Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

298
A. Grau
surgery, the nasal tip can be brought up. If this is
not done, the posterior rim of the alar cartilage
will “bounce” against the triangular cartilage
(Fig. 22.9 ) pushing the tip down, and therefore
the “lift” of the tip is not possible without a “lit-
tle” resection of these cartilages.
Once the incisions are made, undermining of
the dorsum is performed with scissors. It is impor-
tant to introduce the scissors with the points point-
ing deep against the triangular cartilages so that
the skin and muscles are lifted together. The same
is done with the nasal bones. The separation is
a
b
c
d
e
Fig. 22.4 ( a ) Primary asymmetry of the AC that has to
be corrected. ( b ) Marking and partial resection of the AC.
( c ) Right AC resected completely with preservation of the
mucosa below. ( d ) V-shaped wedge done on the right AC
to correct asymmetry. ( e ) Final sutures with strut graft in
place and bending of the right AC

299
22 The Controversy Between Open and Closed Rhinoplasty
done with just the opening of the scissors. Here we
want to resect only cartilages and bone, so we have
to try to leave all the skin and muscles intact.
The next step is to trim the nasal dorsum if
necessary. The TC is fi rst cut on both sides with a
number 15 blade, marking the necessary resec-
tion of the dorsal hump, making the following
step easier. With large dorsum scissors, the exces-
sive dorsum is resected following the precut TC
until the scissor encounters the bone. Then the
excessive bone is resected with a 10- or 12-mm
chisel (Fig. 22.10 ). After this some scraping may
be necessary to even the bones.
Now the NT may need some treatment. To
give some lift to the point, it is possible to resect
some anterior rim of the septum, resect the “point
depressor muscle” (Juri) that is really an exten-
sion of the orbicularis oris muscle that inserts in
the columella, and/or some resection of the “sub-
septum mucosa” (Juri) that is the mucosa between
the septum and the columella. These last two pro-
cedures do help with the lift of the NT.
The following step is to fracture the maxillary
ramus. This is necessary to close the “roof” of the
dorsum left opened after the resection. The author
prefers the external chisels and has never really tried
the internal fracture technique despite having seen
many surgeons obtain excellent results with it.
Once all the changes are made, closing of the
mucosa is performed with 5-0 Monocryl suture.
The last step is the reduction of the nostrils if
Fig. 22.5 Marking of the closed rhinoplasty
a
b
Fig. 22.6 ( a , b ) Marking of the open rhinoplasty

300
A. Grau
necessary. Joseph’s technique is preferred. These
are sutured with 6-0 mononylon.
22.6.2 Open Rhinoplasty
Before introducing the same strip of gauze, some
resection of the center of the septum might be
necessary to obtain the graft cartilages for the
NT. This is done by fi rst separating the mucosa
from the septal cartilage and then extracting a
window of cartilage with a Ballinger scalpel
(Fig. 22.11 ). After closing the incisions with 5-0
Monocryl, the same gauze strip as in the closed
technique is set in place.
The incisions in the columella for the “W” are
made with a number 11 blade. The following
incisions are all made with a number 15 blade
following the outer side of the columella and the
anterior alar rim (Fig. 22.12 ). Now separation is
Fig. 22.7 Closed rhinoplasty incision
a
b
Fig..22.8 ( a , b ) Wedge resection of the posterior rim of the AC

301
22 The Controversy Between Open and Closed Rhinoplasty
needed to expose the AC. This is done with a
small sharp pointed scissor being very carefully
not to injure or cut the AC (Fig. 22.13 ).
Once the NT is exposed, undermining of the
dorsum is performed in the same manner as the
closed technique. The trimming of the nasal dor-
sum is done in the same way as in the closed
technique although there is better exposure of the
dorsum (Fig. 22.14 ).
The treatment of the NT comes next. Here is
where the surgeon can experience the difference
and bene fi ts with the open technique. Resection
of the AC can be done precisely (Fig. 22.15 ), and
grafts can be placed with full exposure
(Fig. 22.16 ). Modeling of the AC with 5-0
mononylon sutures is also possible (Fig. 22.17 ).
Here sometimes the NT needs some subcutane-
ous fat resection to make it thinner (Fig. 22.18 ).
The fracture of the maxillary ramus is done in
the same manner as the closed technique, and the
closure is done with 5-0 Monocryl for the inner
sutures and 6-0 mononylon for the external skin
sutures.
22.7
Wrapping
After fi nishing the procedure, a strip of gauze
anointed with liquid Vaseline is put inside the
nasal cavity and is left in place for 48 h. The nose
is
wrapped
with
skin-colored
Micropore
(Fig. 22.19 ). Over this tape a splint of plaster is
a
b
c
d
Fig. 22.9 ( a ) Trying to lift up the NT without resection of AC. Both AC “bounce” against the TC and are being push
down again. ( b ) With resection of right AC, it is easily lifted. ( c and d ) Left without resection still “pushes” downward again

