Closed (Endonasal) Rhinoplasty

👃 Closed (Endonasal) Rhinoplasty

Closed rhinoplasty, also known as endonasal rhinoplasty, is an approach in which all incisions are placed entirely within the nasal cavity, with no external skin incision.

⭐ In open (external) rhinoplasty, an external transcolumellar skin incision is given.

What are the differences between Open Rhinoplasty VS Closed Rhinoplasty?

✅ Indications of Closed Rhinoplasty

⭐ The approach is limited, so the indications are few.

• Dorsal hump reduction
• Mild to moderate tip refinement
• Alar base reduction
• Narrowing a wide bony pyramid
• Patient preference for no external scar

What are the Indications of Open Rhinoplasty?

💉 Anaesthesia

General Anaesthesia

Reserved mostly for extremely apprehensive patients.

⭐ Hypotensive anaesthesia is preferred.

What is the Systolic BP that is maintained in Hypotensive anaesthesia in Closed Rhinoplasty?

Local Anaesthesia

⭐ Preferred for most cases, as it is safer with less bleeding.

Pre-medication

Given one hour before surgery, intramuscularly:

• Fortwin 30 mg with Phenergan 25 mg, OR
• Fortwin 30 mg with Diazepam 10 mg

⭐ In an extremely anxious patient, continuous sedation with intravenous midazolam through an IV saline drip may be considered.

What is the purpose of the premedications given above in Rhinoplasty?

What are the advantages of Local Anaesthesia in Rhinoplasty?

💉 Infiltration Anaesthesia

Anaesthesia of the external nose is achieved by blocking the nerves supplying it and by infiltration in the subcutaneous plane.

Agent Used

👉 2% Lignocaine with 1:1000 Epinephrine, diluted to a final epinephrine concentration of 1:50,000 to 1:1,00,000

What are the sites of infiltration anesthesia in Rhinoplasty? Which nerves are getting targetted?

🛌 Position of the Patient

• Supine position
• Head end elevated by 20 degrees

What is the purpose of head end elevation in Rhinoplasty?

💡 Lighting

Two lights are required:

1- One focused on the face and nose from above

2- One projecting from the foot end of the patient, to illuminate the inside of the nose

🧼 Preparation of the Patient

Dressing and Draping

• Forehead, nose and face prepared with an antiseptic lotion
• Towels draped so that the forehead and entire face remain exposed
• Lips covered with a wet gauze to prevent dryness

Nasal Packing Before Surgery

The nasal cavities are packed with thin ribbon gauze soaked in 4% lignocaine, to:

• Supplement the topical anaesthesia
• Prevent blood from seeping into the pharynx

🔍 Surgical Steps of Closed Rhinoplasty

The sequence of steps is:

1️⃣ Opening incisions

2️⃣ Mobilization of the skin

3️⃣ Elevation of the periosteum

4️⃣ Management of the upper lateral cartilage

5️⃣ Hump removal

6️⃣ Septoplasty, if required

7️⃣ Narrowing of the nose by osteotomies

8️⃣ Shortening of the nose

9️⃣ Correction of septolabial webbing and lengthening of the upper lip

🔟 Remodelling of the tip

1️⃣1️⃣ Closure of incisions, packing, taping and splinting

1️⃣ Opening Incisions

a. Intercartilaginous Incision is used.

• Given with a No. 15 blade

• Site: Caudal edge of the upper lateral cartilage

⭐ The incision must be long enough for adequate exposure of the dorsum.

What is the extent of Intercartilaginous Incision?

What are the other names of Intercartilaginous Incision?

What are the advantages & disadvantages of Intercartilaginous Incision?

What are the different incisions used in Closed rhinoplasty?

b. Undermining the Skin Over the Dorsum

The blade is slid between the upper lateral cartilage and the overlying skin, keeping it very close to the cartilage to avoid injuring the skin.

c. Transfixion Incision

1- Hemitransfixion incision on the left side

2- Hemitransfixion incision on the right side

3- The two are connected through and through, converting it into a transfixion incision, made just in front of the caudal edge of the septal cartilage

What is Hemitransfixion incision?

What is Partial Transfixion incision?

What is Complete Transfixion incision?

2️⃣ Mobilization of the Skin

Instruments used:

• No. 15 blade, OR
• Blunt ended Metzenbaum scissors

Extent of Undermining

From the root of the nose to the supratip area, only to the extent required.

Why should you avoid excessive lateral undermining?

3️⃣ Elevation of the Periosteum

Instrument used: Cottle's nasal periosteal elevator

• Palpate the lower edge of the nasal bone & incise the periosteum with the tip of the elevator

• Undermine & elevate the periosteum

4️⃣ Management of the Upper Lateral Cartilage

• Assess the scroll of the upper lateral cartilage, and excise it if prominent

• Excise any excessive connective and subcutaneous tissue on the lateral surface of the upper lateral cartilage

• Incise the upper lateral cartilage from its junction with the septum, using angled Fomon scissors on both sides

• Trim the excess portions of the upper lateral cartilage, including the medial border and any portion likely to project into the nasal cavity

What will over resection of upper lateral cartilage lead to?

What is pinched nose appearance?

5️⃣ Hump Removal

Types of Hump

Based on Location :-

• Bony hump only
• Cartilaginous hump only
• Combined bony and cartilaginous hump

What is True Hump?

What is Pseudo Hump?

How will you assess before planning Hump Removal?

Steps of Hump Removal

• Mark the extent of the hump

• Expose and visualize the dorsum with a nasal retractor

• Cartilaginous hump removal first, using a No. 15 blade or scissors, introduced intranasally

• Bony hump removal, using a saw, chisel, rasp or bone forceps

• Delivery of the hump with a straight hemostat, pushing it up and then delivering it out

• Check the bony dorsum for irregularities along the midline or the sides, and smoothen them with a rasp

• Reassess the dorsum with a retractor

What are the advantages of using the osteotome over saw in hump removal?

