CME

Primary Open Rhinoplasty

Rod J. Rohrich, M.D.
Paul N. Afrooz, M.D.
Dallas, Texas; and Miami, Fla.
Learning Objectives: After studying this article and viewing the videos, the
participant should be able to: 1. Describe the operative technique necessary
to perform open rhinoplasty. 2. Summarize the steps necessary in performing
a component dorsal reduction. 3. Develop a surgical plan for nasal tip shap-
ing and cephalic rotation of the nasal tip. 4. Identify the need for aesthetic
improvement of the alar base, and perform successful alar base surgery. 5.
Demonstrate consistency, safety, and predictability in rhinoplasty.
Summary: Rhinoplasty remains one of the most challenging procedures in
plastic surgery, and continues to be one of the top five aesthetic surgical pro-
cedures, with over 223,000 performed in 2016. Rhinoplasty may be performed
by means of the “open” or the “closed” approach, and each approach has its
advantages and disadvantages. This article focuses on the open approach, and
the principles and techniques necessary to achieve consistent and gratifying
results. As with all plastic surgery procedures, successful rhinoplasty begins
with a thorough clinical analysis, definition of the goals, meticulous preopera-
tive planning, precise operative execution, vigilant postoperative management,
and a critical analysis of one’s results.  (Plast. Reconstr. Surg. 144: 102e, 2019.)

PREOPERATIVE ASSESSMENT AND
PLANNING
A comprehensive nasofacial analysis is the most
important initial step in establishing the goals for
the procedure and achieving a gratifying result.1,2
Several methods of nasofacial analysis have been
described.3–6 The nose and face are evaluated
meticulously, and findings are confirmed with care-
ful analysis of life-size photographs.5 Evaluation
of the patient should include static and dynamic
views, as smiling may reveal descent of the nasal
tip, along with several additional dynamic changes
of the nose and upper lip.7 Careful observation of
these subtle dynamic changes is a crucial element
of the analysis and, furthermore, will facilitate an
informative patient discussion, and further delin-
eate the operative goals.
DEFINING RHINOPLASTY GOALS
The aesthetic goals are primarily dependent
on the patient’s concerns and expectations. It is
our common practice to have the patient articu-
late his or her three major concerns. This is fol-
lowed by a very candid discussion of what is and
what is not achievable, thus setting realistic expec-
tations for the patient and reducing the risk of
postoperative patient dissatisfaction.2 In addition,
it is important to enhance nasofacial balance while
also maintaining sex and ethnic congruency.
OPERATIVE TECHNIQUE
Open rhinoplasty is performed almost exclu-
sively under general anesthesia to ensure patient
comfort and protection of the airway (Table 1).
Before preparing and draping, the nose is infil-
trated with 1% lidocaine containing 1:100,000
epinephrine. Using a 27-gauge needle, the local
solution is injected in the columella, along the
Disclosure: Dr. Rohrich receives instrument royal-
ties from Eriem Surgical, Inc., and book royalties
from Thieme Medical Publishing. He is a clinical
and research study expert for Allergan, Inc., Galder-
ma, and MTF Biologics, and the owner of Medical
Seminars of Texas, LLC. No funding was received
for this article. Dr. Afrooz has no financial interest to
declare in relation to the content of this article.

From the Dallas Plastic Surgery Institute and private
­practice.
Received for publication May 20, 2018; accepted February
28, 2019.
Copyright © 2019 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000005778
Related Video content is available for this
article. The videos can be found under the
“Related Videos” section of the full-text article,
or, for Ovid users, using the URL citations pub-
lished in the article.