302
A. Grau
a
b
Fig. 22.10 ( a ) The entire cartilage and bone dorsum resection done with a 10- or 12-mm chisel. ( b ) Shortening of the
nostrils following Joseph’s technique. It is the best and only technique that gives a good result without visible scars
Fig. 22.11 Part of the nasal
septum resected for obtaining
strut and tip grafts

303
22 The Controversy Between Open and Closed Rhinoplasty
left for 4–5 days to compress the nose and prevent
some of the swelling. The author uses a large
splint compressing even the forehead when the
external fracture of the nose is performed
(Fig. 22.20 ) and only a smaller split to compress
only the nose when the fracture is not performed
(Fig. 22.21 ).
22.8
Postoperative Care
Immediately after surgery, the patient is placed in
an almost sitting position in the bed. Cold packs
are put on the eyes to prevent swelling. It is quite
dif fi cult for the patient to support breathing with
the mouth for 2 days, but it is important to main-
tain the gauze in the nose cavity for it to stay open
for the next 48 h after surgery that is where the
worst part of the swelling occurs.
All the sutures and the plaster are removed at
day 5 postoperative. The nose is left wrapped in
Micropore tape for 10 more days to help prevent
more swelling to occur (Fig. 22.22 ).
Fig. 22.12 Dotted line shows where the incision should
be made following the anterior AC rim for OR
Fig. 22.13 Undermining separating muscle, fat, and skin
from the AC
Fig. 22.14 Entire dorsum resection

304
A. Grau
a
b
Fig. 22.15 ( a ) Marking of the AC resection. ( b ) Resection completed
a
c
b
Fig. 22.16 ( a ) Fixing the strut graft with a 27-gauge needle. ( b ) Strut graft sutured in place with 5-0 or 6-0 nylon.
( c ) Tip graft sutured in place with 6-0 nylon

305
22 The Controversy Between Open and Closed Rhinoplasty
Fig. 22.17 All the sutures possible to “model” the AC
Fig. 22.18 Resection of the subcutaneous fat of the NT
with sharp scissors. Sometimes resection of all the fat is
necessary to achieve the “shrinking effect” of the NT
Fig. 22.19 After fi nishing the operation, Micropore tape
is placed in place to model the nose
Fig. 22.20 When external fracture is performed, a “big”
plaster splint is placed compressing the nasal dorsum and
forehead to decrease swelling

306
A. Grau
a
b
Fig. 22.21 ( a ) When no fracture is performed, the author
uses only a plaster splint compressing the nose’s struc-
tures. ( b ) Plaster splint removed
a
b
Fig. 22.22 ( a ) Micropore tape placed after taking away
the splint to keep compressing the nose for 10 more days.
( b ) Tape removed

307
22 The Controversy Between Open and Closed Rhinoplasty
22.9
Cases
Case 1 (Fig. 22.23 )
Fig. 22.23 ( a ) Preoperative. ( b ) Marking. ( c ) Immediately
after surgery. ( d ) Three days postoperative. ( e ) Four days
postoperative after taking off splint. ( f ) Nineteen days
postoperative. ( g ) One month and nine days postopera-
tive. ( h ) Fourteen months postoperative after the edema
has gone and the result is the same as seen at day 4 after
taking off the splint. Normally the edema goes away in
4–6 months. ( i ) After all the surgeries performed includ-
ing rhinoplasty and upper eyelid blepharoplasty
a

308
A. Grau
b
Fig. 22.23 (continued)

309
22 The Controversy Between Open and Closed Rhinoplasty
e
c
d
Fig. 22.23 (continued)

310
A. Grau
g
f
Fig. 22.23 (continued)

311
22 The Controversy Between Open and Closed Rhinoplasty
h
i
Fig. 22.23 (continued)
This 21-year-old female underwent closed
rhinoplasty with resection of the dorsal hump
and lifting of the NT, in combination with upper
eye lid blepharoplasty. She also had liposculp-
ture, fat grafting to the buttocks, and breast aug-
mentation 3 months prior to her rhinoplasty.

