1. Should one use an open or closed rhinoplasty approach?

2. How appropriate is the endonasal approach in modern-day rhinoplasty?

3. Should the tip lobule be divided or preserved?

4. Are alloplastic implants inferior to autologous implants?

5. Does release and reduction of the upper lateral cartilages from the nasal dorsal septum always require spreader graft placement to prevent mid one-third nasal pinching in reduction rhinoplasty?

6. Analysis: over the past 5 years, how has your technique or approach evolved or what is the most important thing you’ve learned in doing rhinoplasty?

Theory without practice is like a one-winged bird that is incapable of flight.

—Sushruta medical writings, India, 600 BC

Science is the father of knowledge, but opinion breeds ignorance.

—Hippocrates, Kos, Greece, 400 BC

Adamson and Kim

Open septorhinoplasty (OSR) was introduced 40 years ago in North America and has since gained wide acceptance as a good approach, if not the preferred approach, for rhinoplasty. In a survey by Dayan and Kanodia of fellowship graduates of the American Academy of Facial Plastic and Reconstructive Surgery between 1997 and 2007, they found that the vast majority, 87.9%, performed open rhinoplasty as their primary approach.1 The open approach to rhinoplasty has been controversial since its inception, but this statistic indicates increasingly wide acceptance of this approach.2 In the past, open rhinoplasty was supported for difficult or revision cases only. Proponents of closed rhinoplasty initially criticized the open technique, citing potential problems such as unnecessary scarring, reduction of tip support, extended operative time, and excessive postoperative tip swelling. The issue of columellar scarring was addressed by Vuyk and Olde Kalter3 in a meta-analysis of 7 articles encompassing 986 patients who underwent open septorhinoplasty. Only 3 had columellar flap necrosis that led to scarring. Another argument against OSR was that the open scar was longer when, in fact, it, and the marginal incision, are shorter than the scars of a cartilage delivery technique and do not affect the internal valve, an area of potential functional compromise in closed approaches.4 Other potential arguments against the open approach are purportedly longer lasting supratip swelling and longer operative times. Toriumi and colleagues5 used cadaver studies to demonstrate that the main vasculature of the nose runs aloft the musculoaponeurotic layer, or in it and parallel to the alar margin, as opposed to vertically in the columella. Thus, it is dissection above the musculoaponeurotic layer that disrupts and perhaps prolongs postoperative tip edema, not the transcolumellar incision of OSR. Indeed, operative times may be longer with OSR because more time may be taken to deal with the asymmetries that are uncovered.

The open approach clearly offers better exposure to a small surgical field, thereby affording the opportunity to better diagnose the deformity through inspection, to better execute certain maneuvers, and to teach and to learn the operation with greater ease.6–8 Indications have expanded with widespread increasing levels of comfort and familiarity with the technique. In my experience, open rhinoplasty is the technique of choice for all cases unless a comparable improvement for a definable deformity can be obtained with the closed approach. The open approach offers clear diagnostic and therapeutic advantages for many challenging functional and cosmetic nasal deformities, primarily resulting from the broad undistorted exposure it affords and the improved opportunity for bimanual correction. This is especially true with respect to the premaxillary spine, caudal septum, dorsal and superior septum, lobule, and superior dorsum. The open approach offers an unparalleled appreciation of the underlying anatomy resulting in the external deformity. Sutures can be placed, grafts trimmed exactly, and asymmetries corrected without distortion of surrounding tissues. Scar tissue and redundant subcutaneous tissue are more easily excised. The valve region can be well protected, and the absence of incisions in the intercartilaginous region diminishes subsequent obstructive phenomena by precluding scar formation and disruption of one of the tip support mechanisms. It may also be that revision rates for primary OSR are less than those for closed rhinoplasty.9,10

OSR provides an opportunity for greater surgical exposure for the operating surgeon and the assistants, and thereby provides an excellent teaching tool. As this approach is used in didactic teaching sessions, more surgeons in training are exposed to the approach and may be more apt to continue with this approach in their later practices. In general, surgeons with the greatest experience (more than 100 rhinoplasties per year) tend to use the closed approach more often, but, nonetheless, even they still perform a notable amount of OSR. There is still some trend to increasing use of the OSR approach: the only group using it slightly less are those in practice 16 to 25 years—older surgeons who were less exposed to the OSR...