External Columellar Incisional Approach to Revision of The Lower Third of The Nose

Abstract

A surgeon’s approach to revisional rhinoplasty of the nasal tip is dictated by his or her philosophy as to how these deformities should be reconstructed. If the appearance of the nose is the primary concern, correction of deformities using precise pocket cartilage grafting may be more appropriate than using the open approach. Certainly, many well-known rhinoplastic surgeons have practiced this philosophy with great success.2,8,l0,15,16,20,25 However, less experienced surgeons may have difficulty attaining acceptable results because the precise pocket grafting techniques require a tremendous amount of experience to master.

Revision rhinoplasty should be performed using the least invasive approach that will allow the surgeon to accomplish the necessary reconstructive maneuvers. In primary rhinoplasty, use of the open approach usually does not negatively affect the surgeon’s chance of attaining a maximal result. However, in revision rhinoplasty the extended dissection of the open approach may weaken whatever support exists between the soft tissue, scar, and remaining cartilaginous structures. Disturbing the tissues previously operated on may increase the possibility of more scar tissue formation and the late vagaries of healing. If possible, precise pocket grafting via small intranasal incisions should be used. However, major reconstruction with correction of functional problems will likely require the use of the open approach to allow precise reconstruction of the major supportive structures of the nose.

Approaching the difficult nasal tip reconstruction through the open approach allows one to visualize the structural abnormalities and identify previously placed grafts and sutures. The surgeon can determine the amount of residual lower lateral cartilage and how it was influenced and changed by scar contracture and healing. The open approach provides the exposure necessary for direct suturing of grafts with bimanual manipulation and binocular visualization to accomplish major reconstruction of the upper and lower lateral cartilages, nasal septum, and nasal valve. Camouflaging deformities does not always correct the underlying structural defects that may continue to change under the forces of scar contracture. Replacement of the compromised supportive structures will permit reconstitution of a stable tripod structure to establish a favorable nasal contour with good nasal function.