312
A. Grau
Case 2 (Fig. 22.24 )
a
b
c
Fig. 22.24 ( a ) Preoperative. ( b ) Markings. ( c ) Four days
postoperative, just after taking the splint away. Note
almost no edema has yet developed because of the com-
pression of the splint. ( d ) Ten days postoperative. ( e ) One
month postoperative. Now there is a lot of swelling on the
nasal tip. ( f ) Six months postoperative. The swelling is
practically gone

313
22 The Controversy Between Open and Closed Rhinoplasty
f
e
d
Fig. 22.24 (continued)
This 20-year-old female has a wide and fallen
nasal tip (NT). The nasal dorsum has a small
hump. An open rhinoplasty was performed with
resection and bending of the alar cartilages. A
strut graft was placed in the columella, and exces-
sive fat was excised from the NT. A chin implant
and a liposculpture of the submental fat were also
performed.

314
A. Grau
a
b
Fig. 22.25 ( a ) Preoperative. ( b ) Two months postoperative
Case 3 (Fig. 22.25 )
This 23-year-old female has a fallen NT, wide
nostrils, and a dorsal hump. A closed rhinoplasty
and an upper eyelid blepharoplasty were
performed. No change was made in the form of
the NT; it was only “brought up.”

315
22 The Controversy Between Open and Closed Rhinoplasty
Case 4 (Fig. 22.26 )

a
b
c
Fig. 22.26 ( a ) Preoperative. ( b ) Dorsum cartilage and
bone resection. ( c ) AC resection and placement of a strut
graft. ( d ) Immediately after surgery. ( e ) Immediately after
surgery with the Micropore tape placed. ( f ) Three days
postoperative with large splint. ( g ) Five days postopera-
tive after taking the splint off
This 31-year-old female has a fallen and wide NT
and dorsal hump. An open technique was per-
formed to resect the AC and the hump. A strut
graft was placed in the columella.

316
A. Grau
d
e
f
g
Fig. 22.26 (continued)

317
22 The Controversy Between Open and Closed Rhinoplasty
Case 5 (Fig. 22.27 )

a
b
Fig. 22.27 ( a ) Preoperative. ( b ) The dorsum cartilage and
bone resection. ( c ) Marking of the AC resection and a view of
the strut graft. ( d ) Dissection of the strut pocket. ( e ) Placement
of the strut. ( f ) Fixing the strut in place with a 27-gauge nee-
dle. ( g ) Resection of the excessive length of the strut graft. ( h )
Resection of the strut graft completed. ( i ) Suturing of the strut
in place. ( j ) Procedure fi nished and before closing. ( k )
Shortening of the nostrils with Joseph’s technique. ( l ) Finished
procedure with the tape in place. ( m ) The “large” plaster
splint in place. ( n ) Five days postoperative

318
A. Grau
c
d
e
f
g
h
Fig. 22.27 (continued)

319
22 The Controversy Between Open and Closed Rhinoplasty
Fig. 22.27 (continued)
This 35-year-old female has a fallen and wide
NT, wide nostrils, and a dorsal hump. Open rhi-
noplasty was performed with resection of the
dorsal hump and AC. A strut graft was also place
to lift and give support to the NT.
k
i
j
m
n
l

320
A. Grau
Case 6 (Fig. 22.28 )

a
Fig. 22.28 ( a ) Preoperative. ( b ) Markings. ( c ) Immediately
after surgery. ( d ) Five days postoperative just after taking
the splint away. There is no edema yet because of the
compression by the splint. ( e ) Two weeks postoperative.
Edema has developed. ( f ) Fourteen months postoperative.
The swelling is gone

321
22 The Controversy Between Open and Closed Rhinoplasty
b
c
d
Fig. 22.28 (continued)

322
A. Grau
e
f
Fig. 22.28 (continued)

323
22 The Controversy Between Open and Closed Rhinoplasty
This 27-year-old female has a wide and short
NT, wide nostrils, and small dorsal hump. Open
rhinoplasty was performed with dorsum and
AC resection. A strut graft was placed. She also
had a chin implant and submental fat
liposculpture.
Fig. 22.28 (continued)

324
A. Grau
b
a
Fig. 22.29 ( a ) Preoperative. ( b ) Immediately after surgery. The result can be seen already. ( c ) Four and a half years
postoperative
Case 7 (Fig. 22.29 )

325
22 The Controversy Between Open and Closed Rhinoplasty
This 19-year-old female has just a fallen NT.
Open technique was performed with AC resec-
tion, placement of a strut graft, and a small short-
ening of the nostrils.
c
Fig. 22.29 (continued)