102e www.PRSJournal.com
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 144, Number 1 • Primary Open Rhinoplasty
Table 1.  Advantages and Disadvantages of Open
and Closed Rhinoplasty Techniques
Open approach
 Advantages
  Direct visualization of anatomy
  Precise identification and correction of deformity
  Availability of both hands
  Relative ease of suturing grafts
  Direct visualization facilitates teaching
 Disadvantages
  Possible visibility of columellar scar
  Prolonged edema
  Longer operative time
Closed approach
 Advantages
  No columellar scar
  Less postoperative edema compared with the open
approach
  Placement of grafts without need for fixation
  Decreased operative time
 Disadvantages
  Minimal direct visualization of anatomy
  More difficult to teach because of lack of direct
­visualization
  Arguably less precision because of lack of exposure and
direct visualization
infracartilaginous incision, the dorsum, and the
soft tissues medial and lateral to the nasal bones.
If necessary, the nasal hair within the vestibule is
trimmed. The nose is then packed bilaterally with
pledgets soaked in oxymetazoline. The use of a
speculum and bayonet forceps will promote visual-
ization and facilitate packing of the posteriormost
and superiormost portions of the airway. A moist
3-inch gauze throat pack is placed by the surgeon.
The patient is then prepared and draped, which
allows for optimal timing and efficacy of the local
anesthetic and vasoconstrictive effect.
Incision Design
A stair-step incision is marked along the nar-
rowest portion of the columella (Fig. 1). The inci-
sion is carried across the columella and continued
into the vestibule for 2 to 3 mm. Attention is then
directed to the infracartilaginous incision. A wide
Fig. 1. Stairstep transcolumellar incision. (From Rohrich RJ,
Adams WP Jr, Ahmad J, Gunter JP. Dallas Rhinoplasty: Nasal Sur-
gery by the Masters. 3rd ed. New York: Thieme; 2014.)
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
double hook is placed in the alar vestibule and
the ala is everted with the long finger to facilitate
visualization (Fig. 2). With eversion of the ala, the
caudal margin of the lateral crus is usually read-
ily apparent. Palpation of the caudal margin of
the lateral crus can also be accomplished with the
back of the knife blade to further delineate the
location of the caudal margin of the lateral crus.
With the double hook in the alar vestibule and the
ala slightly everted, the infracartilaginous incision
is started laterally and carried medially toward the
nostril apex. The double hook is then repositioned
at the nostril apex. The alar rim and nasal tip are
everted and the incision is continued medially
within the vestibule. At the nostril apex and medi-
ally along the middle and medial crus, the inci-
sion is routinely placed 3 mm within the vestibule
above the nostril rim. This will ensure adequate
vestibular tissue for closure without distorting the
soft-tissue triangle and nostril rim. The incision is
continued medially until it joins the extension of
the transcolumellar incision. This is repeated on
the contralateral side. [See Video, Supplemental
Digital Content 1, which displays transcolumellar
and infracartilaginous incisions, available in the
“Related Videos” section of the full-text article at
PRSJournal.com or at http://links.lww.com/PRS/
D537. (From Rohrich R, Afrooz P. Rhinoplasty
refinements: The role of the open approach. Plast
Reconstr Surg. 2017;140:716–719.)]
On completion of the transcolumellar and
infracartilaginous incisions, a double hook is
placed at the nostril apices and retracted gently.
Skin flap elevation is initiated at the transcolu-
mellar incision with a gentle cut-and-push tech-
nique to precisely raise the columellar skin off of
the medial crura. This is performed with great
care, as the medial crura can be easily damaged
during this dissection. As dissection approaches
the soft-tissue triangle, it is stopped and redi-
rected laterally to the infracartilaginous inci-
sion because the soft-tissue triangle is most safely
approached from lateral to medial. The lateral
portions of the infracartilaginous incisions are
carefully undermined while staying directly on
the lateral crura during the dissection. Dissec-
tion then proceeds medially toward the soft-tis-
sue triangle with eversion to facilitate accurate
visualization. When approaching the soft-tissue
triangle from lateral to medial, the dissection
proceeds with great care to maintain 3 mm of
vestibular skin at the caudal margin and also
avoiding damage to the cartilage in the region
of the domes (see Video, Supplemental Digital
Content 1, http://links.lww.com/PRS/D537). Once
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 Plastic and Reconstructive Surgery • July 2019

Fig. 2. Location of the infracartilaginous incision. Exposure is facili-

tated with eversion of the ala. (From Rohrich RJ, Adams WP Jr, Ahmad J,
Gunter JP. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. New
York: Thieme; 2014.)

the infracartilaginous incision is complete and
the underlying lower lateral cartilages have been
partially exposed, a double hook is placed into
the apices of the domes and retracted caudally
to provide countertension for the remainder of
skin flap elevation. Dissection continues over
the lower lateral cartilages and onto the upper
lateral cartilages, maintaining the dissection as
close to the cartilages as possible.
As the dissection proceeds superiorly, the key-
stone and the caudal portion of the nasal bones
are encountered. A Joseph periosteal elevator is
used to dissect the periosteum off of the nasal
bones. Periosteal dissection is limited to the area
of the bony dorsum that will require manipula-
tion. It is important to raise the periosteum with
the skin flap to protect the overlying muscles,
and maintain an additional layer of camouflage
in this thin-skinned region of the nose. Violat-
ing the periosteum can lead to visibility of minor
imperfections along the dorsum, and long-term
telangiectasias.

