Nasal Tip Surgery in Open Rhinoplasty

Abstract

When rhinoplasty is described as ‘the thinking man’s operation’, it is usually because of the complexity of nasal tip dynamics. The advantage of the open approach is the significantly improved exposure to all the deformities and asymmetries of the nasal tip. When performing open rhinoplasty regularly, the rhinoplastic surgeon cannot fail to be impressed with the tremendous variation in configurations of the medial and lateral crura, and the frequent irregularities that are seen in tips that do not appear deformed on preoperative assessment. This improved diagnostic ability, in combination with the ability to see exactly the result of the reconstruction without distortion before closure, represents the most significant benefit of the open approach. In addition, although most of the techniques described can be carried out through various approaches, there is no doubt that the added exposure of the open approach improves one's ability to perform many of the intricate surgical techniques required in reconstructing the nasal tip. This is especially true when one discusses vertical divisions and the placement of grafts., The time-honored disadvantage of the open approach is the purported scar. This has been shown time and again to be of minimal significance in the vast majority of patients.⁵ When using the open approach, time and care are necessary in order to obtain a good closure and acceptable scar. The open approach tends to make a surgeon more fastidious in order to correct as accurately as possible some of the deformities that may not be as readily apparent with other approaches. Occasional concerns are raised about flap viability, but this should not be a problem except in inexperienced hands or in the very exceptional patient who has undergone multiple previous procedures. It is arguable whether edema resolution takes longer in the open than in the closed approach, but inasmuch as the lymphatics tend to drain laterally from the dome to the alar facial groove it does not appear that a single transverse incision across the columella should have any significant negative effect on tip resolution and refinement., In spite of the many obvious advantages of the open approach, this approach alone will not guarantee good rhinoplasty results. The surgeon must still have a grasp of nasal tip dynamics and the ability to apply these to the anatomic and functional reconstruction of the nasal tip.