Commentary

Approximately 6 or 7 years ago, I had the pleasure and opportunity to have Dr. Steve Dayan spend the year with me as a fellow in my practice at the Meridian Plastic Surgery Center in Indianapolis, Indiana. Rhinoplasty procedures constituted approximately one third of my facial plastic surgery practice at the time Steve was with me, and they continue to be about 25 to 35% of my total practice volume. I still perform the same number of rhinoplasties on an annual basis as I did 11 years ago, but other aging face procedures, with particular emphasis on increasing numbers of lesser invasive procedures, have grown within the practice.

Rhinoplasty is and always has been the most challenging facial plastic surgery procedure that I perform and remains the most difficult procedure to teach young developing facial plastic surgeons. I agree with Dr. Dayan that rhinoplasty is a highly complex procedure, which he describes as having a steep learning curve. My opinion differs because I believe that rhinoplasty is an operation that has one of the least steep learning curves of all the procedures we do. It takes an entire career to even begin to learn the nuances of the rhinoplasty operation and even longer to consistently predict its long-term results. Aging face procedures are picked up fairly rapidly with a very steep learning curve, which allows the finishing fellow in my fellowship to leave the practice well prepared to perform most any aging face procedure that we do, whereas most of the fellows are still trying to get a feel for how to execute the multitude of techniques that make a difference between good and excellent rhinoplasty results.

Rhinoplasty remains a very humbling operation even for the more experienced surgeons who are considered masters in the field. Over the past 6 to 10 years, my personal abilities to perform this operation have exponentially increased compared with the first two thirds of my years in private practice. Most of this is due to the critical evaluation of the results of rhinoplasties I performed years ago. At that time, I believed I was doing very appropriate surgical maneuvers taught by my mentors, who were very experienced rhinoplasty surgeons themselves. In addition, I have continued to be a student of the operation and have attended every rhinoplasty meeting that the Academy has offered, and I have participated as a faculty member as well. Every time I attend a meeting, I improve my skills and abilities to recognize potential problems in rhinoplasty as well as add modified, if not new, procedures to improve the overall long-term results. As one of the more mature surgeons, with over 20 years of experience, I have been afforded the opportunity to see and examine long-term results from my own practice experience. Many times patients return to me and the practice for some other facial plastic surgery concern, such as aging face, and have been satisfied, content, and essentially happy with their rhinoplasty results. However, I would evaluate some of these results from a surgeon's perspective and react with a certain degree of “horror.”

Changes that occurred over time demonstrated that reduction rhinoplasty needs to be extremely conservative and many of the things I believed and was taught needed to have another critical assessment. My rate of revision rhinoplasty still is between 3 and 5% of my rhinoplasty practice, as it was 6 to 7 years ago. If I were to choose for the patient, my revision rate would probably rise to 25 to 30% of the rhinoplasties I performed more than 10 years ago. Within my practice, revision or secondary rhinoplasty still is only about 35 to 40% of my total number of rhinoplasties.

Often patients do not know that a revision can be performed that could give them more satisfactory results. In addition, they often have had an uncomfortable, if not miserable, experience from the first operation and do not believe they want to undergo another one. Furthermore, the cost of the revision rhinoplasty is more than a primary rhinoplasty and significantly more than they paid several years ago. These factors limit the total numbers of secondary rhinoplasties that could be performed.

Secondary rhinoplasty affords us the opportunity to learn from what we see as “others' mistakes,” but we also learn from our own mistakes by following patients for at least 10 years and longer. My basic philosophical approach to the rhinoplasty operation is essentially the same as it was when Dr. Dayan spent a year in fellowship with me. My personal approach to the rhinoplasty operation involves the combined and intermixed use of the endonasal approach and the external columellar approach to give each individual patient their optimal immediate and long-term outcome.

I was taught the endonasal delivery flap approach to tip rhinoplasty, and I still thoroughly enjoy this approach; however, my practice of the endonasal approach has decreased over the past 6 to 7 years from approximately 60 or 70% of my primary rhinoplasties to about 30 to 40%. There are specific reasons for performing more of the external columellar approach, primarily the recognition of the need for preventative structural grafting and the ease with which these grafts are placed through the external columellar approach. It has also become apparent that grafting in the nasal lobule for prevention of late untoward changes has necessitated the external columellar approach in increasing numbers of cases.