Video 1. Supplemental Digital Content 1, which displays transcol-

umellar and infracartilaginous incisions, is available in the “Related
Videos” section of the full-text article at PRSJournal.com or at
http://links.lww.com/PRS/D537. (From Rohrich R, Afrooz P. Rhino-
plasty refinements: The role of the open approach. Plast Reconstr
Surg. 2017;140:716–719.)

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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 144, Number 1 • Primary Open Rhinoplasty

Video 2. Supplemental Digital Content 2, which displays outfractur-

ing the inferior turbinates, is available in the “Related Videos” section
of the full-text article on PRSJournal.com or at http://links.lww.com/
PRS/D538. (From Rohrich R, Afrooz P. Rhinoplasty refinements: The
role of the open approach. Plast Reconstr Surg. 2017;140:716–719.)

Inferior Turbinates dorsal hump reduction is carried out.8 A weighted

The nasal packing is removed at this point
in the procedure. If the inferior turbinates are
impinging on the airway, a long nasal speculum
is used to gently outfracture the turbinates along
their entire anteroposterior length to achieve
optimal patency. [See Video, Supplemental Digi-
tal Content 2, which displays outfracturing the
inferior turbinates. This video is available in the
“Related Videos” section of the full-text article on
PRSJournal.com or at http://links.lww.com/PRS/
D538. (From Rohrich R, Afrooz P. Rhinoplasty
refinements: The role of the open approach. Plast
Reconstr Surg. 2017;140:716–719.)]
Component Dorsal Reduction
Following elevation of the skin envelope and
periosteum overlying the dorsum, a component
retractor is placed to retract the skin envelope
and facilitate adequate exposure. Alar retrac-
tors are placed in the domes of the lower lateral
cartilages to facilitate exposure of the anterior
septal angle (Fig. 3) (i.e., the portion of the sep-
tum where the anterior septum meets the caudal
septum). The prominence of the anterior septal
angle is usually easily palpated. The anterior sep-
tal angle is defined, and the mucoperichondrium
of the septum is scored with a no. 15 blade to ini-
tiate the dissection in the proper plane. A Cottle
septal elevator is used for this part of the dissec-
tion. The proper plane is verified by the blue/gray
color of the cartilaginous septum, and the relative
ease of mucoperichondrial elevation. Dissection
proceeds most easily in a posterior direction, and
is then directed superiorly and anteriorly (Fig. 4).

Fig. 3. Placement of lower lateral cartilage retractors for adequate

exposure of the anterior septal angle.

