Nose Surgery Techniques
Open Rhinoplasty and Closed Rhinoplasty
There is a growing trend for surgeons to perform "open" rhinoplasty surgery, and for the better, due to superior results as opposed to those obtained during traditional rhinoplasty, or the "closed" surgical approach. With open rhinoplasty, the surgeon is better able to view the inside of the nose allowing for more precision. The open rhinoplasty technique has many advantages to getting nearly perfect results in every case, even in more complex cases such as revision rhinoplasty, or with patients who have very wide nasal tips, or thick cartilage. With the superiority of rhinoplasty surgery through the open technique, closed rhinoplasty surgery can be reserved for minor and non-complex cases. Nose jobs of years past dramatically changed the patient's appearance, where the nose was not in harmony with the face, looked pinched and or scooped out. The surgical result certainly was not a subtle and natural improvement on what was already there. Having perfected the open rhinoplasty approach for the last 15 years, Manhattan nose surgery expert Dr. Slupchynskyj's patients have better results.
The Difference Between Open Rhinoplasty Surgery and the Traditional, Closed Rhinoplasty Technique
Traditional, or closed rhinoplasty is performed when all of the incisions are on the inside of the nose, and the nasal structures are accessed through the nostrils. The skin is separated from the bone and cartilage through this incision and the surgeon has limited access to all the nasal structures including the nasal tip. The open rhinoplasty technique uses a tiny incision right beneath the nasal tip and between the two nostrils on the outside of the nose–this area is called the columella. This approach allows the surgeon to have better access to the interior structures by "opening" the nose and allowing the surgeon to directly view nasal architecture such as tip cartilages, shape and position of any existing nasal implants as well as degree of scar tissue possibly resulting from previous rhinoplasty surgery.
Disadvantages and Potential Complications of Traditional, Closed Rhinoplasty Technique
Since closed rhinoplasty is a technique where the incisions are made inside the nose, this approach makes it very difficult for the surgeon to correctly dissect in the appropriate tissue planes in order to elevate the soft tissue from the cartilage and bony structures of the nose. It is essential to elevate the correct tissue planes in rhinoplasty surgery without the patient experiencing serious complications. If the tissue planes are violated and incorrect planes created, this will result in distortions of the nasal bone and cartilaginous architecture postoperatively. Second, the inability to plainly see the nasal tissue planes could lend itself to unnecessary bleeding during the procedure. In the open rhinoplasty approach, the correct tissue planes can be directly visualized and dissected once the tiny incision at the columella is made. Once that tissue plane is entered, the nasal soft tissue may easily be dissected off of the cartilaginous and bony structures. This type of elevation has several advantages over traditional methods. First, if dissection is performed in the correct tissue plane, it results in an essentially bloodless plane, meaning no or very little bleeding. In traditional rhinoplasty, the tissue plane may not be easily and specifically chosen for dissection and bleeding may become an issue. Second, dissection in the correct plane elevates all the soft tissue from the cartilage and bone therefore leaving the lower and upper lateral cartilages and nasal bone free of any soft tissue interference and or bleeding when reducing a dorsal hump, carving the nasal septal tissue and/or the lower or upper lateral cartilages. This is not the case with the traditional closed approach.
Do Endoscopes Offer Any Advantage in Rhinoplasty Surgery?
Cosmetic rhinoplasty surgery is not performed through a flexible fibro-optic endoscope, however sinus surgery is. Endoscopes work well in anatomical areas where there is a bloodless, hollow cavity like the sinus, abdomen etc. These cavities are either made by the surgeon, like the abdomen, or they already exist, such as the sinus. Endoscopes do not have instruments on it to manipulate the cartilage and the bone as needed in rhinoplasty. In order to change cartilage and bone in a rhinoplasty the skin had to be elevated, whether it is through a closed or open approach. Once the skin is elevated to expose those structures, there is no need for an endoscope. Endoscopic sinus surgery can, however, be done in conjunction with cosmetic rhinoplasty surgery. One doctor, Ignazio Tasca, MD was one of the first to adapt sinus surgery methods using an endoscope in rhinoplasty surgery. In his 2002 published article "Endoscopy-Assisted Rhinoplasty" in The Archives of Facial Plastic Surgery, Dr. Tasca reports the endoscope allows for direct vision of some of the steps previously left to the judgment and experience of the doctor performing the closed rhinoplasty. This approach may assist the doctor in minor or simple cases of rhinoplasty, such as hump reduction, but there is no replacement for actual direct visualization of all nasal components–including the tip and possible scar tissue–in rhinoplasty surgery and most especially in revision rhinoplasty surgery.