326
A. Grau
22.10 Complications
The primary possible complication is a bad result,
with an unhappy patient. This is the most fre-
quent complication in rhinoplasty. It is probably
one of the most dif fi cult and challenging surger-
ies for the cosmetic surgeon. Much care should
be taken to minimize risks of a bad outcome.
Here is where the term “less is better” can always
come handy. Excessive resection of the nose’s
structures can lead to unpleasing results, asym-
metries, and breathing problems.
It is important to take note that a revisional or
secondary surgery is a lot more dif fi cult and will
almost always need an open approach.
To avoid complications, it is important to use
the open approach whenever the NT is at stake.
With this protocol, complications have been min-
imized, and the protocol is highly recommended
at least for the beginning surgeons to avoid com-
mitting “unforced errors.”
Conclusions
Rhinoplasty is one of the most pleasing proce-
dures in cosmetic surgery when you have a good
result. The patient operated on who is pleased
and happy always brings you more patients
because their nose is something that they cannot
hide and say that their “personal trainer” left
them that way. It is sad but true that most patients
deny cosmetic procedures as liposculpture and
buttocks augmentation to their friends. Every
friend and relative of the rhinoplasty patient
actually knows of his/her surgery.
However, obtaining good results in rhino-
plasty depends upon not leaving asymmetries
and a nose with some stigmata that make them
look “operated” on.
Closed rhinoplasty is less time-consuming
and leaves less swelling. It can be a great elec-
tion when the surgeon does not have to work
or give the NT another shape. Open rhino-
plasty should be preferred when the nasal tip
is a part of the changes planned for surgery. It
should be the fi rst election when the surgeon
encounters a dif fi cult NT or has a secondary
surgery in his hands.
General References
Daniel RK (1993) The nasal tip. In: Daniel RK (ed)
Aesthetic plastic surgery: rhinoplasty. Little, Brown,
Boston
Joseph J (1931) Nasenplastik und sonstige Geisichplastic
Nebst eimen Anbang euber Mannaplastik. Kabitzch,
Liepzig
Peck GC (1990) Techniques in aesthetic rhinoplasty, 2nd
edn. Thieme-Stratton, New York
Sheen JH, Sheen AP (1987) Aesthetic rhinoplasty, 2nd
edn. Mosby, St. Louis
Toriumi DM, Becker DG (1999) Rhinoplasty dissection
manual. Lippincott Williams & Wilkins, Philadelphia

327
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_23, © Springer-Verlag Berlin Heidelberg 2013
23
23.1
Problems with Closed
Reduction Rhinoplasty
Rhinoplasty has evolved into a reduction proce-
dure executed via the closed (transnostril)
approach, with lack of control of tip projection
and tip stability. Nasal skeleton, both cartilage
and bone, is frequently aggressively resected with
little, if any, effort made toward recreating the
structural integrity of the nose. Without a stable
nasal skeleton, nasal tip projection is seldom
maintained and is usually decreased as the carti-
laginous lower third of the nose. Anticipating this
loss of tip projection, which may not be evident
in the operating room, the surgeon may execute a
compensatory overreduction of the nasal dorsum.
A disparity between the size of the overreduced
nasal skeleton and its skin-soft tissue envelope
(S-STE) will eventually result.
This phenomenon is even worse in elderly rhi-
noplasties. The surgeon assumes that the S-STE
will condense to take the shape of the underlying
reduced nasal skeleton. This adaption is even
more critical in thick skin noses, sebaceous gland
tip, and large noses. The difference in the size
between the nasal skeleton and the overlying
S-STE, combined with a loss of structural integ-
rity, leads to a poor aesthetic result. The S-STE
undergoes scar contracture; and because the nasal
skeleton has neither the projection nor the strength
to resist these forces, some degree of distortion of
the nose ensues. The resultant nose frequently
lacks adequate tip projection or de fi nition. If the
nasal skin is thick and sebaceous, or otherwise
nonelastic, as in elderly skin envelope, the result
may be worse.
23.2
Open Structure Rhinoplasty
Open rhinoplasty [ 1 ] has its main indication in
recognizing the dif fi culties inherent in reduction
rhinoplasty techniques. Open structure rhino-
plasty combines the open (external) approach to
rhinoplasty with innovative nasal restructuring
techniques. The open approach to rhinoplasty
provides the adequate anatomical exposure, nec-
essary to diagnose the deformities present, as
well as to execute the required maneuvers of
modeling, sculpturing, reduction, and symmetry
adjustment. With the S-STE retracted superiorly,
the bony/cartilaginous framework is brought into
full view with its components undisturbed in
their true anatomic position. Bony/cartilaginous
deformities and asymmetries are apparent; there-
fore, the surgeon quickly learns to correlate the
surface topography with the underlying skeletal
anatomy.
In open structure rhinoplasty [ 2 ] , more empha-
sis is placed on reshaping the nasal contour than
Open Technique Rhinoplasty
Alberto Di Giuseppe
A. Di Giuseppe , M.D.
Department of Plastic and Reconstructive surgery,
Torrette hospital , Ancona , Italy
e-mail: adgplasticsurg@atlavia.it