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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 4. Elevation of the mucoperichondrium is most easily per-
formed in a posterior, inferior, and anterior direction. (From
Rohrich RJ, Adams WP Jr, Ahmad J, Gunter JP. Dallas Rhinoplasty:
Nasal Surgery by the Masters. 3rd ed. New York: Thieme; 2014.)
As dissection proceeds anteriorly toward the junc-
tion of the septum and upper lateral cartilage, the
septal elevator is rolled gently under the upper lat-
eral cartilage in an effort to dissect mucoperichon-
drium from the overlying upper lateral cartilage
for several millimeters. This will ensure that the
nasal lining is not violated with the forthcoming
separation of the upper lateral cartilages from the
dorsal septum. The mucoperichondrial dissection
is then carried out on the contralateral side. Fol-
lowing mucoperichondrial dissection, the upper
lateral cartilages are separated from the dorsal
septum. The weighted retractor is removed, and
an Aufricht retractor is used for accurate visual-
ization of the dorsum up to the level of the key-
stone. A no. 15 blade is placed underneath the
upper lateral cartilage–septal junction. With the
knife blade flush against the septum, the upper
lateral cartilage–septal junction is separated up to
the level of the nasal bones. The upper lateral car-
tilages are gently retracted and the dorsal septum
is trimmed incrementally to the desired height.
The bony dorsum is then rasped incremen-
tally to the desired level. Rasping is performed
carefully and in an oblique fashion to avoid dis-
ruption of the cartilaginous septum from the per-
pendicular plate of the ethmoid at the level of the
keystone. A meticulous effort is made to ensure a
smooth transition from the bony dorsum to the
cartilaginous dorsum.
Septoplasty and Harvesting Septal Cartilage
A nasal speculum is placed on one side of the
septum to retract the upper lateral cartilage and
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Plastic and Reconstructive Surgery • July 2019
Fig. 5. Design of the L-strut of the cartilaginous septum. Cephal-
ically, the incision aims posteriorly to maximize the surface area
of articulation between the perpendicular plate of the ethmoid
and the cartilaginous septum. (From Rohrich RJ, Adams WP Jr,
Ahmad J, Gunter JP. Dallas Rhinoplasty: Nasal Surgery by the Mas-
ters. 3rd ed. New York: Thieme; 2014.)
gently push the septum to the opposing side. This
maneuver facilitates visualization and accurate
design of the dorsal L-strut. We prefer leaving an
L-strut of at least 15 mm dorsally and 10 mm cau-
dally to ensure stability of the dorsum over time.
Furthermore, at the cephalic portion of the carti-
laginous septum, at the articulation with the per-
pendicular plate of the ethmoid, the cut is directed
in a posterior-oblique direction to maximize the
remaining articulation between the cartilaginous
septum and the perpendicular plate of the eth-
moid (Fig. 5). Caudally, at the incision transition
from dorsal to caudal septum, the cut is designed
in a rounded manner rather than as a sharp angle.
This reduces the risk of fracture of the L-strut at
this transition point. The cartilaginous septum to
be harvested is carefully freed using a septal eleva-
tor to dislodge the posterior and caudal portion
of the septum from the perpendicular plate of the
ethmoid and the vomer. Deviations of the vomer
bone, or spurs, are removed with a rongeur.
The septal L-strut is assessed for residual devi-
ation or irregularities. It is not uncommon for the
caudal portion of the septum to be dislodged to
one side of the maxillary crest. In this scenario, the
caudal septum is freed from the maxillary crest,
trimmed of any redundant excess, and secured
to the midline with a 5-0 polydioxanone suture.
 Volume 144, Number 1 • Primary Open Rhinoplasty

If the anterior nasal spine is off of the midline,
it can be osteotomized into midline while retain-
ing its soft-tissue attachments. Prominence of the
anterior nasal spine can be reduced incrementally
with a rongeur.
Osteotomies
Nasal osteotomies are performed to narrow a
wide bony vault at the base or at the dorsum. They
are also performed to close an open roof, or to
straighten deviated nasal bones. To address a wide
bony base, the senior author (R.J.R.) prefers a low-
to-low percutaneous perforated lateral osteotomy
using a 2-mm osteotome through a lateral stab
incision.9 The incision is placed at the nasofacial
junction, and a discontinuous low-to-low lateral
osteotomy from the pyriform aperture to the level
of the medial canthus is carried out. [See Video,
Supplemental Digital Content 3, which displays
percutaneous low-to-low osteotomies. This video
is available in the “Related Videos” section of the
full-text article on PRSJournal.com or at http://
links.lww.com/PRS/D539. (From Rohrich R, Afrooz
P. Rhinoplasty refinements: The role of the open
approach. Plast Reconstr Surg. 2017;140:716–719.)]
If narrowing the bony dorsum is desired, a medial
osteotomy is performed in a superior oblique
direction using a 4-mm osteotome. Following oste-
otomies, gentle digital pressure is used to mobilize
the nasal bones into the desired position.
Midvault Reconstruction
Repositioning the nasal bones following oste-
otomies will highlight any residual asymmetries
of the upper lateral cartilages, particularly when
correcting significant nasal bone deviation. Asym-
metries between the upper lateral cartilages are
trimmed as necessary. Reconstitution of the car-
tilaginous midvault is performed to achieve ideal
aesthetics of the dorsum and to create a graceful
transition between the bony vault and the cartilag-
inous midvault.10,11 Furthermore, this will optimize
long-term stability and avoid an inverted-V defor-
mity. To ensure a smooth transition and equaliza-
tion of width between the bony dorsum and the
cartilaginous midvault, spreader grafts may be
used12 (Fig. 6). If excess upper lateral cartilage is
available, autospreader flaps may be used by fold-
ing the excess anterior portion of the upper lat-
eral cartilages over13 (Fig. 7). Otherwise, spreader
grafts approximately 3 mm wide are carved from
septal cartilage and sutured to each side of the
dorsal septum. The spreader grafts can be placed
just cephalad to the caudal end of the nasal bones
to control the width of the nasal bones, and they
usually span to the caudal end of the upper lateral
cartilages. The spreader grafts are secured to the
dorsal septum with 5-0 polydioxanone horizontal
mattress sutures.
The upper lateral cartilages are then secured
to the spreader graft–septal complex to reconsti-
tute the cartilaginous midvault with 5-0 polydiox-
anone horizontal mattress sutures. If residual
deviation of the anterocaudal septum exists, a sep-
tal rotation suture is used to shift the septum into
the midline14 (Fig. 8). To do this, a 5-0 polydioxa-
none horizontal mattress suture is begun on the
side where the intended rotation is desired. The

