Discussion

Indications for Endonasal versus External, and Pros and Cons of each.

An operative algorithm may provide a helpful starting point in selecting the incisions, approaches and techniques used in nasal tip surgery (Table 2). 5 In every case, the patient’s anatomy directs the selection of appropriate technique. As the anatomic deformity becomes more abnormal, a graduated, stepwise approach is taken. However, other factors, such as the need for spreader grafts, complex nasal deviation, surgeon preference, and other factors may also appropriately affect the ultimate selection of approach.

The endonasal approach may be generally preferred for patients requiring conservative profile reduction, conservative tip modification, selected revision rhinoplasty patients, and other situations in which conservative changes are being undertaken (Figure). Advantages of less invasive approaches include less dissection, less edema, less “healing.” However, less invasive approaches provide by their very nature less exposure, which in some cases may be a disadvantage.

Indications for external rhinoplasty approach^3,6,7,9 (Table 3) generally include asymmetric nasal tip, crooked nose deformity (lower two thirds of nose), saddle nose deformity, cleft-lip nasal deformity, secondary rhinoplasty requiring complex structural grafting, and septal perforation repair. Other indications may include complex nasal tip deformity, middle nasal vault deformity, Selected nasal tumors. Some surgeons prefer the open approach for less complex nasal tip deformities due to the precision that they feel it offers them, in their hands, compared to the endonasal approach.

Advantages of the external approach include the maximal surgical exposure available, potentially allowing more accurate anatomic diagnosis. The external approach also provides the opportunity for precise tissue manipulation, suturing and grafting. Disadvantages include the transcolumellar incision, wide field dissection resulting in loss of support, nasal tip edema.

Regardless of approach, one must be mindful of the need to maintain appropriate structural support. When the approach is disruptive of tip support, counter measures, such as the placement of a columellar strut, are warranted. When the support to the upper lateral cartilages has been disrupted, spreader grafts may be appropriate.

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