328
A. Di Giuseppe
on reducing it. The idea is to do only what is
necessary either by subtracting or by adding to
the nasal structure where indicated. The open
approach affords the exposure required to make
these structural modi fi cations. Sophisticated tip
[ 3 ] restructuring techniques such as dome divi-
sion with suturing maneuvers and sutured-in-
place columellar, tip, and alar grafts can be
performed in an exacting manner. Tip projection
can be maintained or increased through the lib-
eral use of autologous cartilage grafts sutured
into strategic positions. The tip is actually pro-
jected to the desired position. The surgeon is in
control of tip projection, and with this control
comes a critical option: the height of the dorsum
can be modi fi ed fi rst, and tip projection can be
brought into a favorable aesthetic relation to the
dorsum. This method is the reverse of what is
ordinarily done, with dorsal modi fi cation usually
following the design of the tip.
With structure techniques, the surgeon can
alter the dorsal height to the ideal pro fi le for that
particular patient with con fi dence that he or she
will be able to complement that pro fi le with the
appropriate tip. The overall result is less skeletal
reduction and thus less disparity between the
nasal structure and the S-STE. Therefore, the
skin more readily takes the shape of the underly-
ing structure, and the nose looks less amorphous,
more de fi nite, and more elegant.
The open approach to rhinoplasty permits pre-
cise tissue debulking on the undersurface of the
nasal skin, allowing better draping of the S-STE
over the lower third of the nose. The open
approach [ 4 ] is also revolutionary in its impact on
the teaching of rhinoplasty. With closed (transnos-
tril) techniques, experienced surgeons tend to
agree that many years of experience are required
to gain a “feel” for the procedure. Essentially,
they are saying that only through trial and error,
after many surgical procedures, can the surgeon
determine which maneuvers are appropriate for a
particular problem.
The closed technique is essentially done
“blind,” and most of the work is guided by tactile
sensation. The surgeon generally does not know
precisely what subtle manipulation produces a
particular desirable effect [ 5 ] .
The open technique to rhinoplasty has changed
this approach. Both the surgeon and the student
now have the nasal structures displayed before
them. Surgical techniques can be clearly demon-
strated, and their effects can be evaluated. The
surgeon quickly learns what the structure of an
aesthetically pleasing nose looks like and how it
relates to the contour of the nose. Experience
remains an essential element; however, less time
is required to learn the mechanics of rhinoplasty.
Ef fi cient craftsmanship [ 6 ] and artistic judg-
ment take on greater importance as structure
techniques become more sophisticated.
23.3
Technique
The author uses an open rhinoplasty that starts
with a preoperative evaluation of the candidate to
rhinoplasty. There have been no dif fi culties in
obtaining a consent to the open approach. The
fear for the subsequent scar at the midcolumellar
skin,or lower midcolumellar skin, has decreased
with both the patient and surgeon.
There have been a few cases reported of skin
necrosis of the columella, which may result in a
rather dif fi cult problem to be resolved, requiring
a forehaed paramedian fl ap many times, two
other surgeries, secondary scars, and and even
unnatural fi nal result. The author has not seen this
complication
in
more
than
1,000
open
rhinoplasties.
Photo analysis in classical frontal, three quar-
ter, and pro fi le views of the face of the patient is
the start to the correct planning of the operation.
The new lines of the pro fi les, the three quarters,
the tip, with emphasis on the new width of the
nose and with lines of osteotomies: it is not pos-
sible to reproduce the results from computer
imaging.
23.4
Case Report
This 31-year-old female had a globous tip lack-
ing de fi nition and projection, bony hump and car-
tilage hump, septal deviation, long nose, 90°
nasocolumellar angle, and too short upper lip

329
23 Open Technique Rhinoplasty
(Fig. 23.1 ). Menton appears slightly short, but the
patient is not interested in correcting with mento-
plasty with implant to combine pro fi loplasty. Alar
tip cartilages appear symmetrical but too long,
with an upper projection of the nose, and the nos-
trils are symmetrical and not too wide.
a
b
c
d
Fig. 23.1 ( a – f ) Preoperative 31-year-old female with bony hump, long nose, and lack of tip projection, looking for
rhinoplasty

