A Systematic, Graduated Approach to Rhinoplasty

Rhinoplasty; Editors in Chief, Fred Fedok, M.D., Gilbert J. Nolst Trenité;,M.D., Ph.D., Daniel G. Becker,M.D., Roberta Gausas, M.D.; Guest
Editors, Edwin F.Williams, III, M.D., Samuel M. Lam, M.D. Facial Plastic Surgery, Volume 18, Number 4, 2002. Address for correspondence
and reprint requests: Edwin F. Williams, III, M.D., Williams Center for Facial Plastic Surgery, 1072 Troy-Schenectady Road, Latham, NY
12110. 1Williams Center for Facial Plastic Surgery, Latham, NY; Section of Facial Plastic Surgery, Albany Medical College, Albany, NY; 2Lam
Facial Plastic Surgery Center, Dallas, TX. Copyright © 2002 by Thieme Medical Publishers, Inc., 333 Seventh Avenue, New York, NY 10001,
USA.Tel: +1(212) 584-4662. 0736-6825,p;2002,18,04,215,222,ftx,en;fps00438x.
A Systematic, Graduated Approach to Rhinoplasty
Edwin F. Williams, III, M.D.,1 and Samuel M. Lam, M.D.2
Rhinoplasty may be viewed as one of the most technically demanding procedures in facial plastic surgery and requires a level of sophistication derived from diligent study, repetitive execution, and critical review. During the preoperative evaluation, the physician must exercise a systematic approach that includes a thorough investigation into the psychological and physical aspects of the individual patient. A systematic, graduated approach should be undertaken in every rhinoplasty in which the three cornerstones-planning, simplicity, and flexibility-are recalled. Planning entails a thoughtful and critical analysis of what surgical techniques may be best enlisted to achieve the envisioned aesthetic effect. Simplicity argues in favor of performing only those surgical procedures needed to accomplish the task at hand to minimize the variables that arise from protracted, ill-defined surgery.Flexibility implies that the surgeon be capable of modifying his plan if unforeseen operative events disrupt the proposed course of action. All three principles reflect the authors’ philosophy about the surgical approach to rhinoplasty, that is, the discretionary use of endonasal (non-delivery and delivery) and external incisions as warranted by circumstance.

KEYWORDS: Systematic, graduated, approach, rhinoplasty

Rhinoplasty is generally considered the most difficult surgical procedure that the facial plastic surgeon is required to master. The inherent complexity of rhinoplasty lies not only in the technical, surgical maneuvers necessary to become proficient but also in the judgment that is only acquired from being a dedicated student of rhinoplasty. As part of this tutelage, the rhinoplasty pupil must assiduously work over many years amassing a large number of varied rhinoplasty experiences and must also devote a critical eye to follow his surgical results over a protracted period of time. Unlike other facial plastic procedures, rhinoplasty stands apart, as the outcome is directly influenced by a host of unique factors, including intricate anatomic differences, functional impairment, history of prior surgery, the aging process, and forces of scar contracture that may manifest only after several years of observation. Additionally, unlike other disciplines in medicine, specialized training, a thorough review of the literature, and rigorous scientific methodology do not necessarily ensure successful, long-term aesthetic and functional results. The task may appear daunting to the uninitiated surgeon, but with reliance on a systematic approach throughout every phase of patient care (pre-, intra-, and postoperative periods) the diligent rhinoplasty student may consistently achieve a favorable result and enjoy the satisfaction of a gratified patient.


