, and as with any patient, they should perform medication reconciliation to head off any potential drug-drug interactions, reporting to the surgeon if they see anything noteworthy. Only through collaborative interprofessional teamwork can rhinoplasty cases achieve their optimal result with minimal adverse events. [Level V]

Nursing, Allied Health, and Interprofessional Team Interventions

The surgeon can prescribe adequate pain medication, as patients often report mild pain for about 3 days post-operatively. To minimize edema and ecchymosis, the patient should intermittently ice the bridge of the nose and eyes for the first 24 hours, sleep with the head elevated for 1 week, and avoid rigorous activity for 2 weeks. The patient may be given a low-dose corticosteroid taper and/or Arnica montana to help lessen bruising and swelling. Patients are asked to return at 7 days for cast and suture removal, at which time they may be given “nasal massage exercises” to help resolve swelling. The patient may be instructed to continue nasal taping if residual supra-tip fullness, external deviation, tip edema, and nostril deformities are present. The patient should avoid putting direct pressure on the bridge (e.g., with glasses) until 6 weeks postoperatively. Return visits occur at 6 weeks and 6 months for further wound assessment. Photographic documentation should occur at around 12 months postoperatively.

Patients should understand that it may require several weeks for the majority of edema to resolve postoperatively, particularly in thick-skinned patients and/or patients where the surgeon performed excessive tip manipulation. Moreover, incremental nasal refinement occurs for up to 1 to 2 years after surgery. The patient may benefit from steroid injections to the tip if significant swelling lingers post-operatively.

Nursing, Allied Health, and Interprofessional Team Monitoring

Close follow-up during the initial post-operative period, either by a wound care nurse and/or clinician experienced in the post-operative care of the open rhinoplasty, should monitor the patient for possible complications including septal hematoma formation and epistaxis.