Sunday, December 10, 2023

Tip Rhinoplasty

History of the Procedure

Reconstruction of the injured nose was discussed in the earliest medical literature as part of the Susruta Samhita, the Hindu book of revelation, about 800 BC. However, it was not until 1891 that John Roe, an American surgeon, described an operation to improve the cosmetic appearance of the nose. He exposed the underlying osteocartilaginous structures through direct external incisions to reduce the size of a large nose. In 1896, Jacques Joseph, a German surgeon, manipulated the framework of the nose through intranasal incisions to avoid visible scarring of its skin surface. This closed technique remained the standard well into the late 20th century.

Good results in rhinoplasty depend on a structurally sound nasal skeleton covered by a conforming skin and soft tissue envelope. The endonasal (closed) approach exposes the osteocartilaginous midlayer of the nose through intercartilaginous, infracartilaginous, and transcartilaginous incisions. The overlying skin envelope is elevated to identify the abnormality and allow its aesthetic modification. Many experienced surgeons find the closed technique adequate to obtain their desired results. However, when incisions are limited only to those within the nostrils, exposure is restricted and visibility and space to work limited. Because of these restrictions, many surgeons find the results of closed rhinoplasty to be less favorable than expected.

Anderson, Johnson,
and Juri
repopularized the open approach during the late 20th century. Bilateral rimming incisions were combined with an external transcolumellar incision. This allowed elevation of the nasal skin and wide visualization. The open technique allows the underlying supportive framework to be modified without the intraoperative distortion caused by closed delivery techniques. Diagnosis of the underlying deformity is easier, and bony and cartilaginous excision is more accurate. The underlying osteocartilaginous anatomy is more easily reshaped, and the suture modification and fixation of cartilage grafts facilitated.

Importantly, open rhinoplasty is considered more adaptable because it permits the use of surgical maneuvers that are precluded by the limited exposure provided by a closed approach. The open method creates a more rigid support and greater architectural stability and, some believe, a more predictable outcome.

When major changes are needed in cosmetic appearance or nasal function, open rhinoplasty has become the common approach. However, all methods have pros and cons. The wider exposure and more extensive dissection that occur with the open technique diminish normal nasal support. It must be restored before the surgery is completed, as each part of the nose is modified. To prevent postoperative collapse and loss of long-term shape, strong structural support is even more important in an open rhinoplasty to project and shape the nose. This has led to the development of refined suture and cartilage grafting techniques during open rhinoplasty to stabilize the modified intranasal anatomy. See the image below.

A small dorsal hump and a slightly underprojected

A small dorsal hump and a slightly underprojected and round ball-like tip are visible preoperatively.

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The essential elements of the open technique are as follows:

Exposure by open rhinoplasty

Anatomic diagnosis

Anatomic reconstruction by reduction, reshaping, or augmentation of the osteocartilaginous structure

Controlled contouring by in situ cartilage and graft sculpture, tip suturing techniques, and onlay grafting, if necessary

Secure suture fixation of modified cartilage structures and cartilage grafts

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