Not only has evaluating the long-term results in tip rhinoplasty affected my choice as to the external columellar approach or the endonasal approach, but so has the nasal pyramid. In fact, it is the nasal pyramid that has increased the number of external columellar approaches I perform more so than maintenance of external nasal valve and alar cosmetic competency. The traditional cephectomy operation performed for hump removal has been changed significantly in my hands to prevent delayed occurrence of an “hourglass” visible deformity (Fig. [1]). This inverted V deformity is not usually due to the dislocation of the upper lateral cartilages from the nasal bones but is caused by the inevitable contracture of scar tissue overpowering the strength of the disarticulated upper lateral cartilages from the dorsal septum. The central cicatricial inward contraction either results in unilateral or bilateral depressions of the midnasal dorsum. In addition, with the upper lateral cartilages falling away from the septum, there have been more dorsal ridges and irregularities visible over time. Shrink-wrapping of the skin envelope is particularly evident after 5 years and highlights dorsal irregularities that were otherwise not noticed in the first 2 years of follow-up (Fig. [2]).

Figure 1 Patient with late development of hourglass deformity or inverted V.

Figure 2 Shrink-wrapping of dorsal skin showing irregularities.

Recognition of the preexisting condition of the nasal pyramid consisting of a tall, narrow hump with thin skin and short nasal bones, predisposing to long-term inverted V deformities, increases the number of external approaches.

Recognition of a preexisting condition in a lobule has also increased the use of the external columellar approach with grafting to prevent external nasal valvular collapse and recurvature of the lower lateral cartilages internally. The weakened, collapsing alar cartilages create visible deformities of the ala as well as airway obstruction. To prevent the pyramid deformities that have occurred, I have significantly increased the use of spreader grafts, which are much easier to suture in place through the external columellar approach than the endonasal approach (Fig. [3]). Alar strut grafts, which are placed between the vestibular skin and the alar cartilage, are significantly easier to place from the cephalic direction using an external columellar incisional approach than from the caudal aspect. These grafts support the lateral ala and correct the preexisting cephalic malposition of the alar cartilage (Fig. [4]). This is currently a more recognizable preoperative deformity that lends itself to late recurvature or collapse of the external nasal valve (Fig. [5]). By placing the alar strut graft, the airway is maintained and the nasal contour is also maintained (Fig. [6]).

Figure 3 Strut grafts in place via external columellar approach.

Figure 4 Patient with cephalic malposition of alar cartilages.

Figure 5 Patient with late recurvature and partially collapsed lateral ala and external nasal valve.

Figure 6 Placement of alar strut graft between lateral crus and vestibular skin.

Finally, I have recognized that many primary rhinoplasty patients have markedly asymmetrical alar cartilages from the medial crura to the intermediate crura. Using an endonasal approach to suture these together can create twists, asymmetries, and irregularities in both the nostril shape as well as the columella itself.

I have most frequently divided the intermediate and medial crura, either symmetrically or asymmetrically, to create improvements in the projection and symmetry of the lobule. The Lipsett or modified Lipsett procedure is performed much more easily through an external columellar incision (Fig. [7]).

Figure 7 Modified Lipsett maneuver used to correct medial crural discrepancies.

Therefore, it is the more experienced rhinoplasty surgeon who can learn to recognize preexisting conditions that are “setups” for pyramid abnormalities. Recognizing cephalic malposition of the alar cartilages with extremely convex cartilages as one of these problematic preexisting conditions requires a plan to correct and prevent this (Fig. [8]). Convex nasal cartilages are often best corrected with alar-spanning sutures that, again, are placed much more easily under direct vision through the external columellar approach (Fig. [9]). Prior to 6 or 7 years ago, I either never or very rarely placed an alar-spanning suture. (This has been a great addition to the narrowing and defining of strong convex lower lateral cartilages.)

Figure 8 Patient with strong convex alar cartilage.

Figure 9 Placement of alar-spanning sutures.

Understanding tip projection and maintaining this is fundamental to the rhinoplasty operation. This has not changed in the last 6 to 7 years. Nasal tip projection should not be compromised by endonasal delivery flap approaches. It is easier to maintain tip projection and place stronger columellar struts, if required, through the external columellar approach. Both techniques use tip-sculpting techniques as well as strut grafting and reestablishing medial crural septal relationship to maintain, if not improve, tip projection.