External and Endonasal Approaches to the Upper Third

The bony pyramid can be reliably reduced, repositioned or augmented through a closed approach. However, Larrabee reports that open rhinoplasty may allow more precise refining of its contour.  Larrabee reports that the incidence of profile irregularities may be reduced when procedures are performed via the open approach.

Larrabee points out that while there is a tendency to treat the bony pyramid in an essentially closed fashion when using the open approach, the benefits of increased exposure to the dorsum available with the open rhinoplasty approach should be exploited whenever possible.

In my experience, a closed approach has been reliable for addressing most bony profile problems. However, when I perform an open rhinoplasty, I now prefer to undertake hump reduction under direct visualization. When using an osteotome, I use an 8mm non-guarded osteotome. (Wider osteotomes can create an injury to the skin-soft tissue envelope.) When rasping during open rhinoplasty, I employ a powered rasp under direct visualization.  

External and Endonasal Approaches to the Middle Nasal Vault

The determination of the need for spreader grafts may play a significant role in determining whether open approach will be used, even when the tip could be satisfactorily addressed by endonasal approaches. Modern rhinoplasty techniques increasingly emphasize preservation of cartilaginous and bony substructure. This is of particular importance in the middle nasal vault, as preservation of support for the upper lateral cartilages helps to avoid collapse of the middle vault and the associated internal nasal valve. Middle vault and nasal valve collapse can cause overnarrowing of the middle third of the nose, with the "inverted V" deformity and nasal obstruction. When support and contour of the middle vault require reconstitution, spreader grafts can be used.

Use of spreader grafts in primary rhinoplasty is becoming much more common.10, 17-18 Spreader grafts can be effective in maintaining the contour of the middle vaults after hump reduction. While it may be technically easier to place spreader grafts via an external approach, spreader grafts can be placed via the endonasal or the external(open) approach.

Narrowing of the middle nasal vault that occurs when the T configuration of the nasal septum is resected with dorsal hump removal may be problematic in the high risk patient.10 Spreader grafts act as a spacer between the upper lateral cartilage and septum, preventing excessive narrowing in the high risk patient or correcting an over-narrow middle vault when it exists.

As described by Sheen, a submucoperichondrial tunnel on one or both sides of the dorsal aspect of the septum may be prepared by elevating the mucoperichondrium bridging the upper lateral cartilages to the septum. This dissection provides a space to be filled by a cartilage strip insinuated and secured by suture-fixation into the pocket (Figure), lateralizing the upper lateral cartilage(s), improving the airway and effectively maintaining the width, or widening when indicated, the appearance of the middle third of the nose (Figure).

Spreader grafts may be comfortably carried out through traditional, less invasive endonasal techniques. In more complex reconstructions, particularly complicated by multiple abnormalities, an external rhinoplasty approach may facilitate accurate dissection and graft suture fixation. Some surgeons find that the external approach is simply a technically easier method to undertake spreader graft placement.

It should be noted that the use of the external rhinoplasty approach may lead to a greater need for spreader grafts to preserve the nasal valve and middle nasal width, which may put at risk due to the loss of support to the upper lateral cartilages caused by more extensive skin undermining.

Identifying the high risk patient during initial preoperative analysis is essential to the prevention of excessive narrowing of the middle nasal vault with internal nasal valve collapse.¹⁰ Sheen¹⁹ identified an anatomical variant that he labelled the "narrow nose syndrome." Short nasal bones, long weak upper lateral cartilages, thin skin, and a narrow projecting nose predispose to middle vault collapse. As described by Toriumi, commonly performed surgical maneuvers can result in loss of support to the middle vault. A large en bloc hump removal should be avoided, as the T-shaped support of the nasal septum is eliminated and the intranasal mucosa (which provides important support to the upper lateral cartilage) is at risk of injury. Cephalic trim (volume reduction) of the lateral crura disrupts the scroll (recurvature) and frees the caudal margin of the upper lateral cartilage. Lateral osteotomies may further medialize the upper lateral cartilages. The upper lateral cartilages can fall toward the narrowed dorsal septal edge, producing middle vault and internal valvular collapse. Collapse of the middle vault may highlight the caudal edges of the nasal bones to produce the characteristic "inverted V" deformity.

In the majority of patients the combination of these maneuvers will not result in a problem; however, in high risk patients this combination of maneuvers may contribute to excessive narrowing of the middle vault with internal valve collapse. Experience is required to develop reliable surgical judgment regarding the appropriate use of spreader grafts. After spreader grafts are secured in position via the open approach, or if they are placed endonasally after dissection of the soft tissue envelope, the middle vault may appear slightly wide. Over time, this area of the nose tends to narrow as edema resolves and scar contracture pulls the upper lateral cartilages medially.

External and Endonasal Approaches to the Nasal tip

Complex nasal tip procedures can be performed via endonasal and external approaches. Certain grafting techniques such as lateral crural strut grafts, and certain manipulations of the tip cartilages such as lateral crural overlay and intermediate crural overlay, and “tongue-in-groove” retrodisplacement of the medial crura onto the caudal septum, may be performed via either approach, but certainly the exposure afforded by the open approach may be preferable (Figure). 