330
A. Di Giuseppe
The new lines for osteotomy and tip correc-
tions in relation to nose anatomy are marked with
new lines of lateral osteotomies, new shape of
reducted alar cartilages, new contour of the nos-
trils, correction of bony hump, tip projection,
naso-columellar angle, and nasal spine retraction
(Figs. 23.2 and 23.3 ). Lines are marked for lateral
and central osteotomies to reduce bony width,
with a higher osteotomy line on the left side in
this case, due to higher bone insertion on this
side. The anatomical landmarks of the patient are
marked in the operating room (Fig. 23.4 ). This
helps to remind the existing features. Preoperative
photos, with planning, are placed on a screen and
may be checked by surgeon all over surgery, for
correct assesment of the planned corrections.
The majority of the author’s open rhinoplasties
are performed under general anesthesia, with
nasotracheal intubation. The author routinely
in fi ltrates with local anesthesia using a dental car-
pule syringe with 2% carbocaine with adrenaline,
as vasoconstrictor (Fig. 23.5 ). Local in fi ltration
starts on the hump line and on the osteotomy
lines, lateral and central. Once completed the
external in fi ltration in a subcutaneous fashion, the
needle is directed in the nostrils, in the submar-
ginal mucosa incision, in the septal mucosa, in the
nasal spine, in the nasal tip, and in the columella.
The operation starts with the midcolumellar
incision, in a subcutaneous fashion, trying to har-
vest a subpericondrial fl ap, in order to ensure the
highest vascularization to the skin envelope
(Fig. 23.6 ). With a bipolar, the columellar artery
and vein are coagulated in this phase to preserve
the best vascular network. The incision is carried
into the marginal nostril mucosa, bilaterally, and
then joined in the midline.
The surgeon utilizes a double skin hook to
protect the soft skin envelope and at the same
time carries on a precise skeletonization of the
cartilages in a subcutaneous plane, preserving
carefully the subdermal plexus to protect vascu-
larization (Figs. 23.7 and 23.8 ). A pair of Stevens
blunt scissors is essential in this dissection phase
to acquire a symmetrical exposure of the lower
tip cartilages.
e
f
Fig 23.1 (continued)

331
23 Open Technique Rhinoplasty
Once the dissection has been completed and
appears symmetrical, the anatomy of the lower
third of the nose becomes evident, revealing real
shape of the alar cartilages. Lateral and medial
alar cartilages are under direct view. Dissection
of the soft tissue envelope continues with the
upper third of the nose, always in a deep subcuta-
neous plane. Dissection is minimal, limited to
dorsum hump (Figs. 23.9 , 23.10 , and 23.11 ). A
larger dissection may create a third space, with a
subsequent unnecessary edema and uncontrolled
area.
A self-sustaining soft tissue retractor is placed
to expose the bony hump. In preparation for the
bony hump osteotomy, a subperiosteal plane is
achieved with the help of a periosteum elevator. In
preparation for cartilage hump resection, the alar
cartilages are retracted with a clamp, and septal
mucosa is opened to expose the septum and the
uppper lateral cartilages, in preparation for trim-
ming (Fig. 23.12 ). A pair of scissors is used to cut
the cartilage hump formed by septum and upper
lateral cartilages,which are resected en bloc.
The resected hump must be symmetrical.
After its removal, the remaining portion of the
bony hump appears. The resection of the carti-
lage hump has to be submucosal. The framework
of resected hump is shown and checked
(Figs. 23.13 , 23.14 , 23.15 , 23.16 , 23.17 , and
23.18 ). The septum is exposed. Further trimming
of septum and lateral upper lateral cartilages is
performed (Fig. 23.19 ). The bony hump is
checked with a rasp, and correction of bone irreg-
ularities is achieved under control (Fig. 23.20 ).
With a guide-protected osteotome, the central
osteotomy is performed, and the bony hump is
removed with a clamp and checked to verify its
shape and symmetry.
Anterior nasal septum resection is acheived by
gentle exposure of the septal mucosa limited to
the lower anterior part of the septum (Fig. 23.21 ).
Limited septum excision is performed with a #15
blade knife. Minimal septum resection, combined
with lower cartilage reduction and reshaping,
gives an extra tip projection to the nose
(Figs. 23.22 and 23.23 ).
Junction of
upper lateral
and lower
cartilages
Rhinion
Nasal bone
Nasion
Uper lateral
cartilage
Lower lateral
cartilage
b
a
Fig. 23.2 ( a ) Marking of new lines of osteotomy and tip
corrections in relation to nose anatomy. The proposed cor-
rections. New lines of lateral osteotomies, new shape of
reducted alar cartilages, and new contour of the nostrils.
( b ) Nasal anatomy in comparison with existing shape

