Open rhinoplasty: the technique of choice for complex revisions and reconstructions

Is it true that open nose surgery takes longer to heal? Does it cause permanent scarring? Is the post-operative recovery more prolonged and troublesome? Will the nasal tip remain stiff, swollen, and numb for a long time? These are among the most frequently asked questions about open rhinoplasty. And there are many good reasons for these questions. In recent years, the external technique has acquired a not always positive reputation, paradoxically because of its main advantages. The open view of the nasal structures makes open rhinoplasty surgery apparently less complex than endonasal or closed rhinoplasty. So, even less experienced surgeons have found the courage to venture into the difficult task of reshaping the sophisticated anatomy of such a delicate organ. Unfortunately, the results are not always satisfactory and not always meet patients expectations.

Nevertheless, by itself, external rhinoplasty is in no way “inferior” to other rhinoplasty approaches. On the contrary, in experienced hands, it can lead to results of great aesthetic harmony. Moreover, it is a reasonable choice in complex revision rhinoplasty cases where challenging reconstruction procedures are needed. However, even in complex revision cases, the open approach is not a mandatory choice as finest results can be obtained by advanced endonasal (closed) techniques.  With all these advantages, external rhino-septoplasty nevertheless has several drawbacks that may lead a surgeon to choose closed or intranasal techniques.

Let’s focus on these drawbacks:

  • First of all, it leaves a columellar scar. However, the risk of visible scar on the columella is significantly reduced in the hands of experienced surgeons even if the healing process is never entirely predictable.
  • Secondly, the possible swelling of the tip can persist for a long time inducing formation of fibrous tissue resulting in poorly defined contours of nasal tip and dorsum.
  • Finally, the recovery time is generally longer if compared to closed rhinoplasty.

However, structural rhinoplasty has had the great merit to allow nasal surgeons to improve the outcomes of both complex revision rhinoplasties and nasal reconstructions after trauma, tumor resection or due to malformations.

Open rhinoplasty before and after

My Patients’ Journey with Me

From closed to open to hybrid: evolutions in rhinoplasty surgery

Why rhinoplasty is still today the most requested and, at the same time, the most complex procedure in facial surgery? On the one hand, the nose is absolutely unique with regard to function and aesthetic impact. On the other, its technical complexity has pushed generations of rhinoplasty surgeons to explore surgical techniques that can improve the aesthetics and function of the nose.

Over the decades, one or the other technique has known more thriving phases, but neither has ever been definitively abandoned. Indeed, while one procedure was predominant, the other was refined and ended up integrating the first. The two main philosophies in which we traditionally divide nasal surgery are open or external rhinoplasty and closed or internal nose jobs.

  • Endonasal or closed rhinoplasty was widely used in the 20th century. Traditional closed rhinoplasty was mainly a reduction operation, often involving excessive removal of the osteo-cartilaginous framework. With the introduction of more conservative surgical techniques from the 1960s, closed rhino-septoplasty also began to incorporate techniques that were more respectful of the stability of nasal structures.
  • Starting in the late 1970s, the external approach began to take hold. So, open rhinoplasty became the foundation for teaching in academic centers around the world as it allowed the trainees to visualize the osteocartilaginous framework in an unparalleled fashion, thus making the manipulation of nasal structures easier and more understandable. Its evolution toward structural rhinoplasties allowed rhinoplasty surgeons to reconstruct missing parts with cartilaginous grafts harvested from different donor sites (nasal septum, ear, ribs) and sutured in place.

 

External rhinoplasty: healing and post-operative time

Thanks to the anatomical knowledge it offered, external nose surgery has allowed generations of surgeons to acquire increasingly in-depth practical-theoretical skills. However, it is true that external rhino-septoplasty entails longer healing times and often also a more demanding post-operative follow-up. These aspects have prompted an increasing number of nasal surgeons to convert to the modern techniques of endonasal (closed) rhinoplasty.

Needless to say, each approach has pros and cons. On the one hand, we must not reject an approach that also has significant advantages. On the other hand, we should not give into the opposite excess of praising only its merits. It would be misleading to claim the superiority of one of the two approaches over the other at all costs. All the branches of modern surgery follow the principles of minimal invasiveness and tailor-made approach. It is our strong belief that also rhinoplasty should stick to these sound principles.

Hybrid rhinoplasty, published in 2010 by Prof. Palma and trademarked by him soon after, places the patient at the centre of a unique, tailor-made rhinoplasty plan that addresses each patient’s highly individual and particular requirements. With its shorter healing times and with enhanced precision compared to the traditional closed approach, combines the best sets of techniques from both the endonasal and open approach.

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Postoperative recovery: what to expect after external rhino-septoplasty

In the postoperative period, the patient must strictly follow the surgeon’s recommendations. Bruising and swelling around the eyes, nose, and lips is normal. The patient should not worry about these side-effects that are variable from case to case.