Video 3. Supplemental Digital Content 3, which displays percu-

taneous low-to-low osteotomies, is available in the “Related Vid-
eos” section of the full-text article on PRSJournal.com or at http://
links.lww.com/PRS/D539. (From Rohrich R, Afrooz P. Rhinoplasty
refinements: The role of the open approach. Plast Reconstr Surg.
2017;140:716–719.)

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Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.

Fig. 6. Spreader grafts. (From Rohrich RJ, Adams WP Jr, Ahmad J, Gunter
JP. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. New York:
Thieme; 2014.)
horizontal mattress suture is placed more cephali-
cally on this side and more caudally on the oppo-
site side. As the suture is tightened, the septum
shifts in the intended direction. Additional hori-
zontal mattress sutures are placed as necessary to
reconstitute the cartilaginous midvault.
Columellar Strut
Sometimes, a columellar strut is necessary to
increase projection or to fortify and straighten the
columella (Fig. 9). If a columellar strut is necessary,
it is carved from the longest and sturdiest portion
of autologous cartilage, measuring approximately
4 to 5 mm wide. A pocket is created within the soft
tissue between the medial crura. The pocket is not
Fig. 7. Autospreader flaps. (From Rohrich RJ, Ahmad J. The Dallas
Rhinoplasty and Dallas Cosmetic Surgery Dissection Guide. 1st ed.
New York: Thieme; 2018.)
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Plastic and Reconstructive Surgery • July 2019
extended all the way to the nasal spine, thereby
maintaining a pad of soft tissue between the pos-
terior end of the strut and the nasal spine to pre-
vent the strut from directly contacting the nasal
spine. Contact between the columellar strut and
the nasal spine is frequently reported to cause a
“clicking” sensation. Furthermore, the soft-tissue
pad between the posterior end of the strut and
the nasal spine provides a small amount of recoil.
Because the strut is not contacting the unyielding
nasal spine, the tip complex has a more natural
dynamic with facial animation.
The strut is secured to the medial crura at the
base of the columella with a 5-0 polydioxanone
horizontal mattress suture. This horizontal mat-
tress suture is initiated between the medial crura
on one side of the strut to bury the knot between
the medial crura. Additional sutures are placed in
a similar fashion between the strut and the middle
crura while monitoring the angle of divergence
between the middle crura.
Tip Shaping
The shape of the nasal tip is evaluated and
correlated with the preoperative photographs.
Bulbosity of the nasal tip is a frequent motivat-
ing factor in primary rhinoplasty. A cephalic trim
of the lateral crura will partially address bulbos-
ity of the nasal tip.4 The cephalic trim is marked
based on the excess portion contributing to bul-
bosity and also maintaining a minimum of 5 mm
anteriorly and 6 mm posteriorly. This will ensure
adequate residual cartilaginous support. After the
 Volume 144, Number 1 • Primary Open Rhinoplasty

Fig. 8. Depiction of the septal rotation suture. A 5-0 polydioxanone horizontal mattress suture is
begun on the side where the intended rotation is desired. The horizontal mattress suture is placed
more cephalically on this side and more caudally on the opposite side. As the suture is tightened,
the septum shifts in the intended direction. (From Guyuron B, Behmand R. Caudal nasal deviation.
Plast Reconstr Surg. 2003;111:2449–2457; discussion 2458–2459.)

