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Aesth. Plast. Surg. 30:155À158, 2006 DOI: 10.

1007/s00266-005-0125-x

Closed Rhinoplasty with Marginal Incision: Our Experience and Results

Stefano Bruschi, M.D., Maria Alessandra Bocchiotti, M.D., Maurizio Verga, M.D., Nicola Kefalas, M.D., and Marco Fraccalvieri, M.D.
Department of Plastic Surgery, University of Turin, via Cherasco 23, Turin 10100, Italy

Abstract. Supporters of traditional rhinoplasty and promoters of open rhinoplasty have debated their approaches for many years. From among different possible techniques, a surgeon must always choose the approach that provides the best aesthetic result. The surgeonÕs experience and artistic sense are essential for the closed technique, whereby most of the corrections are performed without exposing the nasal frame. The open technique allows a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. This report highlights the marginal technique, described in 1990 by Guerrerosantos, which uses a twosided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach, together with the extramucous technique, permits complete exposure of the skin and nasal septum without a columella incision. Therefore, the marginal technique is suitable for primary rhinoplasty cases in which complex modeling of the nasal tip and an excellent aesthetic result are required. Key words: Closed rhinoplasty—Extra mucous technique—Marginal technique—Open rhinoplasty—Traditional rhinoplasty—Two-sided circular incision

Supporters of traditional closed rhinoplasty and promoters of the open rhinoplasty technique have debated their approaches for many years. From among different possible techniques, a surgeon must always choose the approach that provides the best aesthetic result.
Correspondence to M. Verga; email: maurizioverga@ yahoo.it

A surgeonÕs experience and artistic sense are essential for the closed technique, in which most of the corrections are performed without exposing the nasal frame. The open technique, with the incision made in the columella, allows the nasal skin to be lifted off the tip of the nose, permitting a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. For this reason, we believe it is not the skin scar on the columella, which usually is hardly visible, that deters the use of open rhinoplasty, but rather the reduced ability for intraoperation evaluation of the proportions of the nose [7]. According to the preceding description, the surgeon should not choose to use open rhinoplasty for all patients. However, if nasal shattering is massive, it may be necessary to forego an optimal aesthetic evaluation in favor of good nasal tip modeling. This can be the case with posttraumatic noses, cleft lip and palate, and complex secondary rhinoplasties in which the open method has been the primary technique. In this report, we highlight the marginal technique, described in 1990 by Guerrerosantos [5]. The marginal technique uses a two-sided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach together with the extramucous technique makes it possible to visualize the entire cartilage frame of the tip and nasal septum without a columella incision. The marginal incision negates the use of open rhinoplasty in the case of borderline noses. In these borderline cases, there are significant anatomic alterations of the tip, but these are not sufficiently severe to require the use of the open technique. Therefore, the marginal technique is indicated for

The incision chosen by the surgeon classifies the rhinoplasty as open or closed. according to the corrections that need to be made. Preoperative and postoperative frontal and lateral views are shown. it is possible to use a marginal bilateral incision allowing complete subversion. 3). ‘‘open rhinoplasty’’ allows a better view of the cartilage structures to the detriment of a better aesthetic evaluation. Discussion Materials and Methods For the past 7 years. freeing the alar cartilage arch from the vestibular mucous. The skin drape is completely lifted up from the nasal tip. Surgical Technique The marginal incision starts at the medial crux at the caudal columella level and proceeds along the margin of the columella to the medial crux up to the dome. primary rhinoplasty cases in which complex modeling of the nasal tip and excellent aesthetic evaluation are required. 1 and 2). 1. we have used the marginal incision technique in rhinoplasty to treat 107 patients (46 men and 61 women) with a mean age of 42. Case 1. and then additional incisions are made inside nose. and secondary rhinoplasty [12]. where the incision is placed a few millimeters inside the margin. the surgeon makes a small incision in the columella between the nostrils. and limit the use of the open technique to more complex cases such as those involving cleft lip and palate. We stress the use of traditional rhinoplasty in primary aesthetic rhinoplasty.156 Closed Rhinoplasty with Marginal Incision Fig. The main advantage of open rhinoplasty is that the surgeon can work on the nasal cartilages more easily in their natural position. The detaching is extramucous and under the submucosal aponeurotic system (SMAS). To obtain a wide view of the nasal cartilage structures and to avoid cutaneous scars. it is possible to expose the cartilage frame of the tip and the septum because the medial crux is separated such that the edge of the septum is exposed and dry from its perichondrium (Fig. In fact. With open rhinoplasty. Deviated nose with nasal obstruction corrected by functional and aesthetic rhinoplasty using the marginal incision technique.3 years (Figs. . underlying cartilage. Through this incision. tip modeling techniques. Detachment of the mucous from the body of the medial and lateral crux continues until the triangular cartilage is shown. The incision then follows the border of the lateral crux up to its caudal pars. This permits a wide variety of possible choices among Rhinoplasty alters the aesthetic appearance and functional properties of the nose with surgical manipulation of the skin. posttraumatic noses. Closed rhinoplasty is characterized by incisions only in the interior of the nose so that skin drape remains unchanged and attached at the columella [2]. and bone.

