Open (External) Rhinoplasty

👃 Open (External) Rhinoplasty

Open rhinoplasty, also known as external rhinoplasty, is an approach in which the nasal skeleton is exposed through a transcolumellar incision combined with bilateral marginal incisions.

⭐ This gives direct visualization of the osteocartilaginous framework, so both visualization and surgical access are far greater than in closed rhinoplasty.

⭐ External rhinoplasty is based on Rethi's technique.

✅ Indications of External Rhinoplasty

• Major deformities of the nose, such as a large dorsal hump
• Extensive saddle deformity
• Very wide nose
• Marked nasal tip deformity, including significant rotation and projection issues
• Cleft lip nasal deformity
• Nasal deformity with benign tumors
• Repair of very large septal perforations
• Significant septal deviations, especially high dorsal deviations
• Severe nasal trauma
• Revision cases, where post-operative scarring and fibrosis are expected
• Situations where assessment of the exact underlying pathology is difficult

What are the Indications of Closed 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 targeted?

What is the surgical anatomy of the nose in relation to rhinoplasty?

🛌 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

• Operative area cleaned with an antiseptic solution
• Towels draped so that the forehead and entire face remain exposed
• Lips covered with wet gauze to prevent dryness
• Nasal cavities packed with ribbon gauze soaked in 4% lignocaine, to supplement topical anaesthesia and prevent blood seeping when the incisions are given

🔍 Surgical Steps of External Rhinoplasty

The sequence of steps is:

1️⃣ Opening incisions

2️⃣ Dissection of the soft tissue envelope

3️⃣ Septal surgery, if required

4️⃣ Hump removal

5️⃣ Osteotomies

6️⃣ Tip remodelling

7️⃣ Closure of incisions, packing, taping and splinting

1️⃣ Opening Incisions

Two incisions are given:

A- Marginal Incisions

• Made along the caudal border of the lateral crura of the lower lateral cartilages

What are the other names of Marginal incision?

B- Transcolumellar Incision

Given in the columella, and joined to the medial arms of the marginal incisions.

What are the types of Transcolumellar Incision?

What is the site of the Transcolumellar Incision? Why?

What are the incisions used in rhinoplasty?

2️⃣ Dissection of the Soft Tissue Envelope

• Using a fine skin hook and fine scissors, dissect the skin off the columella first

• Continue the dissection from the columella upwards to the dorsum

• Identify the ligament of the nasal tip, divide it close to the skin, and remove it along with the fibrous tissue between the domes of the lower lateral cartilages

• Continue skeletonization up to the nasofrontal angle, dissecting close to the perichondrium and periosteum

What is the lateral extent of dissection?

• Lift the skin off with a retractor and fix it to the drapes with a clamp

3️⃣ Septal Surgery (Septorhinoplasty)

Septoplasty if required is done at this step.

What are the two approaches of Septal surgery in Open Rhinoplasty?

What are the steps of the septoplasty procedure?

4️⃣ Hump Removal

⭐ Performed under direct visual control.

• Excise the cartilaginous hump with a knife

• Resect the bony hump with an osteotome

• If necessary, modify the nasofrontal angle by excising soft tissue and sculpturing the bone with a chisel or osteotome

• Palpate the area for irregularities, and rasp any rough edges

What is Nasofrontal angle? What is its normal value?

5️⃣ Osteotomies

• Lateral and medial osteotomies are performed before shifting the bony walls towards the midline
• Once all the cuts are given, the bony walls are shifted medially and adjusted as required
• Transverse osteotomy is not always required

👉 After narrowing, palpate the entire nose and correct any irregularities.

⚠️ Never force the movement of a bone without giving the osteotomy cut properly, as this causes fractures of the bone at unintended sites.

What are the osteotomies performed in rhinoplasty?

What are the steps of Lateral Osteotomy?

6️⃣ Tip Remodelling

Performed according to the pre-operative planning.

• Columellar struts placed in their exact position
• Tip grafts, if needed, accurately positioned and stitched in situ
• Domes sutured to each other, to achieve narrowing of the lobule
• Medial crura sutured to each other, if the septum was approached through them

7️⃣ Closure of Incisions

The skin flap is replaced and sutured back into position.

🩹 Packing of the Nose

• Material used: Vaseline or paraffin lubricated ribbon gauze
• Packing must be light, not tight

What is the purpose of Nasal Packing in Rhinoplasty?

Why should you avoid tight nasal packing in Rhinoplasty?

Depth of Packing

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 External Rhinoplasty

• Accurate diagnosis of deformities
• Accurate assessment of asymmetries
• More precise placement and fixation of grafts
• Advantageous in difficult and revision cases
• Very teaching friendly, ideal for demonstration and training
• Better assessment of the nasal tip

❌ Disadvantages of External Rhinoplasty

• External scar, although tiny, which the patient may dislike
• More manipulation of soft tissues, leading to more post-operative edema, especially at the tip
• Longer recovery time
• Longer operating time
• Temporary columellar numbness in the post-operative period

⭐ Exam Pearls

• External rhinoplasty is based on Rethi's technique
• Incisions used → Transcolumellar incision with bilateral marginal incisions
• Ligament of the nasal tip is divided close to the skin
• Hump removal is done under direct visual control
• Transverse osteotomy is not always required
• Marginal incision closed with absorbable sutures; columellar incision with 5-0 prolene
• Pack removed after 48 hours, or 72 hours after septorhinoplasty
• Best splint material → Plaster of Paris
• Splint removed after 7 to 10 days
• Post-operative columellar numbness is temporary

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