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.

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.