Rhinoplasty Approaches: Closed versus Open By: Arian Mowlavi M.D.

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Two approaches are available for nasal contouring and these include the closed versus open rhinoplasty approach. The closed rhinoplasty approach requires two separate incisions that are made inside each of the nares in a semicircular pattern which are placed at the junction of the middle and lower 1/3rd of the nose (called the intercartilagenous incision). These two incisions allow access to the upper and middle 2/3rd of the nose. As such, the nasal tip; or lower 1/3rd of the nose, its not accessible and not alterable by virtue of this incision placement. In contrast, open rhinoplasty utilizes a modified form of the closed rhinoplasty incisions (marginal incisions) which are then connected across the lower aspect of the columella. By connecting these two incisions, the entire nasal skin envelope can be elevated and the infrastructure of all three components of the nose are visualized and alterable. As such, the open rhinoplasty provides full access of the entire nasal infrastructure and most importantly including the nasal tip.

Closed Rhinoplasty Before and After Picture Gallery

One might enquire why the open rhinoplasty approach is not utilized for all prospective rhinoplasty patients since it allows for contouring of the entire nose. The reason for not utilizing this approach for all patients is multifold. First of all, The open rhinoplasty requires substantially longer operative times by virtue of requiring not only increased dissection and closure times but also more extensive structural supporting maneuvers. Longer operative times translate to increased financial constraints on patients since surgical prices are most depending on operative lengths. As alluded to above, placing an incision in the columella and dissecting the nasal tip structures and subsequent repair of the columellar incision will affect nasal tip projection. During the healing of the columella incision line, the tip structures is required during all open rhinoplasties to avoid nasal tip collapse does introduce unnecessary risk to nasal surgery that are avoided by theclosed rhinoplasty approach. In contrast, when the nasal tip requires alteration and improvement in highlights, then the open rhinoplasty is far superior to the closed rhinoplasty technique.

Nasal Hump by: Arian Mowlavi M.D.

Figure 17(Figure 17)

Most commonly sought out nasal contouring procedure involves lowering and/or narrowing of the nasal dorsal bridge (top of the dorsum) or nasal dorsal base (bottom of the dorsum) and eliminating of the nasal dorsal hump (Figure 18). The dorsal hump is the undesirable prominence that is frequently seen on the dorsum of the nose and is comprised of two components. The upper part of this hump is made up of prominent nasal bones located over the upper 1/3rd of the nose. The lower part of the dorsal hump is made up of a prominent upper lateral cartilage and septum located over the middle 1/3rd of the nose. The treatment of an isolated wide and prominent dorsal hump only requires a closed rhinoplasty, as this internal nares incision provides access to both of these regions as described prior.

First, the lower part of the hump is addressed. This procedure requires isolation of the fusion point of the upper lateral cartilage and the dorsal septum that creates a canopy, this fusion point is released bilaterally. This maneuver then allows for differential lowering and/or narrowing of the dorsal hump. To only lower the dorsal hump height, the dorsal septum is trimmed down and to only narrow the dorsal width the medial aspect of the upper lateral cartilages are trimmed which allows the upper lateral cartilages to medialize (Figure 17). If both lowering and narrowing of the dorsal hump is desired, then both structures are trimmed. Following reduction of the cartilaginous component of the hump, the bony component of the hump is addressed.

Figure 18(Figure 18)

First, the roof of the hump is lowered to lower the dorsal bony height and resulting upper part of the hump; this is done by a combination of a medial osteotome and/or rasp which is used to literally remove the top of the nasal dorsal roof. This maneuver completes reduction of the dorsal hump height, but results in a disconnect of the bony dome, often referred to as an open roof deformity (Figure 18). Thus, the lateral base of the nasal bones where they rise off of the maxillary bony foundation require release by use of a lateral osteotome This maneuver allows the nasal bones to be transposed medially thus re-establishing the bony roof os well as to narrow the nasal bony dorsum bridge and base. Less frequently, patients may have some asymmetry of the actual dorsum in addition to a hump.

Minor asymmetries are correctable by adjusting degree of nasal bone medialization during the above release. For example, if one side is narrower the the other, then naturally the narrower side does not have to be brought i as much. Following release and repositioning of the nasal bones, the bones are held in place to fuse by use of an external splint which is kept in place as a cast for one week. Others might have nasal dorsum asymmetries related to having a crooked/or twisted dorsum. Minor crooked/twisted noses can be set back to the center by differential medialization of the nasal bones as above, and differential trimming of the upper lateral cartilages and with the use of graphs between the upper lateral cartilage and septum. When sewing in the graphs (named spreader graphs). It is possible to further influence the lean of the nasal dorsum. For example if the nose is crooked and leaning to the right, one can use the left upper lateral cartilage and sewn in graphs to act as cantilevers and to pull over the septum to the middle.

How our patients feel about us:

Very kind and gentle... Dr. Mowlavi is very kind and gentle. He took an extra few minutes to calm my fears and had me laughing by the end of the procedure. I will have him take care of any future procedures. I am even sending my husband to see him.

Kathryn

I am so happy with my results... I had my procedure with Dr. Mowlavi in March of this year. I am so happy with my results. He was kind and caring from the beginning to the end. His coordinator Claudia is the sweetest. I felt very welcome each time. The staff was always friendly. The office is beautiful and very high end. I would definitely recommend this surgeon. He is very skilled and knowledgeable. I would recommend him to all my friends!

Kayla S. Laguna Niguel, CA

Could not be happier... I was so nervous about getting a rhino to fix a deviated septum. Mowlavi made me feel super comfortable and the staff made it easy! I really was so nervous to do this, and had met with a couple of doctors. When I came into this office I felt so confident and at ease. Could not be happier I chose him. So happy with it all :)

Cas

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