Fig. 9. Columellar strut. (From Rohrich RJ, Adams WP Jr, Ahmad J,

Gunter JP. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd ed. New
York: Thieme; 2014.)

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markings have been made, the portions of the lat-
eral crura to be resected are injected to facilitate
dissection of the nasal lining. Next, the cartilage
is incised, carefully dissected from the underlying
nasal lining, and removed.
Interdomal Suture
If the distance between the two domes is exces-
sive, or if the distance between the tip-defining
points is too wide, an interdomal suture is used
to narrow the interdomal distance15 (Fig. 10).
Using 5-0 polydioxanone, the interdomal suture
is placed from lateral to medial through one
dome, and again from medial to lateral through
the opposite dome as a loop stitch. If the domes
are misaligned, or if they overlap with use of a
simple loop stitch, a figure-of-eight suture can
be used such that the suture is placed from lat-
eral to medial through one dome, and then lat-
eral to medial through the opposite dome. The
Fig. 10. Interdomal suture. (From Guyuron B, Behmand RA. Nasal tip sutures
part II: The interplays. Plast Reconstr Surg. 2003;112:1130–1145; discussion
1146–1149.)
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Plastic and Reconstructive Surgery • July 2019
figure-of-eight suture will prevent overlap of the
domes, and will serve to properly align them. The
suture is tightened incrementally to achieve the
desired interdomal distance. The cephalocaudal
placement of the interdomal suture along the
domes may also have considerable effects on the
orientation of the domes and the lateral crura.
Therefore, depending on the desired change, the
orientation of the domes and lateral crura should
be monitored carefully when placing the inter-
domal suture.
Transdomal Suture
If the arch of the domes is excessively wide
or broad, the transdomal suture can be used to
narrow the arch of the domes15 (Fig. 11). As the
arch of the dome is narrowed, the dome becomes
more projected. Therefore, the transdomal suture
slightly increases nasal tip projection and the
sharper contour of the apex of the dome increases
 Volume 144, Number 1 • Primary Open Rhinoplasty
Fig. 11. Transdomal suture. (From Guyuron B, Behmand R. Nasal tip sutures part II: The interplays.
Plast Reconstr Surg. 2003;112:1130–1145; discussion 1146–1149.)
tip definition. A 5-0 polydioxanone suture is placed
from medial to lateral across the dome in a hori-
zontal mattress fashion, and tied on the medial
aspect of the dome, making sure the suture does
not violate the nasal lining. The suture is tightened
incrementally until the desired shape is achieved.
Similar to the interdomal suture, the cephalocau-
dal placement of the transdomal suture can have a
significant impact on the orientation of the domes
and the lateral crura. Therefore, these dynamics
must be anticipated and monitored during place-
ment of transdomal sutures.
Middle Crura Suture
The middle crura suture is used to control the
angle of divergence between the middle crura15
(Fig. 12). Depending on the length of the colu-
mellar strut, the middle crura suture may incorpo-
rate the strut. By reducing the angle of divergence
between the middle crura, this suture will increase
tip projection, increase tip support, narrow the
anterior columella, and reduce the interdomal
distance. Similar to the aforementioned tip-shap-
ing sutures, the middle crura suture may have
additional effects on the infratip lobule size. The
position of the domes and lateral crura should be
monitored during suture placement.
Tip Rotation
Cephalic rotation of the nasal tip is a frequent
motivating factor for patients seeking rhinoplasty.
Cephalic rotation of the nasal tip can be achieved
by means of several techniques.16
Cephalic Trim
The cephalic margin of the lower lateral car-
tilages lies adjacent to the caudal border of the
Copyright © 2019 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
upper lateral cartilages. Cephalic trimming of
the lateral crura reduces the length of the carti-
laginous framework, and facilitates a degree of
passive cephalic rotation of the lower lateral carti-
lages (Fig. 13).
Caudal Septal Trim
The caudal septum can also be trimmed incre-
mentally to the desired angle to further facilitate
passive cephalic rotation of the lower lateral car-
tilages. Through the open approach, the medial
crura are separated and retracted for access and
visualization of the caudal septum. The septum
is then trimmed incrementally according to the
desired degree of rotation (Fig. 14). [See Video,
Supplemental Digital Content 4, which displays
caudal septal trim. This video is available in the
“Related Videos” section of the full-text article on
PRSJournal.com or at http://links.lww.com/PRS/
D540. (From Rohrich R, Afrooz P. Rhinoplasty
refinements: The role of the open approach. Plast
Reconstr Surg. 2017;140:716–719.)] This technique
can be very powerful and should be performed
incrementally to avoid overrotation. Depend-
ing on the degree of caudal septum removed,
a portion of membranous septum may need to
be removed to facilitate rotation and to avoid
creating a redundancy of nasal lining following
cephalic rotation.
Lateral Crural Shortening
The tripod concept describes the limbs of the
tripod as the individual lateral crura making up
two individual limbs of the tripod, and the paired
medial crura constituting the third limb (Fig. 15).
The nasal tip represents the apex of the tripod,
and can be manipulated by strategic shortening
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 Plastic and Reconstructive Surgery • July 2019