What are the contents on the excised hump?

6️⃣ Septoplasty (Optional)

Performed after hump removal, if there is a septal deviation.

⚠️ Septoplasty must always be done before any lateral osteotomy.

What is the minimum age at which Rhinoplasty can be done?

7️⃣ Narrowing of the Nose by Osteotomies

After removal of the dorsal hump or lowering of the dorsal line, the dorsum becomes flat and wide, producing an open roof deformity.

• Excise excess width and bulk of the upper lateral cartilage
• Remove excessive fat and connective tissue from the outer surface
• Excise the scrolls if required
• Osteotomies are done

What are the different types of osteotomies performed in rhinoplasty?

Movement of the Bones

• The nasal bones and the frontal processes of the maxilla are moved inwards with the thumb and fingers, by gently infracturing the bony segments

• The bones carry the upper lateral cartilages medially with them into proper position.

• Rasp or resect any bony irregularity

• Steady the nasal wall with a gauze piece

8️⃣ Shortening of the Nose

What are the factors assessed before shortening of the nose in Rhinoplasty?

Two Methods of Shortening

A- Shortening the Lateral Wall

• Rotation of the lower lateral cartilage over the upper lateral cartilage
• In an excessively long nose, the caudal part of the upper lateral cartilage and the cephalic part of the lower lateral cartilage are excised, in addition to the rotation

B- Shortening the Septum

A strip is excised from the caudal edge of the septum.

What are the different ways to shorten the septum?

What is the desired nasolabial angle in men and in women?

9️⃣ Correction of Septolabial Webbing & Lengthening of the Upper Lip

The upper lip may be altered and lengthened by:

• The complete transfixion incision
• Rotation of the tip upwards
• Resection of part of an enlarged anterior nasal spine
• Dissection of the attachments of the lip to the maxilla

What are the causes of Septolabial Webbing? How will you correct it?

🔟 Remodelling of the Tip

⭐ Minor tip deformities may become prominent after the nose is narrowed and shortened.

What is the best view to judge the height and width of the nasal tip?

👉 If reduction is required, the tip is remodelled by cutting down the height, width and length of the lower lateral cartilages.

⭐ Some surgeons recommend performing tip surgery before narrowing the nose and hump removal, as a routine.

1️⃣1️⃣ Closure of Incisions

1- Inspect and palpate all reshaped parts of the nose one final time, and carry out any further trimming, rasping or refinement

2- Squeeze out blood and blood clots from under the soft tissue using two square gauze pieces

• One gauze piece held in the right hand against the nostril, supporting the tip
• The second gauze piece in the left hand squeezes and compresses the skin of the dorsum, moving from above downwards

3- Sutures are placed to closed the incisions

Which incision is NOT closed in Closed Rhinoplasty? Why?

🩹 Packing of the Nose

• Nasal cavities packed with vaseline or paraffin lubricated ribbon gauze
• Packing must be loose

⚠️ Tight packing can cause splaying of the bony segments of the mobilized lateral walls.

What is the purpose of Nasal Packing in Rhinoplasty?

Depth of Packing

If septoplasty was not done, light packing just beyond the vestibule is sufficient.

Time of Removal

🩹 Fixing the Skin (Taping)

The skin is first cleaned and any collection of blood removed.

⭐ Purpose of Taping

1- Helps the skin to redrape and fix effectively

2- Prevents hematoma formation

3- Reduces dead space

4- Prevents malpositioning and asymmetry of the reshaped alar cartilage

What is the technique of taping in Rhinoplasty?

🦴 Splinting the Nose

⭐ Purpose of Splinting

1- Prevents development of swelling

2- Maintains the position of the mobilized bones

3- Prevents accidental displacement of bones during sleep

4- Provides protection from minor injuries

What are the different materials used in splinting the nose in rhinoplasty? What is the most preferred material out of these?

What is the technique of splinting the nose in rhinoplasty?

⚠️ The splint should not extend lateral to the site of the lateral osteotomy, as this transmits facial movements such as smiling, laughing and chewing to the operated area.

When is the nasal splint usually removed in Rhinoplasty?

✅ Advantages of Closed Rhinoplasty

• No external scar
• Less post operative edema
• Shorter operative time
• Faster recovery
• Nasal support structures are well maintained
• Reduced risk of columellar complications, as no transcolumellar incision is given

❌ Disadvantages of Closed Rhinoplasty

• Limited surgical exposure, hence limited indications
• Technically more demanding
• Difficult in complex tip surgery and severe nasal deformity
• Difficult to place and adjust grafts
• Reduced accuracy in assessment of symmetry
• Difficult in revision cases, where external rhinoplasty is preferred
• Limited teaching value

⭐ Exam Pearls

• All incisions in closed rhinoplasty are placed entirely within the nasal cavity
• Pre-medication → Fortwin 30 mg with Phenergan 25 mg or Diazepam 10 mg, one hour before surgery
• Infiltration agent → 2% Lignocaine with epinephrine 1:50,000 to 1:1,00,000; wait 10 to 15 minutes
• Position → Supine with 20 degree head-end elevation
• Periosteum elevated with Cottle's nasal periosteal elevator
• Hump is removed above a line joining the tip projection and the nasofrontal angle depth
• Sequence → Hump removal, then septoplasty, then osteotomy
• Pack removed after 48 hours, or 72 hours after septorhinoplasty
• Best splint material → Plaster of Paris
• Splint removed after 7 to 10 days

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