Although mastery of the technical, operative aspects of rhinoplasty remains a fundamental concern in any rhinoplasty endeavor, preoperative planning using a systematic, graduated approach should merit equal weight and successfully guide the rhinoplasty surgeon to meet his intended objective. Rather than attack every rhinoplasty venture with a prescribed formula, the surgeon should always remain flexible and carefully determine which surgical approach is warranted, relying on the full arsenal of techniques that he should have at his disposal.
As part of the early patient encounter, the physician must devote considerable effort to discern the pertinent psychological aspects that inform a patient’s motivation and desire. Part of a systematic approach involves a detailed assessment of the patient’s disposition and psychological framework. It is important to identify certain character traits that could predispose toward a dissatisfied patient no matter how objectively stellar the surgical outcome may apparently turn out. For example, the overly expectant patient may have inflated notions of the surgical result and fail to recognize the limitations imposed by his or her own peculiar anatomy and physiognomy. With these patients, the physician must establish realistic goals based on these particular constraints and attempt to reach a mutual understanding before electing to proceed. Characteristic of this type of patient is the so-called “engineer mentality” often ascribed to the male gender in which the patient arrives to the initial interview clutching in tow elaborate, self-executed, nasal diagrams that impart little practical information except to reveal the patient’s fixated frame of mind. Similarly, individuals who tirelessly “shop around” for the proper surgeon may reflect again an overly ambitious agenda. Further, patients who have already undergone prior rhinoplasty may harbor resentment toward their erstwhile surgeon and transmit that negativity to their current selection. Digital imaging, employing morphing software, may at times assist the surgeon to communicate in a concrete, visual fashion what the mutually conceived goal of surgery may be and thereby align the surgeon’s and patient’s visions. However, if the patient’s motivations and desires are clearly and rationally expressed so that the physician can reasonably appreciate those goals and feel that his surgical efforts can approximate the patient’s vision, then further consideration for surgery may be entertained. Besides the overwhelming importance that the intangible qualities of a patient’s psyche may carry, the physician must also strive to elicit the salient aspects of the patient’s history and physical examination that could affect the operative procedure. Prior nasal trauma, related sinus and allergy disease, systemic illnesses, medication abuse, and nasal respiratory impairments are among the many factors that must be determined before embarking on aesthetic nasal surgery. As the nose is foremost a respiratory organ, the functional constituents that define the nasal anatomy, for example, the nasal valves and septal-turbinate complex as well as any external contributing deformities, must all be remarked upon by the thoughtful surgeon. Particular aesthetic qualities or deficiencies that guide surgery must all be delineated; these aspects will be elaborated upon in the forthcoming section on a systematic approach to surgical decision making. In the patient who has had previous surgery, it is imperative to examine carefully the nasal septum for remaining usable cartilage and/or sub-clinical perforations and to determine what the prior surgeon may have performed. Unfortunately, previous operative reports are of only limited benefit, as these narratives are often derived from standard macro-type formulas.After the pertinent psychological and anatomic elements have been properly explored, the surgeon must now confront the task of preparing a blueprint for his surgical endeavor. The details of this assessment will be addressed in the next section, but it is important to emphasize at this point that all the surgical maneuvers that are planned should be recorded in the patient’s chart immediately following the initial patient contact. As the actual surgical procedure may be postponed somewhat after the preliminary patient consultation, the surgeon should formulate a decisive strategy at the outset to avoid the vicissitudes of failing memory and the unnecessary task of rethinking the proposed undertaking again at a later date. Even cursory notations that include key phrases such as “right spreader graft, transdomal suture, and dorsal onlay graft” may serve as a reminder at the time of surgery for critical aspects that should be executed to maximize rhinoplasty results.We have also found that a separate date should be scheduled during the preoperative period after the initial consultation for the appropriate preoperative workup.After a lengthy consultation, the patient is usually sufficiently fatigued that any further dialogue toward operative intervention may be overwhelming. At this second date, a complete history and physical examination is recorded, standard digital photographic views are taken, pertinent related insurance matters are clarified, and preoperative counseling is undertaken. Of note, the digital photographs that are taken during this session are projected on an enlarged monitor in the operative suite during the actual surgical procedure so that the surgeon may view the nasal tissues in an undisturbed state. The prominent display of these images facilitates accurate surgical assessment, especially after a supine patient has been subjected to infiltration of local anesthesia and to surgical manipulation.


Herein lies the crux of this article: planning, simplicity, and flexibility are the cornerstones to successful rhinoplasty. If these three tenants are carefully followed in every case,

Figure 1 Schematic diagram illustrating factors to consider when formulating the surgical approach prior to undertaking rhinoplasty.These factors tempered by experience should inform on every rhinoplasty venture.