332
A. Di Giuseppe
The resection and shaping of the lower third of
the nose now starts. The proposed resection of
the alar cartilages is marked to ensure symmetry
(Fig. 23.24 ). The incisions of the lower alar carti-
lages are done with a scalpel, but the undermin-
ing from the underlying nasal mucosa is better
achieved with blunt scissors (Fig. 23.25 ). Blunt
scissors with delicate tips work to dissect care-
fully the nasal mucosa, without damaging the
mucosa (Fig. 23.26 ). Once completed on one
side, the operation is performed on the contralat-
eral side (Fig. 23.27 ).
A #15 blade scalpel is utilized just for the inci-
sion of the marked cartilage (Fig. 23.28 ). The
incision and the dissection are performed bilater-
ally (Fig. 23.29 ). The alar cartilages are resected
(Figs. 23.30 and 23.31 ). In order to reduce the
length of the tip of the nose, a precise minimal
resection of the dome is performed under direct
vision (Figs. 23.32 and 23.33 ). With a blade, the
proposed incision is performed, but undermining
and cartilage resection is performed with blunt
a
b
Fig. 23.4 ( a , b ) Marking anatomical landmarks of lines
of osteotomy and alar cartilages. Lines of lateral and cen-
tral osteotomies to reduce bony width, with a higher
osteotomy line on the left side, due to higher bone inser-
tion on this side
Fig. 23.3 Marking lines of correction of bony hump, tip
projection, nasocolumellar angle, and nasal spine retraction

333
23 Open Technique Rhinoplasty
a
b
c
d
e
Fig. 23.5 ( a – e ) In fi ltration of local anesthesia with dental syringe

334
A. Di Giuseppe
scissors in order to prevent damages to underly-
ing mucosa (Figs. 23.34 and 23.35 ). With the
wedge resection of the dome completed, suturing
with 6–0 nylon and reshaping of the reduced
dome
is
perfomed
under
direct
control
(Figs. 23.36 , 23.37 , 23.38 , and 23.39 )
The lower portion of the septum is exposed,
and anterior nasal spine is resected in a moderate
fashion to free the deviated septum (Figs. 23.40
and 23.41 ). The skin envelope is redraped to
show new shape of the dome (Fig. 23.42 ). Bony
hump is removed with a Rubin osteotome, direct-
ing the reception into the nasofrontal angle
(Fig. 23.43 ). An upward cutting rasp is used to
re fi ne the dorsum hump (Fig. 23.44 ). Stab inci-
sion is made at the pyriform aperture near the
insertion of the inferior turbinate (Fig. 23.45 ).
The periosteal elevator is used to elevate perios-
teum along the path of the lateral osteotomy
Fig. 23.6 Open rhinoplasty: midcolumellar transverse
skin incision and submarginal alar mucosa incision
Fig. 23.7 Subcutaneous delicate undermining in a supra
perichondrial plane. Skin hook is utilized to expose soft
tissue or retract anatomical structures
Fig. 23.8 Undermining of soft tissues completed
Fig. 23.9 Limited undermining of the soft tissues of the
bone pyramid

335
23 Open Technique Rhinoplasty
(Fig. 23.46 ). The osteotomy is set at the level of
the inferior turbinate and is guided toward the
face to preserve the triangular aspect of the pyri-
form aperture (Figs. 23.47 and 23.48 ). A transcu-
taneous osteotomy is performed to complete the
back-fracture (Fig. 23.49 ). A 2-mm osteotome is
used to make a few postage stamp perforations to
aid in controlling the fracture. Once lateral and
central osteotomies are performed, the new shape
of the nose is achieved (Fig. 23.50 ). The skin is
sutured with 6.0 nylon, and mucosa lining is
sutured with 4.0 Vicryl (rapid) (Fig. 23.51 ).
The results can be seen at 2 weeks (Fig. 23.52 )
and 1 month (Fig. 23.53 ).
Fig. 23.10 The soft tissues of the nose are exposed with
an elevator
Fig. 23.11 Retractor helps visualizing bony hump and
cartilage septum
Fig. 23.12 Septal mucosa incised to expose septum
Fig. 23.13 The framework of resected hump is showed
and checked