Immediately after surgery, patients should avoid blowing their nose. They are instructed to do nasal washings with saline water and use a nasal spray with hyaluronic acid, in order to keep the inside of the nostrils moist. Furthermore, in the postoperative period with open or closed nose job, they will have to avoid intense physical exercise and exposure to direct sunlight for few weeks.

Open nose job in Milan? Seek for the best surgeon.

Nowadays, more and more men, women, and adolescents want to feel more confident about themselves and decide for a primary or secondary rhinoplasty to improve their facial features and often nasal breathing as well. Increasing one’s self-esteem means having a fuller and more rewarding social life, with a series of psycho-emotional benefits, triggering what we call a virtuous circle.

One of the first dilemmas the patient has to face with is the choice of the surgical technique. Nowadays, patients are pretty much informed about rhinoplasty surgery as the web is overfilled by information about almost every single aspect of rhinoplasty. Some patients even choose the surgeon based on the type of approach and techniques. The modern-day surgeon should possess a wide variety of technical skills and should choose the technique that suits best that specific patients. The wise patient should select the specialist rhinoplasty surgeon carefully. Regarding the choice of the specific technique, the expert surgeon should have the last say.

Open or closed nose surgery: a decision to make with the specialized rhinoplasty surgeon

It is normal that each patient wants to collect solid information about the surgical procedure he or she is about to undergo. But patients should understand that the information collected on the Internet is meant for the general public, and might be inaccurate, imprecise or even misleading. Surgery is a completely different story. Surgery entails technical complexities, exceptions, and hitches. Patients are urged not to make their final choice between open and closed rhinoplasty or the innovative hybrid approach developed by Prof. Pietro Palma just researching on the web. Only an in-depth specialist consultation will provide valuable information about the best path to follow in order to maximize benefits and reduce complications.

The surgeon has to assess the whole nose inside and outside. Are there hypertrophic turbinates, septal deviation, nasal valves abnormalities? Is the patient an adult man, an over-fifty woman, or a teenager? How is the quality of the external skin? Does the problem only concern the nasal tip? For instance, at the end of a thorough specialist consultation, it might become evident that the open structure technique might NOT be the best choice for secondary rhinoplasty, especially in cases of multiple previous rhinoplasties.

The specialist must carefully evaluate all these diagnostic variables as surgery should be tailored for each specific patient. In Milan, you can count on the long-standing experience of Prof. Pietro Palma, creator of the innovative hybrid technique. With over 25 years of exclusive dedication to rhinoplasty and surgical rhinology, Prof. Palma is considered one of the leading authorities in the sector.

For more information on hybrid, open or closed rhinoplasty, make an appointment with the specialist nose surgeon in Milan.

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Pietro PALMA Chirurgo Rinoplastica


FAQ

HOW THE FIRST CONSULTATION IS CARRIED OUT?

The aim of the first consultation is to make a correct diagnosis of your external and internal nose as well as to evaluate your past medical history. Specific nose-related symptoms will be evaluated by taking a thorough history, a nasendoscopy, and performing morphological analysis of the external nose. Finally, I will take professional quality photographs of your face and nose for detailed analysis.

IS THE FIRST CONSULTATION FREE OF CHARGE?

The first consultation is not aimed to sell a product. It cannot be free of charge as it is a very specialized consultation lasting 30’-45’ by an international rhinoplasty expert using high tech-tools in a modern, comfortable and well equipped medical office.

HOW MUCH DOES RHINOPLASTY COST?

As each case is different, a standard cost cannot apply. Costs are related to the extent of surgery and the duration of the operation. Within the first 48-72 hours of the first consultation, a detailed quotation will be emailed to you.

WHICH TECHNIQUE DO YOU USE?

As your surgeon, I will adapt my technique to match your specific anatomical findings and with respect to your wish list of desirable changes. Due to my decades of dedicated rhinoplasty surgery, I can call upon a vast array of techniques in order to safely cope with the myriad variants of nasal anatomy.

I prefer closed (endonasal) rhinoplasty for most of my patients in order to be respectful of nasal anatomy and avoid unnecessary surgical aggressiveness. In more complex cases, I use an “hybrid” closed approach that allows me to utilize techniques commonly used in the open approach (sutures, grafts) but without opening the nose. I opt for the open approach in severe malformations or in specific revision cases.

IS IT POSSIBLE TO OPERATE SEPTUM AND TURBINATES AT THE SAME TIME OF RHINOPLASTY?

The nose is a complex structure in which form and function are intimately connected. Almost always, rhinoplasty is a septo-rhinoplasty because the septum not only plays a functional role, but also contributes to common problems of the external nose. Examples include: crooked nose, hump, drooping tip, excessive nasal length, over-projection of the nasal tip, just to name a few of the common deformities seen in my practice.

Inferior turbinates are probably the commonest cause of nasal obstruction, and their treatment is commonly associated with septo-rhinoplasty or rhinoplasty. Modern, minimally invasive endoscopic techniques allow the surgeon to manage these important structures precisely and conservatively.
Therefore, it is absolutely indispensable that your rhinoplasty surgeon possesses specialist training and substantial experience in treating problems of the internal nose.

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