the deliberate and methodical surgeon will achieve his intended goals on a more consistent basis. Planning entails a thoughtful and critical analysis of what surgical techniques may be best enlisted to achieve the envisioned aesthetic effect. Simplicity argues in favor of performing only those surgical procedures needed to accomplish the task at hand to minimize the variables that arise from protracted, ill-defined surgery. Flexibility implies that the surgeon be capable of modifying his plan if unforeseen operative events disrupt the proposed course of action. All three principles reflect the authors’ philosophy about the surgical approach to rhinoplasty,
that is, the discretionary use of endonasal (non-delivery and delivery) and external incisions as warranted by circumstance (Fig. 1).Planning is a requisite first step in rhinoplasty.The thought and time that are invested early in the process will translate into a shorter procedure, more fruitful and directed surgery, and less attendant patient morbidity associated with protracted surgery. The very real constraints imposed by the progressively diminishing
effect of vasoconstriction from the local anesthetic combined with the ineluctable edema from a lengthy procedure restrict the workable timeframe that a surgeon has to accomplish his goals and reinforces the notion of diligent planning. In addition, the increased exposure time to anesthesia with its known risks and sequelae may be reduced with successful planning. Part of the planning process involves a careful assessment of both the particular anatomy (nasal skin thickness and cartilaginous integrity) and related deformity (functional impairment, deviation, bifidity, etc.) to determine the best course of action. Simplicity with regard to rhinoplasty signifies the understanding that every added surgical maneuver introduces another variable during the healing phase and should be avoided if deemed unnecessary.1,2 With each variable, the forces of scar contracture that occur over time will impose a degree of unpredictability regarding long-term outcome. Aggressive rhinoplasty that involves extensive dissection and grafting may ultimately yield a distorted and unnatural result many years later. As part of this doctrine, the experienced rhinoplasty surgeon should understand the “law of diminishing returns” in which further operative labor will not favorably add to the outcome but only serve to encourage the introduction of more variables. Accordingly, the surgeon should formulate a plan that will accomplish all the desired goals with the fewest surgical maneuvers.3 Flexibility should guide both preoperative and intraoperative decision making. During the preoperative phase, the surgeon should carefully consider whether an open-structure approach is justifiable given the patient’s corrective need. We carefully restrain ourselves from the indiscriminate desire to open every nasal tip for supposed better visualization of the nasal architecture. When endonasal approaches will suffice to meet the objective, we advocate use of this modality only to restrict the amount of unnecessary dissection and operative time and thereby maintain the governing rule of simplicity. Further, a non-delivery, transcartilaginous resection to refine the nasal tip will be employed in those cases where even an endonasal delivery technique may be excessive and superfluous to the intended goal. Similarly, the rhinoplasty surgeon should also remain flexible during the actual procedure.Despite even the best-laid plans, the skillful surgeon may encounter unanticipated events during a procedure that compel him to alter his projected mission.However, intraoperative flexibility should never be an excuse for poor planning.Perhaps the best method of illustrating the previous principles is via concrete, clinical scenarios in which different techniques are recruited as justified. Three clinical examples are presented that demonstrate the effective implementation of non-delivery, delivery, and open approaches, respectively, as well as adjunctive measures. The first patient (Fig. 2) exhibits the following unaesthetic qualities and functional impairments: under projection of the nasal tip; a dorsal convexity; minimal deformity with regard to the size, orientation, and attitude of the lower lateral cartilages; and a deviated nasal septum. Using an endonasal approach, a septoplasty was performed through a hemi transfixion incision, preserving an inverted L-shaped strut of septal cartilage for support and harvesting sufficient septal cartilage for grafting. Cephalic refinement of the lower lateral cartilages was accomplished via a non-delivery, intracartilaginous incision. A non-delivery approach was elected given the minimal lobular bulbosity and negligible bifidity in the domal region. The dorsal profile was reduced using sharp dissection of excessive upper lateral cartilage and Ruben-style osteotomes for the bony pyramid. Septal cartilage was fashioned into a tip graft and columellar strut to enhance tip support and add projection. All grafting material was secured in defined soft-tissue pockets rather than suture fixation as is typical in the open structure approach. In a patient with nasal-tip anatomy characterized by broad, firm, overdeveloped, and asymmetrical lower lateral cartilages possessing a large buckle bilaterally in the area of the intermediate crus, the decision was made to use an endonasal delivery approach so as to inspect and address these aforementioned deformities (Fig. 3).A full septal transfixion incision was performed to de-project the nasal tip and to facilitate delivery of the lower lateral cartilages. After delivery of the lower lateral cartilages was accomplished, a cephalic resection; weakening of the lateral-crural region via noncoalescent, multiple, partial-thickness, stab incisions; resection of the asymmetric, buckled intermediate crus; and then reconstitution of the transected domes were carried out to achieve desired tip structure. A transdomal suture was placed to enhance refinement and to deter any development of nasal bossae. However, we have found that significant contouring of the lower lateral cartilages with onlay grafting and delicate positioning of the lower lateral crura using lateral-crural transection and overlay techniques would be justifiable reasons to open the nose for better visualization, symmetrical correction, and suture fixation. Revision rhinoplasty is typically the most cited reason for an advocate of the endonasal approach to consider open evaluation of the nose.4,5 Although some endonasal champions may successfully navigate the treacherous terrain of a revision nose via closed techniques, we feel that oftentimes an open approach is the preferred route. The abnormal scarring, absent tissue planes, uncertain trauma inflicted from the previous rhinoplasty, and more advanced recontouring maneuvers needed are all legitimate concerns that warrant proper visualization via an open approach. The patient in Figure 4 presents several years after initial rhinoplasty in which an overzealous removal of framework is evident. Bilateral conchal cartilage grafts were harvested, contoured, and sutured into place over the existing lower lateral cartilages under direct vision. Based on the preoperative evaluation, it was felt that the degree of structural and framework loss complicated by the extent of soft-tissue envelope contracture necessitated a more aggressive approach via an open technique. By opening the nose, the soft tissue envelope scar contracture was released, and the more ambitious task of major structural grafting and restoring nasal anatomy was afforded.


