Rhinoplasty - External Approach

Considerations

Preparation

• Photos sitting up before time-out with blue towel background

  • Frontal, basal, oblique, lateral +/-  bird's eye views  

• Topical intranasal decongestion and anesthesia

  • 4% Cocaine soaked 1/2 inch x 3 inch pledgets x 4 

• Local vasoconstriction and anesthesia

  • 1% Lidocaine with 1:100,000 Epinephrine local infiltration with 25-gauge needle, 10 ml controlled syringe x 2

  • Usually inject 15-20 ml total including septum

  • Inject septum, columella, marginal incisions, domes, dorsum via intercartilaginous 

  • Drape

    • Medium Tegaderm cut in half taped over the eye, placed obliquely with the corner adjacent to the medial canthus as to avoid the nose or path of osteotomies 

    • ETT to midline lower lip, avoid tape on the upper lip

    • 4 blue towels squared off showing face, from trichion to stomion, from tragus to tragus, no staples

  • Prep

    • Iodine external nose sterilization

Procedure

• May start with septoplasty via caudal septal incision

  • To open the nose

    • Mark 5 points for the inverted V trans-columellar incision at the thinnest portion of the columella and its junction with the marginal incision

    • Marginal incision with 15 blade 

      • Palpate the caudal edge of the lower lateral crural cartilage; May mark

        •  You may notice this edge aligns well with the line of transition from hair-bearing to non-hair-bearing skin

      • Medium double prong skin hook in surgeon's non-dominant hand under the nostril rim (vestibular surface) at the junction of the alar lobule and nostril lobule 

      • The goal is to create a flat surface to incise.  Move finger frequently to always be cutting on a flat surface

    • *** Explain the use of fingers, especially while turning the corner, photos/video would be perfect here 

    • Connect the marginal incisions with the Converse scissor 

    • Trans-columellar incision with 15 blade while the Converse scissor is in place protecting the medial crura 

    • Dissect the alar cartilages

      • Large double prong skin hook in the surgeon's non-dominant hand, one prong hooking the center of the inverted V and the other hook in the marginal incision, elevating the skin and soft tissue envelope (SSTE) to the ceiling 

      • Small double prong skin hook in the assistant's hand, hooking the dome of the alar cartilage, retracting to create counter-tension

      • Dissect with the Converse

        • Start at the medial crura and move superior to the dome and then lateral to the end of the lateral crus

        • Stay on the cartilage

        • Watch out for knuckles or discontinuities (if revision/traumatic) in the cartilage

        • Follow the bend of the dome and shift your arm to stay in line with the direction of the cartilage 

        • A Q-tip can be safe and effective for dissecting over the dome and onto the lateral crus

    • Complete the marginal incision with the Converse 

      • Never cut what you can't see

        • You may dissect bluntly from the surface of the cartilage into the incision creating a safe exposure to complete the incision 

      • Cut orthogonal to the skin

    • Identify the anterior septal angle 

    • Dissect the dorsum

      • Remain on the cartilage (subaponeurotic and supraperichondrial plane)

      • Stay midline, moving cephalic to the rhinion

      • Expose the upper lateral cartilages 

        • May connect from lateral to medial by creating a pocket from the alar cartilage to the midline dissection

        • Keep elevating the SSTE with a small double prong skin hook with the assistant retracts the tip inferiorly with the wide double prong hooked under the domes on either side intranasally 

      • Expose the bony dorsum

        • After dissecting the cartilaginous septum, use the Converse to dissect onto the bony dorsum in the subperiosteal plane

      • Place the Joseph elevator into the subperiosteal plane and dissect superiorly to the nasion and laterally just a few mm on either side

        • Do not destabilize the nasal bones

        • Place the Aufricht retractor to elevate the SSTE

        • Continue to use the Joseph to fully expose the ULCs

Sample operative report

Post-op

Pearls & Pitfalls

High-Yield

Links

• Rhinoplasty Archive

  • • Excellent free online textbook. Basically, everything you need to know, included photos.

• Iowa Protocols - Rhinoplasty. 

• YouTube "External Rhinoplasty Open Nose Job" 

• YouTube "Nose Job - Rhinoplasty and Deviated Septum Surgery"