This patient had a significant caudal septal deviation and severe concavity of the right lateral crus. Correction of the tip deformity required excision and "flipping" of the right lateral crus. While this can be performed using an external or a delivery approach, the surgeon found that the exposure afforded by the external approach was preferable.

External and Endonasal Approaches to Revision Rhinoplasty

In revision surgery, once the nose is open, any supportive relationships that exist between the scar tissue and underlying structure is lost, and cartilage grafting may be required to support and contour the skin/soft tissue envelope that will now undergo renewed scar contracture and healing. If not, healing and scar contracture may leave a worse deficit than before. Therefore, in revision cases with relatively mild deformities or those that can be corrected with precise pocket grafting, closed approach is preferred. The surgeon should seek an endonasal approach, but may find that in complex cases an open approach is unavoidable. Spreader grafts, batten grafts, onlay grafts are examples of maneuvers that can be well-placed via precise pocket, endonasal techniques (Figure – closed rhinoplasty). 

This patient required a triple layer onlay graft to address her saddle nose abnormality. This graft was well-placed via a precise pocket, endonasal approach.

Endonasal and external approaches to the deviated caudal and dorsal septum

For severe caudal septal deviation, the open approach may provide a more facile and efficacious approach, when swinging door, doorstop and other similar maneuvers have failed. Although many techniques to address a severe caudal deviation can be done open or closed, it is an issue of balancing the downsides of a technique against the increased chance of achieving the technique as desired. To some extent, this is ultimately a personal judgment, guided by critical self-evaluation.

Philosophical Considerations – A Graduated Approach. The Big Picture

When considering the decision-making around the choice of approach, much can be gained by considering the experiences of surgeons who have had the opportunity to see the consequences over time of the choices they have made. The important philosophical concept is not open or closed, but instead, the emphasis on anatomic diagnosis and preservation of supportive structures.

A central tenet of rhinoplasty decision-making has been the concept of a graduated approach. This concept is based on the idea that achieving the desired goals with the least amount of surgical dissection provides the best chance of success. However, the critical issue here is how much exposure is needed for reliable execution of any specific technical maneuver.

Adamson has astutely observed that there is no ideal approach, each surgeon will develop a unique approach based upon the concepts outlined and based on the techniques and experiences he or she has developed in the course of an eclectic training. The skillful surgeon can make astute intraoperative anatomic diagnosis via the endonasal or external approach. Notwithstanding this, an important factor that can compromise results is the potential difficulty in diagnosis of various deformities and abnormalities using closed approaches, Another factor is the manual difficulty in correcting such deformities once diagnosed, especially effecting such maneuvers as vertical cartilage division, graft placement, and suturing techniques. Those trained in the closed approach will still tend to perform the majority of their rhinoplasties in this fashion, reserving the open approach for more difficult noses. This assessment will vary from surgeon to surgeon (Figure – open rhinoplasty).

While some surgeons may choose address this revision rhinoplasty via a closed approach, the author felt that, in his hands, the exposure obtained from the external approach offered the best opportunity for successful correction of the tip deformity.

Perkins describes an evolution in his personal philosophy that reflects some of the issues involved in the decision making process, and provides valuable insight into the evolution in the decision making that has occurred over the last  years. While the concept of a graduated approach to achieve a pleasing aesthetic result has been foremost in his personal philosophy, the evolving need to achieve more refined results and prevent late complications has resulted in his increased use of the open approach, which allows the opportunity to use certain grafting techniques. Perkins continues to strongly advocate the philosophy that the approach selected should provide the least intervention in the shortest time to achieve a satisfactory result and satisfy the patient’s goals. However, his choice of approach has changed due to late complications that he has seen occur. The 2 areas that he found most commonly cause late complications in rhinoplasty are the midnasal pyramid and lateral alar sidewalls. Paramount to provide a structural foundation for the middle vault (ie spreader grafts). While issues such as these can be addressed using the endonasal approach, it is sometimes far easier to place structural grafts via the external approach. Also, when marked reduction of overprojection is required, it is often easier to use the external columellar approach.

Although I was asked to write a chapter on “Open Versus Closed Rhinoplasty,.” I have instead written a chapter on “Open And Closed Rhinoplasty.” While this may seem like a semantic point, I believe that the surgeon should understand the advantages offered by every surgical approach. The concepts of minimizing dissection, born from endonasal techniques, also apply to external rhinoplasty. Every surgeon should be able to “think like an endonasal surgeon” – that is, to understand the advantages of limiting the surgical dissection. But, one should also be able to recognize when the additional exposure offered by the external approach may be useful and even necessary. When the external approach is undertaken, the surgeon must understand the commitment that has been made to additional support maneuvers.

There is no single answer to the question, “open versus closed rhinoplasty.” In each patient, diligent attention must be paid to the patient’s goals and to the patient’s anatomy. The wise surgeon includes external and endonasal rhinoplasty as choices in his or her armamentarium, and understands the critical issues of maintaining or adding structural support for improving long-term outcomes. The choice for a specific patient will ultimately depend upon the surgeon’s personal opinion as to which approach, in their hands, will provide the best chance of long-term success with the least amount of surgical dissection.

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