Periodic, long-term follow-up must be maintained in every rhinoplasty patient to ensure that the rhinoplasty surgeon properly matures through critical evaluation of his own work. Just as a rigorous, systematic approach informs the pre- and intraoperative phases of rhinoplasty, the surgeon must not relinquish this task after the operative procedure has transpired. All too often, the junior rhinoplasty surgeon who suffers from myopic distortion of his work due to foreshortened follow-ups applauds himself on a job well done after the first postoperative visit. In addition, he may not request that his patients continue to return on a consistent basis for further evaluations, deeming such purportedly frivolous exercises as unnecessary ritual. Clearly, we condemn this shortsightedness and encourage all rhinoplasty surgeons, no matter how seasoned, to reflect on their own work in an honest and critical fashion. During the postoperative period, patients are seen at 1 week, 1 month, and 3 months and on a yearly basis thereafter.During each visit, digital images are captured and stored for review and archiving.We have found that printing the preoperative and 1-month, postoperative images are most useful for patients anxious or interested in observing the resultant changes or for reassurance. We simply advocate a compulsive approach consisting of a policy whereby the patient is never discharged from the practice and annual office visits are scheduled, admitting that many satisfied or likewise dissatisfied patients may not return. At times the patient will return many years later for an unrelated reason, allowing the opportunity to obtain an unsolicited, long-term photograph.As mentioned, the rhinoplasty surgeon should systematically review his work on a periodic basis. Relying on casual examination of the patient during the postoperative visit only yields part of the education.

Figure 2 An endonasal, transcartilaginous approach was elected given the limited degree of bulbosity and bifidity of the nasal tip. Surgical maneuvers that were undertaken included septoplasty, dorsal reduction, and placements of a columellar strut and tip graft (both fashioned from septal cartilage and secured using the pocket principle).

Figure 3 The patient presents with the following unaesthetic attributes: broad, firm, lower lateral cartilages with a buckle in the region of the intermediate crus and an over projected, displeasing nasal tip. An endonasal, delivery approach was elected to address these more significant nasal-tip deformities. A cephalic reduction of the lower lateral cartilages, noncoalescent weakening of the lateral crus using multiple, partial-thickness stab incisions, resection of the intermediate crural buckling, followed by reconstitution and refinement of the domal region using a transdomal suture accomplished the desired surgical goals.

Figure 4 A patient who had formerly undergone rhinoplasty and presents for revision surgery. The patient demonstrates the following unaesthetic qualities: an overly narrowed nose, an inverted-V deformity, and alar collapse and retraction. Revision rhinoplasty was undertaken via an external approach due to the need for significant corrective work to the nasal tip and framework and to expose the underlying deformities engendered by the prior surgery. Surgical maneuvers included placement of bilateral spreader grafts, bilateral alar-batten grafts, a columellar strut, and a tip graft.

Instead, the surgeon should compare pre- and postoperative portraits in the standardized four views (frontal, oblique, lateral, basal) for definitive and accurate analysis. Short and long-term photographs are equally important in the analytic process to determine the effects that edema, scar contracture, and aging have on one’s surgical results. We have instituted a strict policy in which all rhinoplasty results are reviewed at the end of each calendar year that circumscribes the past 3 years’ work. This approach, albeit labor intensive, we contend is paramount to the education and maturation of a successful rhinoplasty surgeon, who should remain a student for life.


In summary, we advocate a systematic, graduated approach to rhinoplasty in every phase of patient encounter from the pre- to intra- to postoperative period. This approach is contingent on three guiding principles: planning, simplicity, and flexibility, which should inform on every rhinoplasty venture. With a detailed plan well thought out in advance, the surgeon may avoid protracted operative time and ill-defined goals. Using the full arsenal of techniques, including delivery, non-delivery, and open approaches (which celebrates the goal of flexibility), the surgeon may select only the “simplest” method that will correct the deformity and thereby reduce unnecessary variables associated with radical dissection and reestablishment of nasal structure. Despite the best efforts, the surgeon should also exercise a systematic review of all his work for as many years as patient compliance permits so as to ensure that all his surgical efforts are enduring.

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3. Tardy ME. Rhinoplasty. The Art and the Science. Philadelphia,
PA:WB Saunders; 1997
4. Kamer FM, McQuown SA. Revision rhinoplasty. Analysis
and treatment. Arch Otolaryngol Head Neck Surg 1988;114:
5. Johnson CM, Toriumi DM. Open-Structure Rhinoplasty.
Philadelphia, PA:WB Saunders; 1989

*Patient Results May Vary
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