What are the different types of rhinoplasty?

Types of Rhinoplasty

Rhinoplasty can be categorized by surgical approach (open vs. closed), by purpose (functional vs. aesthetic), and by technique (reduction, augmentation, or restructuring), with modern practice emphasizing tissue preservation and cartilage grafting over traditional reductive methods. 1

Classification by Surgical Approach

Open (External) Rhinoplasty

• Involves a transcolumellar incision connecting bilateral marginal incisions, providing direct visualization of the entire nasal framework without tissue distortion 2
• Offers superior exposure for complex deformities including severe septal deviation with nasal valve collapse, tip asymmetries, and revision cases 2, 3
• Enables precise placement of structural grafts (spreader grafts, batten grafts, columellar struts) under direct vision 4, 2
• The additional surgical time required for dissection is justified when complex repositioning and anchoring procedures are necessary 4

Closed (Endonasal) Rhinoplasty

• Utilizes intranasal incisions only, avoiding external scarring and preserving natural tissue planes 5, 6
• Appropriate for straightforward cases including minor dorsal hump reduction, tip refinement without major structural changes, and less complex septal deviations 5, 3
• Offers faster recovery with less postoperative edema compared to open approach 5
• Both approaches demonstrate comparable patient satisfaction in systematic reviews, with no clear superiority of one technique over the other 7

Important caveat: Surgeons should be trained in both techniques, as each has specific indications—open rhinoplasty is not always necessary and may be disadvantageous in simpler cases 5, 6

Classification by Purpose

Functional Rhinoplasty

• Addresses nasal airway obstruction through septoplasty, turbinate reduction, and nasal valve reconstruction 8, 4
• Septoplasty is medically necessary only when septal deviation causes continuous obstruction unresponsive to at least 4 weeks of medical therapy (intranasal corticosteroids, saline irrigations, antihistamines) 8, 9
• Anterior septal deviation is more clinically significant than posterior deviation, as it affects the nasal valve area responsible for over two-thirds of airflow resistance 8
• Combined septoplasty with turbinate reduction provides superior outcomes compared to either procedure alone when both conditions coexist 8

Aesthetic (Cosmetic) Rhinoplasty

• Focuses on improving nasal appearance including dorsal profile, tip projection/rotation, nasal width, and overall facial harmony 2
• Must account for functional consequences—aesthetic goals sometimes conflict with functional requirements 1

Combined Functional-Aesthetic Rhinoplasty

• Addresses both airway obstruction and cosmetic concerns simultaneously, which is common in practice 2
• Requires balancing structural support with aesthetic refinement 1

Classification by Surgical Technique

Reduction Rhinoplasty

• Traditional approach involving framework reduction through humpectomy, cartilage resection, and tissue removal 1
• Associated with loss of structural support and potential long-term complications 1
• Modern practice has evolved away from aggressive reduction techniques 1

Augmentation/Restructuring Rhinoplasty

• Modern approach emphasizing tissue preservation, rearrangement, and autogenous cartilage grafting for repositioning, reinforcement, recontouring, and reconstruction 1
• Utilizes spreader grafts for nasal valve reconstruction, batten grafts for lateral wall support, and columellar struts for tip support 4, 2
• Increases stability of the realigned framework and prevents postoperative drifting to malaligned states 1
• Cartilage grafts can be harvested from septum, ear, or rib depending on the amount needed 2

Camouflage Rhinoplasty

• Creates the illusion of straightening through strategic placement of onlay grafts to fill depressions and mask asymmetries 1
• More conservative and predictable than realignment procedures for certain deformities 1
• May involve both addition (grafting) and removal (contralateral rasping) of tissues 1

Special Considerations for Deviated/Asymmetric Nose

Systematic Analysis Required

• Divide the nose into horizontal thirds (upper, middle, lower) and assess each component separately 1
• Evaluate facial asymmetry patterns including orbital level differences, piriform aperture rotation, non-horizontal alar base, and midface asymmetries 1
• Approximately 80% of the population has off-center septums, but only 26% have clinically significant deviation causing symptoms 8, 4

Surgical Principles

• Traditional correction involves septal straightening, separation of upper lateral cartilages from septum, and osteotomies—these are intrinsically destabilizing 1
• Modern approach combines realignment with structural grafting to increase stability 1
• Complex deviations (high septal deviation with mid-vault stenosis plus low caudal deviation with valve stenosis) require open approach with spreader grafts and caudal repositioning 4

Common Pitfalls to Avoid

• Proceeding with surgery without documented failure of at least 4 weeks of medical management for functional cases 8, 9
• Assuming all septal deviations require surgical correction when most are asymptomatic 8, 4
• Excessive turbinate tissue removal leading to nasal dryness and reduced sense of well-being 8, 9
• Choosing open approach for simple cases where closed approach would suffice 5
• Failing to account for facial asymmetry as a limiting factor in achieving perfect nasal symmetry 1