VIDEO+

Rhinoplasty Refinements: The Role of the

Open Approach
Rod J. Rohrich, M.D.
Paul N. Afrooz, M.D.
Dallas, Texas
Summary: The open rhinoplasty technique facilitates accurate visualization of
deformities and aesthetic disharmonies in addition to visualization for precise
correction. Through a series of videos, this case represents the evolution of
the open rhinoplasty technique, demonstrating a wide range in complexity of
maneuvers to achieve the desired correction in rhinoplasty. The video dem-
onstrates reduction of the nasal dorsum by way of a component dorsal reduc-
tion, reconstitution of the cartilaginous midvault, and suture techniques for
reshaping the nasal tip. Nasal tip deprojection and placement of alar contour
grafts are also demonstrated in this case. The aim is to provide the rhinoplasty
surgeon with examples of basic and sophisticated techniques and also to dem-
onstrate the minutia and nuance of open rhinoplasty.  (Plast. Reconstr. Surg.
140: 716, 2017.)

T
echniques in open rhinoplasty have evolved
considerably during the course of the senior
author’s career (R.J.R.). Deformities and
aesthetic imbalances have been scrutinized and
classified, along with the delineation of specific
strategies for correction. Through a series of vid-
eos, this case represents the evolution of the open
rhinoplasty technique, demonstrating a wide range
in complexity of maneuvers. The aim is to provide
the rhinoplasty surgeon with examples of basic and
sophisticated techniques and also to demonstrate
the minutia and nuance of open rhinoplasty.
APPROACHING THE NASAL DORSUM
The open technique provides direct visualiza-
tion of the anatomical deformities and precise cor-
rection. (See Video, Supplemental Digital Content
1, which demonstrates the preoperative patient
analysis and the open rhinoplasty approach, avail-
able in the “Related Videos” section of the full-text
article on PRSJournal.com or, for Ovid users, avail-
able at http://links.lww.com/PRS/C376.) If the nasal
dorsum is to be reduced, reshaped, or refined,
it is typically carried out in a component fash-
ion, whereby the components of the dorsum are
addressed individually.1 (See Video, Supplemental
Digital Content 2, which demonstrates exposure
of the anterior septal angle, component dorsal
From the Dallas Plastic Surgery Institute.
Received for publication January 20, 2017; accepted March
2, 2017.
Copyright © 2017 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000003743
reduction, trimming the cephalic portion of the
lateral and middle crura, trimming the caudal por-
tion of the upper lateral cartilages, trimming the
caudal septum, and the upper lateral cartilage ten-
sion spanning suture, available in the “Related Vid-
eos” section of the full-text article on PRSJournal.
com or, for Ovid users, available at http://links.lww.
com/PRS/C377.) Subsequently, the components of
the dorsum are restored as a unified complex. It is
imperative to understand the direct and indirect
effects of dorsal reduction, particularly with regard
to discrepancies in dorsal width following dorsal
reduction. Reducing the dorsal hump at the apex
of its triangular architecture will inevitably widen
the dorsum. This is in contrast to the more mal-
leable cartilaginous midvault, where the upper
lateral cartilages migrate to lie juxtaposed to the
septum, thereby creating a narrow apex relative to
the bony vault. This is a common pitfall leading
Disclosure: Dr. Rohrich receives instrument royal-
ties from Eriem Surgical, Inc., and book royalties
from Thieme Medical Publishing. No funding was
received for this article. Dr. Afrooz has no financial
interest to declare.
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Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 140, Number 4 • Rhinoplasty Refinements

Video 1. Supplemental Digital Content 1 demonstrates the preoper-

ative patient analysis and the open rhinoplasty approach, available
in the “Related Videos” section of the full-text article on PRSJournal.
com or, for Ovid users, available at http://links.lww.com/PRS/C376.

