Rhinoplasty: Open, Closed, or Non-invasive

Dr.Yang Explains… Rhinoplasty: Open, Closed, or Non-invasive

In response to KadeeBelleMD’s question, I wrote that a closed rhinoplasty would be less invasive and fewer factors come into play when it comes to healing. If a surgeon exclusively likes to perform one method only, I would not ask that surgeon to perform the alternative method just for the patient situation. The consistency of their results is based on their comfort level with the open and/or closed rhinoplasty technique.

I perform both open and closed rhinoplasties, so I don’t have an exclusive bias to either method; however, for certain situations the open rhinoplasty method has its advantages, and other situations closed rhinoplasty has its advantages. I will try to explain why.

One thing that the public does not know is that after a rhinoplasty the nose continues to heal over the period of months to several years. Once the nasal skin has been lifted off of the nasal cartilages and bones, there is a “shrink-wrap” effect that can occur over this time. So for many early rhinoplasty results (less than 1 year), the results look great. However, as the skin shrinks (especially with thin nasal skin) there can be changes and potential asymmetries if the nasal cartilages are not structurally sound. With the reductive rhinoplasties of the past, the noses were shaved down, and ski-slope noses were common place. However, these noses developed problems over the years. Most people will have their rhinoplasties in their 20′s-30′s, so the nose has to be stable for 50-60 years. This is where the open rhinoplasty gained it popularity in revisions, along with structural grafting (using cartilage grafts to strengthen the nose to resist these shrinking forces.) There are so many rhinoplasty patients out there, that some facial plastic surgeons can have a practice geared towards performing revision rhinoplasties (Better with open technique.)

Based on this knowledge, you would think that I would exclusively perform open rhinoplasties. I can see all of the nasal structures better, the work on the tip of the nose can be performed more symmetrically, and the cartilage grafts can also be placed with more accuracy. However, if the entire nose is opened up in an open septo-rhinoplasty, I would say that it would be a requirement to perform all of these things to prevent future problems.

In my response to KadeeBellMD’s question, I wrote: “If it ain’t broke, don’t try to fix it.” If the nasal tip looks fine to the patient, I would avoid degloving the skin over the lower nasal cartilages. By not doing this the tip will unlikely “shrink-wrap” since it was essentially untouched. One minor benefit is that there is no incision on the columella (the skin dividing the nostrils.) Although the columellar incision usually heals fine, and is very hard to detect, it looks even better if there is no incision. The “shrink-wrap” effect can occur over the upper nasal cartilages on the bridge of the nose, if a significant bump is shaved off, and if the patient has short nasal bones, and long nasal cartilages. If this occurs in the middle third of the nose, an inverted-V deformity can occur. (I will try to put these into layman’s terms later.)

Continuing along the lines of “If it ain’t broke, don’t try to fix it,” I will briefly discuss fillers for improvement of the nasal profile. This is worth discussing as a non-invasive way of improving the profile of the nose, and is often an overlooked option. With this method the nasal cartilages and bone is completely untouched and should not cause any future nasal collapse. That being said, silicone injections was very popular in Asia (Korea, Taiwan, etc.) in the 1980′s when used to build up the bridge of Asians with low nasal bridges. Instant Fix! Problems did not begin to occur until the 1990′s, when the silicone began to migrate, and cause “melting wax” appearance, and granulomas. Now with more temporary fillers such as Restylane, Juvederm, and Radiesse, I think that performing fillers on the bridge of the nose has become safer, since the material eventually goes away. With Radiesse, there is some collagen deposition, so the subsequent injections can be less. The main issue with the repetitive injections is cost over time. Although the cost may be a fraction of a rhinoplasty, depending how long you want the nose to look good, it may cost more (>15 years) or (<15 years) less money than a traditional rhinoplasty (Do the math.) Remember, in order to stop the cost of the perpetual rhinoplasty, you have to stop the injections, when you stop the result that you want will eventually go away. The same issue comes up for Botox, and other temporary fillers. If the patient already spent (5-6K) for the fillers, they may think back and say that they should have had the traditional rhinoplasty ($6-9K)which is a little more expensive but lasts a lifetime.

If you offer all three methods of Rhinoplasty, how do you decide with the patient which is the best option for them?

My goal is to offer the patient the least invasive technique, with the least amount of potential long term issues, while meeting the patient’s aesthetic desires, and considering their budget.

My Consultation Process:

1. Clearly identify the patient’s dislikes about their nose, as well as what they do like about their nose. I don’t like my: Profile, the tip, nostrils are too wide, nose is too big, tip is droopy, the tip is too upturned, etc. I like my: Profile, my tip, etc.
2. Understand the patient’s prior history with their nose (trauma, prior nasal or sinus surgeries), nasal breathing issues, medical issues (Allergies, polyps, etc.)
3. Computer imaging: When performing computer imaging for nasal bumps/humps, I usually provide three images for their comparison. The first computer imaging, I take the entire bump down from the radix (the bridge of the nose between the eyes) to create a straight profile.


http://www.noses.co.nz/Nasal%20Anatomy

The second image, I take the bump down partially, leaving a small depression at the radix, and build up the radix area a little to create a straight profile. Lastly, I show them what a non-invasive rhinoplasty would look like, although they did not come in for this procedure, they may not have heard of it, and they may feel that the Pro’s and Con’s of the non-invasive rhinoplasty suits them more than a traditional rhinoplasty. With this last imaging, the nose is not taken down at all, the radix area is built up until the profile is straight.

4. Saline Simulation: After the computer imaging, if they like how the non-invasive rhinoplasty looks, I offer them an injection of local anesthetic to simulate how the bridge might look with the filler. Immediate post-procedure photos are take, since the fluid can shift within minutes, although it does not shift with the Restylane or Radiesse. They get to examine themselves in the mirror, ask their friend or family member how it looks.

5. Surgical Quote: They receive a quote for both traditional and injection rhinoplasty. I explain how long the fillers last (Restylane 6-8 months, Radiesse ~2 years). When they go home, they can weigh their options and calculate out what works best for them financially.

   If they really like how the injection rhinoplasty looks, but don’t want the continual cost of the temporary fillers, they can have cartilage graft to the same area as the fillers, which should last the lifetime of the nose.

The approach to tip narrowing, projection, nostrils, etc is the same as with traditional rhinoplasty techniques since I think that filler injections to the tip may shift or not give enough structure to the nose (angular structure) and may make the tip more amorphous.

Best,

Dr. Yang