Nasal Implant Complications with the Traditional, Closed Method
The open approach allows the surgeon much more precision to correctly create tissue pockets for placement of nasal implants. Many of the revision rhinoplasty cases Dr. Slupchynskyj performs are as a result of, a) incorrect tissue plane dissection and, b) placement of a nasal implant graft, where it be Silastic, Goretex or another implant material, in the wrong tissue plane. These are a result of previous rhinoplasty surgery from another doctor most likely using the traditional closed method. Several attending complications may arise regarding incorrect placement of an implant–movement, visibility of the implant because of movement, potential infection and necrosis (dying off) of the nasal skin due to incorrect plane dissection and excessive tension over the implant. The ability to directly view allows for precise dissection in the correct tissue plane so an implant can be properly placed, secured to the nasal bone and cartilaginous structures and adequate soft tissue and skin cover is available to cover that plane. Improper tissue plane elevation is the most common reason for any kind of implant failure in nasal implant surgery.
What Surgeon is Qualified to Perform Rhinoplasty?
The open rhinoplasty approach requires advanced surgical skills and for this reason many surgeons do not perform this technique. Only a Facial Plastic Surgeon, Double Board Certified through the American Academy of Facial Plastic and Reconstructive Surgery and the American Board of Otolaryngology is sufficiently trained and experienced enough to perform this surgery and produce the most natural results. With these credentials and more than 18 years of experience, Dr. Oleh Slupchynskyj is often regarded as one of the best rhinoplasty surgeons in New York.
Doctors not trained or experienced in this area (often general plastic surgeons who perform body work such as liposuction and breast augmentation) fear of making an incision at the collumella and creating a potential scar. In reality, this incision heals very well to the point of imperceptibility unless the incision is not performed correctly or closed correctly. Then you can have scarring if you are not in the right surgical hands. The open rhinoplasty approach is technically more difficult, requiring a more skilled and experienced surgeon and for this reason most surgeons do not opt for this technique. That said, there are surgeons who perform through a closed rhinoplasty technique, and they typically achieve good results however in a very straightforward routine case, such as reducing a nose bump or correcting a minor tip issue. Bony hump reduction or removal can be done through a closed technique and even in this case you need a skilled facial plastic surgeon that specializes in nose surgery.
Dr. Slupchynskyj's Proven Results
"Every nose is different and rhinoplasty is one of the most technically difficult procedures that I perform. In my opinion, the best way to obtain a precise, accurate result on most noses is to have open access to better visualize the structures you're working on. Although I use both approaches, I prefer the open rhinoplasty approach in my practice due to superior results or almost perfect results. Using a tiny incision at the columella, I am able to lift the nasal skin, revealing the entire frame of the lower portion of the nose. This direct visualization and greatly improved access allow for the most precise augmentation or reduction possible. There are also those situations where the open approach is particularly justified, such as in revision rhinoplasty and procedures requiring the placement of grafts to better support the nose, like ethnic and African American nose surgery. Having honed the open rhinoplasty technique for more than 15 years, I am able to achieve consistent, proven results with this method. As you can see from the photos of my patient below, the tiny incision at the columella is imperceptible once it has healed. In my opinion, a nearly undetectable scar is well worth the operative advantages of the open rhinoplasty technique."
About Dr. Oleh Slupchynskyj
Dr. Oleh Slupchynskyj is an experienced facial plastic surgeon, performing both open and closed rhinoplasty surgery for patients who wish to enhance the appearance of their facial features. With his well-trained aesthetic eye and advanced surgical skills, Dr. Slupchynskyj is able to provide for the needs of New York ethnic rhinoplasty, and male and female rhinoplasty patients. Contact his practice today to learn more.
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