What are the steps of open rhinoplasty?

Open Rhinoplasty Surgical Steps

The open rhinoplasty approach involves a transcolumellar incision connected to bilateral marginal incisions, followed by elevation of the nasal skin envelope to expose the osteocartilaginous framework for systematic modification of the dorsum, tip complex, and bony vault. 1

Incision and Exposure

• Make a low stairstep or inverted-V transcolumellar incision at the narrowest portion of the columella, connecting bilateral marginal incisions along the caudal border of the lower lateral cartilages 1, 2
• Extend the incision with bilateral intercartilaginous or marginal incisions inside each nostril to connect with the columellar incision 3, 4
• Elevate the nasal skin envelope as a single flap in the subperichondrial and subperiosteal planes, proceeding from caudal to cephalic direction 1
• Maintain periosteal and mucosal attachments during framework manipulation to minimize destabilization 5
• Achieve complete exposure of the lower lateral cartilages, upper lateral cartilages, and nasal bones through this approach 2

Dorsal Modification

• Address the cartilaginous dorsum first by removing excess septal and upper lateral cartilage as needed for dorsal reduction 1
• Perform bony hump reduction using rasps or osteotomes if indicated, working systematically from anterior to posterior 1
• Create spreader grafts from septal cartilage if middle vault narrowing occurs or to maintain the internal nasal valve 1

Tip Complex Reshaping

• Perform cephalic trim of the lower lateral cartilages conservatively, leaving at least 6-8mm of intact lateral crus to maintain structural support 1
• Place interdomal sutures to refine tip definition and control projection as needed 4
• Insert a columellar strut between the medial crura for tip support, particularly when using composite grafting techniques 5, 4
• Apply tip grafts (shield, cap, or onlay grafts) using autologous cartilage as the gold standard, harvested from septum, ear, or rib depending on availability 5
• Balance graft volume against potential for unesthetic nasal width and graft visibility 5

Osteotomies and Bony Vault

• Perform lateral osteotomies using a 2mm or 3mm osteotome through percutaneous or endonasal approaches to narrow the bony base if indicated 1
• Execute medial osteotomies to complete mobilization of the nasal bones when narrowing is required 1

Alar Base and Airway Management

• Address alar rim asymmetries or width through alar base resection if needed, performed at the conclusion of the procedure 1
• Evaluate and correct nasal valve compromise with spreader grafts, batten grafts, or alar rim grafts as indicated 1

Closure

• Close the columellar incision with 5-0 or 6-0 absorbable or non-absorbable sutures in interrupted fashion 2
• Reapproximate the marginal incisions inside the nostrils 3
• Apply external nasal taping and splinting to maintain the new framework position and minimize edema 1

Critical Technical Considerations

• Use deep sedation and avoid excessive manipulation to minimize tissue trauma and postoperative edema 1
• The columellar scar becomes invisible within weeks postoperatively in the vast majority of patients 2
• Avoid excessive cephalic trim of lower lateral cartilages, as this can lead to alar collapse and external valve compromise 1
• Maintain at least 6-8mm of intact lateral crus to preserve structural integrity 1

Common Pitfalls to Avoid

• Inadequate tip support leads to loss of projection over time; always consider structural grafting with columellar struts or tip grafts 4
• Over-resection of dorsal structures creates a scooped or "ski-slope" deformity that is difficult to correct 1
• Failure to address the middle vault during dorsal reduction results in inverted-V deformity and nasal obstruction 1
• PCL mesh undergoes biodegradation affecting nasal projection over time with a 5% decrease in Goode ratio, though 96.4% of patients maintain satisfactory outcomes 5