Rhinoplasty Incision Selection
For most adult rhinoplasty patients, the choice between endonasal (closed) and external (open) approaches should be determined by the complexity of the deformity: use endonasal approaches with limited incisions for straightforward primary cases, but employ the external approach for complex deformities requiring extensive structural grafting, severe asymmetry correction, or revision surgery.
Approach Selection Algorithm
Use Endonasal (Closed) Approach when:
- Primary rhinoplasty with straightforward goals (dorsal reduction, minor tip work)
- Minimal structural grafting required
- Patient has adequate skin thickness to hide irregularities
- No severe septal deviation requiring extensive reconstruction
- Desire to avoid external scarring and preserve ligamentous support
The modified rim incision technique provides excellent access for most primary cases with minimal soft tissue disruption 1. This approach maintains structural integrity and has demonstrated a low revision rate (6.0%) in consecutive series 1.
Use External (Open) Approach when:
- Complex revision rhinoplasty requiring extensive visualization 2
- Severe nasal deviation or asymmetry necessitating multiple structural grafts 3
- Extensive cartilage grafting planned (spreader grafts, batten grafts, tip grafts)
- Thin skin requiring precise structural modification
- Septal extension grafts needed for tip projection 4
The external approach provides unparalleled exposure of underlying anatomy, which is critical when performing the modern grafting techniques required for deviated, asymmetric noses 3, 2. For severely deviated noses requiring septal realignment, dorsal batten grafts, and multiple onlay grafts, the external approach allows precise graft placement and fixation 3.
Specific Incision Techniques
For Endonasal Approach:
- Bilateral isolated modified rim incisions for standard access 1
- Cross-cartilaginous incision for enhanced access without external scarring 5
- Add unilateral Killian incision when septoplasty is required 1
- Add vestibular stab incisions for lateral osteotomies 1
For External Approach:
- Inverted-V mid-columellar incision (traditional) for standard cases
- V-shaped columella-labial incision with V-Y closure for cases requiring increased nasal projection and columellar height—this provides significantly greater improvement in projection (adjusted p=0.002) and columellar height (p<0.001) without increased scarring 6
Critical Considerations for Deviated/Asymmetric Noses
When addressing nasal deviation, the surgical plan must account for:
Facial asymmetry as a limiting factor—the nose may need to align with facial midline rather than true vertical 3
Septal correction must precede all other maneuvers, as septal position determines tip position 3
Modern grafting techniques (spreader grafts, batten grafts, onlay grafts) provide stability and prevent postoperative drift, unlike traditional mobilization techniques that are inherently destabilizing 3
Camouflage techniques using cartilage grafts may avoid destabilizing osteotomies while achieving aesthetic correction 3
Common Pitfalls to Avoid
- Don't perform tip work before septal correction—this leads to unpredictable results 3
- Avoid excessive mobilization without structural support—traditional reduction techniques without grafting lead to instability and unpredictable outcomes 3
- Don't ignore facial asymmetry—attempting perfect nasal midline position when the face is asymmetric creates an unnatural appearance 3
- In thin-skinned patients, avoid closed approaches for complex work—irregularities will be visible and the limited exposure increases risk of asymmetric correction
The evolution from reductive rhinoplasty to structure-preserving and augmentation techniques has fundamentally changed surgical planning, with modern approaches emphasizing cartilage grafting for stability rather than mobilization alone 3.