This increases operative time. Thus. The marginal incision.2%. Fig. Case 2. 2. Various articles in the rhinoplasty literature describe valuable statistical analyses of large rhinoplasty series managed with the closed approach. 3. the columellar scar is not the principal deterrent to the choice of the ‘‘open’’ technique because it can be visible in varying degrees but usually is not noticed at conventional distances. Preoperative and postoperative frontal and lateral views are shown. and numbness and consequent scar tissue contraction. limiting the evaluation between dorsum and tip projection [9]. according to the patientsÕ subjective evaluation of the rhinoplasty [8]. In a comprehensive statistical analysis of 500 consecutive rhinoplasty cases treated with the open approach.8% of the cases. Bruschi et al. with the possibility of a hypertrophic reaction or columellar flap necrosis [6]. the transcolumellar scar was found to be unnoticeable in 97% of the cases. The advantages of open rhinoplasty include direct exposure and assessment of the osseocartilaginous framework. Deviated nose with nasal obstruction corrected by functional and aesthetic rhinoplasty using the marginal incision technique. persistent postoperative nasal tip edema. The greatest disadvantage is the extensive dissection of the skin over the osseocartilaginous framework. noticeable but acceptable in 2. the direct relation between the cartilage structures and skin coverage is lost. with precise modification of the cartilage frame abnormality and more options for changing and stabilizing the framework. similar reports on open rhinoplasty are rare [8]. The visible incision usually is across the columella and appears as a ‘‘step’’ or an inverted ‘‘V. as compared with closed rhinoplasty. However. The disadvantages of the open technique include the transcolumellar scar.S. The surgical procedure for exposing the cartilage frame of the tip and the septum is shown. and unacceptable in only 0. . The difference between the open and closed techniques is simply the columella external incision permitting the surgeon to view the complete cartilage framework. Other authors in the literature quoted similar results [1]. 157 Fig. However.’’ allowing the nasal skin to be lifted off the tip of the nose.

Tebbetts JB: Shaping and positioning the nasal tip without structural disruption: A new. 1999 10. 2003 9. Secondary rhinoplasty. However it can represent a serious complication for an inexperienced surgeon. This is reflected in the absence of prolonged postoperative edema. Cardenas-Camarena L. 1990 2. Plast Reconstr Surg 94:61À77. to obtain this projection. Guerrerosantos J: Open rhinoplasty without skin-columella incision. In the past. Second. 2005 . Tropper GJ: Incision and scar analysis in open (external) rhinoplasty. J Laryngol Otol 117:473À477.11]. Plast Reconstr Surg 115:1778À1779. Gunter JP: The merits of open approach in rhinoplasty.’’ Furthermore. Plast Reconstr Surg 99:863À867. discussion 2199À 2201. Aesth Plast Surg 26:161À166. 2002 15. This. References 1. systematic approach. it is completely accepted by the patients [6]. Daniel KD: Rhinoplasty: A simplified. Smith O. the current practice in tip modeling mentioned earlier is possible. Rolling KD: Rhinoplasty: A simplified three-stich. Facial Plast Surg Clin North Am 13:93À113. Regalado-Briz A: Aesthetic rhinoplasty with maximum preservation of alar cartilages: Experience with 52 consecutive cases. Plast Reconstr Surg 97:321À 326. Use of the marginal technique avoids the risk of interrupting the lymphatic and venous draining of the tip. Plast Reconstr Surg 105:1491À1502. it allows greater predictability of the aesthetic proportions of the nose. With the marginal technique. Finally. 2002 4. Primary rhinoplasty. which allow for a better aesthetic result and more natural tip conformation [3. Guerrero MT: Improving nasal tip projection and definition using interdomal sutures and open approach without transcolumellar incision. The marginal incision presents numerous advantages over the traditional techniques (transcartilage or eversion). 2005 3. Arch Otolaryngol Head Neck Surg 116:671À675. Sheen J: Closed versus open rhinoplasty—and the debate goes on. which. Facial Plast Surg Clin North Am 10:1À22. Plast Reconstr Surg 104:2187À2198. and it is not over the nasal valve. it allows a wide operating area and a direct view of the anatomic structures of the nasal tip and the base of the septum. discussion 681À682. instead using nonabsorbable monofilament stitches. which make modeling easier. The current practice tends to avoid these techniques for tip modeling. Foda MD: External rhinoplasty: A critical analysis of 500 cases. Holmstrom H. in our opinion. 1999 12. Hossam MT. Plast Reconstr Surg 85:955À960. 1994 14. The final aesthetic outcome is better because the relationship between the dorsal slope and tip projection can be optimized.158 Closed Rhinoplasty with Marginal Incision In most cases. three-stitch. Adamson PA. Menick FJ: Anatomic reconstruction of the nasal tip cartilages in secondary and reconstructive rhinoplasty.13À15]. open tip suture technique: Part I. 1997 7. characterizes ‘‘open rhinoplasty. Using the marginal incision technique. this technique eliminates the risk of mishap to the columellar flap.10. 1997 13. there is only one incision line. open tip suture technique: Part II. especially when better tip projection is needed or a bulbous tip requires accentuation of the domeÕs angle [13]. 1999 5. 1990 6. First. it was essential to interrupt the domes using the Goldman or Ponti techniques or inserting grafts [4. Luzi F: Open rhinoplasty without transcolumellar incision. Plast Reconstr Surg 103:671À680. the surgeon has the ability to correct the alar cartilages with ‘‘ad hoc’’ suture stitches. Toriumi DM: Structure approach in rhinoplasty. Plast Reconstr Surg 103:1503À1512. Plast Reconstr Surg 99:859À862. is fundamental in obtaining an optimal aesthetic result. Aiach G: Atlas of rhinoplasty : Open and endonasal approaches 2nd ed. Toriumi DM: Structure approach in rhinoplasty. 1996 8. although this represents a rare complication when the cutaneous flap is detached from the cartilage according to the correct plan. according to some authors. 1999 11.