336
A. Di Giuseppe
Fig. 23.14 Septum after removal of strip
Fig. 23.15 Bone hump removal with osteotome. Check
the amount and shape removed
Fig. 23.16 The bony hump is placed on the dorsum to
check its symmetry
Fig. 23.17 Anatomical relations of the resected bony
hump with the nose

337
23 Open Technique Rhinoplasty
Fig. 23.18 Bony hump and cartilage hump are placed on
the skin envelope dorsum to show amount of resection
Fig. 23.19 Further trimming of septum and upper lateral
cartilages is performed, and the amount resected is shown
a
b
Fig. 23.20 ( a ) The bony hump is checked with a rasp,
and ( b ) correction of bone irregularities is achieved under
control

338
A. Di Giuseppe
Fig. 23.21 Anterior nasal septum resection is acheived
by gentle exposure of the septal mucosa limited to the
lower anterior part of the septum
a
b
Fig. 23.22 ( a ) Limited septum excision is performed
with a #15 blade knife. Minimal septum resection, com-
bined with ( b ) lower cartilage reduction and reshaping,
gives an extra tip projection to the nose

339
23 Open Technique Rhinoplasty
Fig. 23.23 The amount of the resected septum is showed
Fig. 23.24 Marking the planned resection of lower alar
cartilages
a
b
Fig. 23.25 ( a ) The incisions of the lower alar cartilages
are done with a scalpel, but the ( b ) undermining from the
underlying nasal mucosa is better achieved with blunt
scissors

340
A. Di Giuseppe
Fig. 23.26 Blunt scissors with delicate tips work to dis-
sect carefully the nasal mucosa, without damaging the
mucosa
Fig. 23.27 Once completed on one side, the operation is
performed on the contralateral side
Fig. 23.28 A #15 blade scalpel is utilized for the incision
of the marked cartilage
Fig. 23.29 The incision and the dissection are performed
bilaterally

341
23 Open Technique Rhinoplasty
Fig. 23.31 Resected alar cartilages
Fig. 23.32 In order to reduce the length of the tip of the
nose, a precise minimal resection of the dome is per-
formed under direct vision. The proposed excision is in
the form of a small strip, bilaterally
Fig. 23.33 The two wedge excisions are marked
Fig. 23.30 The amount of the resected portion of the
upper cartilage

342
A. Di Giuseppe
Fig. 23.34 With a blade, the proposed incision is per-
formed, but undermining and cartilage resection is per-
formed with blunt scissors in order to prevent damages to
underlying mucosa
Fig. 23.35 Wedge resection of the dome completed and
ready for suturing with 6.0 nylon
a
b
Fig. 23.36 ( a , b ) Suturing and reshaping of the reduced
dome under direct control

343
23 Open Technique Rhinoplasty
Fig. 23.37 Interdomal mucosal apposition mattress suture
Fig. 23.38 Suturing completed with the last suture in the
upper portion of the dome
Fig. 23.39 The resected and reshaped dome is showed
a
b
Fig. 23.40 ( a , b ) The lower portion of the septum is
exposed, and anterior nasal spine is resected in a moderate
fashion to free the deviated septum

344
A. Di Giuseppe
Fig. 23.41 Anterior nasal spine exposed before resection
Fig. 23.42 Skin envelope is redraped to show new shape
of the dome
Fig. 23.43 Bony hump is removed with a Rubin osteot-
ome, directing the reception into the nasofrontal angle
Fig. 23.44 An upward cutting rasp is used to re fi ne the
dorsum hump
Fig. 23.45 Stab incision is made at the pyriform aperture
near the insertion of the inferior turbinate

345
23 Open Technique Rhinoplasty
Fig. 23.46 Periosteal elevator to elevate periosteum
along the path of the lateral osteotomy
Fig. 23.47 The osteotomy is set at the level of the infe-
rior turbinate and is guided toward the face to preserve the
triangular aspect of the pyriform aperture
Fig. 23.48 The line of the osteotomy (back-fracture)
Fig. 23.49 A transcutaneous osteotomy is performed to
complete the back-fracture. A 2-mm osteotome is used to
make a few postage stamp perforation to aid in crontrol-
ling the fracture
Fig. 23.50 Once lateral and central osteotomies are per-
formed, the new shape of the nose is achieved

346
A. Di Giuseppe
a
b
Fig. 23.51 ( a ) New shaped dome, tip, and bone. ( b ) The
skin is sutured with 6.0 nylon, and the mucosal lining is
sutured with 4.0 Vicryl (rapid)
Fig. 23.52 ( a – e ) Two weeks postoperative
a
b