Rhinoplasty Techniques

There are many different rhinoplasty techniques. Its been said there are as many different rhinoplasty techniques as there are surgeons! This is clearly not true, but it illustrates the point that surgery varies between surgeons, even when the similar rhinoplasty techniques are used. It’s similar to orchestral conductors; there’s a spectrum between a high school music teacher leading the school band and the someone standing on the podium of a world renowned orchestra like the Berlin Philharmonic. Even when leading world class conductor perform the same music, their interpretation will create a different sound and a listener’s response will alter.

Open & Closed Rhinoplasty Techniques

A fundament separation exists between open and closed approaches to nose surgery. The closed approach was championed by Professor Joseph and for many decades was the only acceptable technique used. However starting in the 1970’s slowly surgeons came to accept another way to surgically access the nose. This technique came to be called the open method or approach. The closed approach hides all the incision inside the nose; where they are placed varies between surgeons and noses. The open approach makes an incision across the fleshy part just below the nose and between the nostrils, called the columellar. The difference between the open and closed techniques only extends to accessing the nose; the actual techniques to modify the shape can be done using either way.

Advantages & Disadvantages

There are advantages and disadvantages between these two rhinoplasty techniques. The closed approach is quicker, causes less initial swelling and doesn’t create a visible scar. However it provides less of a view and makes the surgical maneuvers more difficult to perform. On the other hand, the open approach provides unparalleled view of the nose and increased ease of carrying out the surgical maneuvers. However it adds about 20 minutes to the surgery and of course creates a visible scar. Notice I didn’t say noticeable scar, because in about 99% of cases, the incision although always visible, isn’t noticed by people. Both the patient and surgeon can see it, but then they are aware of its existence and have watched to mature from initially being red into a thin white line. In addition the scar is fortunately partially hidden below the nose where it’s seldom seen during the usual day to day interactions. In the 1% of times where its noticeable to others, its usually due to skin puckering at the side of the columellar where the incision makes a 90 degree change. Some times this is due to poor suturing, but other times it couldn’t have been avoided as it arises from the natural contraction of scars during the healing process.

The Open Approach in Toronto

Toronto is a center of excellence of the open rhinoplasty technique due to Dr Wilf Goodman, an Otolaryngologist, who championed this method during his distinguished career at the University of Toronto (Please see Otolaryngology history at the University of Toronto website). Against strong and at times critical opposition, he continued to carry on using this rhinoplasty technique for many years during the early 70’s. Slowly it gained acceptance until it is now recognized as a very legitimate and valuable way to perform rhinoplasty. Many of the rhinoplasty techniques now used around the world were only able to be developed because of the excellent view and unrestricted access of the open approach.

Good and Not so Good Rhinoplasty Techniques

The majority of open incisions take the shape that’s called the “inverted gullwing” incision. The notch allows the scar to stretch thereby reducing the risk of indentations at the side arising from the inevitable scar contracture. There is another technique called the “stair step” incision which you can see illustrated at the side. You can see the scar is more noticeable. I feel this type of incision should be avoided. I have never seen a good result (however I recognize I’m not likely to see good examples arriving for revision surgery). It’s interesting to note different specialties prefer different incisions. Otolaryngologists/Facial Plastic Surgeons use the ‘gullwing incision’, while Plastic Surgeons use the ‘stair step’ incision.

Weir Incisions or Alar Base Narrowing

Beside the columellar incision used in the open approach to rhinoplasty, there can be incisions made at the sides of the base of the nose too. These are used to help narrow the base of the nose. These incisions are commonly required in noses which have been aggressively de-projected towards the face as the side walls can flare outwards. They are frequently used in Afro-Canadian and Oriental noses as they are commonly wide based. They are known as “Weir incisions” named after Dr Weir who invented them.  The incision starts in the crease between the side of the nose and the cheek.
Here it is camouflaged by the shadow in the natural crease. It curves around and heads upward in the base of the nostril between the ala and the columella. This short area is called the sill of the nose. Unfortunately because of the quality of the skin in this area these incisions are at risk of being noticeable. The skin here is thicker and contains many glands. Furthermore the incision must be cut on the bias which always results in some of the skin glands being severed. As they regrow, cysts and skin bridging can occur. Finally suturing the angled edges together is a real technical challenge, which unfortunately occurs at the end of the surgery, when the surgeon is becoming tired.  This risk of a noticeable scar is between 5-15% depending on the skin, surgical skill, post care, and degree of narrowing.

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