External rhinoplasty approach (open)

The external rhinoplasty approach to the nasal skeleton can be used for primary treatment of traumatic injuries and for secondary procedures such as septorhinoplasty to correct posttraumatic nasal deformities.

It is important to mark the planned incision in the columella with a fine marker before injecting local anesthesia it since the injection will distort the skin.

This is followed by the placement of pledgets soaked topical and injected vasoconstrictors. These should be placed at least 10 minutes before the incisions to allow for adequate vasoconstriction.

At this time, the lower nose and septum are injected with a local anesthetic with vasoconstrictors.

The columellar incision is marked with a fine marker at approximately the junction between the proximal one-third and the distal two-thirds of the columella. Most people use a horizontal incision with a small “v” in the center pointed either superiorly or inferiorly or a stepped incision. The illustration indicates the most common incisions.

The easiest way to perform this incision is first to identify the caudal border of the cartilage using the back end of the knife handle.

Then the mucosa is incised, taking care not to violate the cartilage itself.

The caudal end of the medial crus of the lower lateral cartilage is very close to the skin of the columella. Great care must be taken not to injure these structures when making the incision.

The elevation is carried out between the perichondrium and the cartilage. The perichondrium is elevated over the external surface of the lateral crus and the medial surface of the medial crus.

Once this has been completed bilaterally, a scissor’s tip may be passed between the medial crura and the columellar skin. When the scissors are opened, the columellar skin separates from the cartilages.

Great care must be taken not to damage the columellar skin. The most precise incision is made by using the tip of a number 11 blade.

Perforate the skin at the point of the previously marked “v” and complete the incision by sawing the skin with small movements of the blade tip, taking care to maintain forward motion. Do not remove the blade from the skin until the incision is completed to one side, as this may result in nick marks. Also, be careful not to violate the caudal end of the medial crus.

The blade is reinserted at the point of the “v,” and the incision is completed on the contralateral side of the columella.

The columellar flap is lifted with a fine skin hook (preferably a double hook to distribute the force on the skin). Elevation continues superiorly, lifting the skin and perichondrium off the domes of the lower lateral cartilages, the nasal septum, and the upper lateral cartilages.

If no septal work is necessary, injection of vasoconstrictor in the area of the bony dorsum may be completed at this time.

This can be accomplished by passing the needle through the exposed area into the subcutaneous tissues overlying the bony dorsum.

The nasal septum is located between and behind the medial crura of the lower lateral cartilages. It is exposed by separating the two medial crura.

Each medial crus is grasped with atraumatic forceps (eg, Brown-Adson). The loose fibers between the two medial crura are divided with scissors exposing the caudal end of the septum. Once the septum is identified, the elevation of the mucoperichondrium can be accomplished on either or both sides as needed for the particular procedure.

Once the septum is exposed, the appropriate repair or cartilage harvest can then be accomplished.

Some surgeons perform two elevations over the dorsum, while others perform one. If undraping of the dorsal nasal skin is desired, a subcutaneous elevation is carried out at this time using blunt scissors. This frees the nasal dorsal skin so that it can re-drape itself into the most natural position after the procedure. If a single elevation is preferred, it is accomplished in a sub-periosteal plane. An elevator or sharp scissors may be used to elevate the periosteum off the bone.

Keep in mind that if the nasal bone is fragmented, the periosteum may hold the fragments together while the repair is carried out.

Many surgeons use a quilting suture to reapproximate mucoperichondrium to the septal cartilage to minimize the risk of postoperative septal hematoma formation. An absorbable suture is passed back and forth, usually in a random fashion, and then secured with a single knot. Distribute the sutures over the entire area of the septal cartilage.

Doyle splints (silastic) are used to maintain septal height and prevent bowing while also reducing hematoma formation.

The columellar incision is closed first to ensure precise realignment. Some surgeons will first place a single deep suture; others will go directly to skin sutures, typically using a 6-0 non resorbable suture.

One or two absorbable sutures may be placed intranasally to reapproximate the mucosal edges. Take great care to ensure that these sutures do not distort the lower lateral cartilages. This is best accomplished by grasping only the very minimum of mucosa with each suture.

Nasal packing may be placed for hemostasis and support according to the surgeon’s preference and particular circumstances.

A variety of external dressings can be applied. Most surgeons tape the nasal dorsum after applying an adhesive to the skin. A rigid splint of some type is commonly applied over the tape. Care should be taken to avoid wrinkles in the tape, which may form pressure points under the splint.