Video 2. Supplemental Digital Content 2 demonstrates exposure

of the anterior septal angle, component dorsal reduction, trimming
the cephalic portion of the lateral and middle crura, trimming the
caudal portion of the upper lateral cartilages, trimming the caudal
septum, and the upper lateral cartilage tension spanning suture,
available in the “Related Videos” section of the full-text article on
PRSJournal.com or, for Ovid users, available at http://links.lww.
com/PRS/C377.

to long-term undesirable contours at the keystone.
Congruency of the bony and cartilaginous dorsum
is achieved with lateral osteotomies to narrow the
bony vault, and upper lateral cartilage tension
spanning sutures2 in this particular case.
TIP REFINEMENT
Tip refinement is achieved by multiple tech-
niques that involve reshaping the lower lateral
cartilages. This is accomplished by direct shap-
ing of the lower lateral cartilages by excision and
suture-shaping techniques.3 In this particular case,
the nasal tip was refined through a combination
of cephalic trimming of the lateral and middle
crura. This facilitates reduction of tip bulbosity
and the elegant refinement with suture-shaping
techniques. (See Video, Supplemental Digital
Content 3, which demonstrates tip-suturing tech-
niques, and transection and overlap of the medial
crura to achieve tip deprojection, available in the
“Related Videos” section of the full-text article on
PRSJournal.com or, for Ovid users, available at

717
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Plastic and Reconstructive Surgery • October 2017

Video 3. Supplemental Digital Content 3 demonstrates tip-sutur-

ing techniques, and transection and overlap of the medial crura to
achieve tip deprojection, available in the “Related Videos” section of
the full-text article on PRSJournal.com or, for Ovid users, available at
http://links.lww.com/PRS/C378.

Video 4. Supplemental Digital Content 4 demonstrates transection

of a portion of the lateral crura to balance nasal tip deprojection
and maintain tip rotation, and the low-to-low percutaneous lateral
osteotomies. Also demonstrated are the placement of alar contour
grafts, the medial crural footplate control suture, and closure and
splinting techniques, available in the “Related Videos” section of the
full-text article on PRSJournal.com or, for Ovid users, available at
http://links.lww.com/PRS/C379.

http://links.lww.com/PRS/C378.) Interdomal and depending on the desired effect on tip rotation.

transdomal sutures were used for tip reshaping.
NASAL TIP DEPROJECTION
Nasal tip deprojection can be achieved by sev-
eral means.4 One method of achieving nasal tip
deprojection is to shorten the limbs of the lower
lateral cartilages. This can be carried out by tran-
section and overlap of the medial or lateral crura,
Cephalic tip rotation and deprojection can be
achieved by shortening the length of the lateral
crura. (See Video, Supplemental Digital Content 4,
which demonstrates transection of a portion of the
lateral crura to balance nasal tip deprojection and
maintain tip rotation, and the low-to-low percuta-
neous lateral osteotomies. Also demonstrated are
the placement of alar contour grafts, the medial
crural footplate control suture, and closure and

718
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 140, Number 4 • Rhinoplasty Refinements
splinting techniques, available in the “Related Vid-
eos” section of the full-text article on PRSJournal.
com or, for Ovid users, available at http://links.lww.
com/PRS/C379.) Contrary to this, caudal tip rota-
tion and deprojection can be achieved by shorten-
ing the medial crura. Furthermore, deprojection
alone can be achieved without altering tip rotation
by equal shortening of the medial and lateral crura,
as is illustrated in this particular case.
CONCLUSIONS
The open rhinoplasty technique facilitates
direct visualization of the underlying anatomy
contributing to aesthetic imbalance or deformity.
Direct visualization has facilitated the evolution of
precise techniques to address a range of disharmo-
nies and deformities. This case—represented by a
series of four videos—depicts the subtle nuance
and a wide range of modern open rhinoplasty
techniques used to achieve consistent and pleas-
ing results.
Copyright © 2017 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Rod J. Rohrich, M.D.
Dallas Plastic Surgery Institute
9101 North Central Expressway
Suite 600
Dallas, Texas 75231
Rod.rohrich@dpsi.org
@DrRodRohrich
REFERENCES
1. Rohrich RJ, Muzaffar AR, Janis JE. Component dorsal hump
reduction: The importance of maintaining dorsal aesthetic
lines in rhinoplasty. Plast Reconstr Surg. 2004;114:1298–1308;
discussion 1309–1312.
2. Roostaeian J, Unger JG, Lee MR, Geissler P, Rohrich RJ.
Reconstitution of the nasal dorsum following component
dorsal reduction in primary rhinoplasty. Plast Reconstr Surg.
2014;133:509–518.
3. Guyuron B, Behmand RA. Nasal tip sutures part II: The
interplays. Plast Reconstr Surg. 2003;112:1130–1145; discus-
sion 1146–1149.
4. Unger JG, Lee MR, Kwon RK, Rohrich RJ. A multivari-
ate analysis of nasal tip deprojection. Plast Reconstr Surg.
2012;129:1163–1167.
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