Fig. 12. Middle crura suture. (From Guyuron B, Behmand R. Nasal tip sutures
part II: The interplays. Plast Reconstr Surg. 2003;112:1130–1145; discussion
1146–1149.)

Fig. 13. Cephalic trim of the lateral crus of the lower lateral cartilages. (From Afrooz PN, Carboy JA, Men-
dez BM, Rohrich RJ. Cephalic rotation of the nasal tip. Plast Reconstr Surg. 2019;143:734e–743e.)

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 Volume 144, Number 1 • Primary Open Rhinoplasty

Fig. 14. Caudal septal trim. (From Rohrich R, Afrooz P. Components of

the hanging columella: Strategies for refinement. Plast Reconstr Surg.
2018;141:46e–54e.)

or lengthening of any of these limbs alone or in
combination. Shortening the lateral crura of the
tripod effectively pulls the nasal tip posteriorly
and cephalad, causing slight deprojection and
cephalic rotation.17 The nasal lining is dissected
from the posterior surface of the lateral crura.
The lateral crus is then transected. The transected
portions are overlapped to the degree of desired
rotation, and the overlapped cartilage is sutured
in place with a 5-0 polydioxanone horizontal mat-
tress suture (Fig. 16).
Tip Rotation Suture
The tip rotation suture is a simple and effec-
tive method to achieve accurate and predictable
tip rotation.15 A suture is placed to harness the
middle or medial crura, which is then secured
to a more cephalad position along the septum
(Fig. 17). In the open approach, the mucoperi-
chondrium is elevated from the septum, and a
suture is then placed harnessing the middle or
medial crura. The suture is then passed through
the anterocaudal septum in a position that is
appropriately cephalad to achieve the desired
cephalic rotation when the suture is tightened.
The suture is passed through the middle or medial
crura again in a mirroring fashion. As the suture
is tightened incrementally, the lower lateral car-
tilages rotate cephalically along the septum. The
position of the domes is monitored as the desired
degree of cephalic rotation is achieved.

Video 4. Supplemental Digital Content 4, which displays caudal

septal trim. This video is available in the “Related Videos” section of
the full-text article on PRSJournal.com or at http://links.lww.com/
PRS/D540. (From Rohrich R, Afrooz P. Rhinoplasty refinements: The
role of the open approach. Plast Reconstr Surg. 2017;140:716–719.)

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 Plastic and Reconstructive Surgery • July 2019

Fig. 17. Tip rotation suture. (From Afrooz PN, Carboy JA, Mendez
BM, Rohrich RJ. Cephalic rotation of the nasal tip. Plast Reconstr
Surg. 2019;143:734e–743e.)

Fig. 15. Tripod concept. (From Rohrich RJ, Adams WP Jr, Ahmad
J, Gunter JP. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd
ed. New York: Thieme; 2014.)
Alar Contour Grafts
To correct or prevent retraction of the alar
rim, alar contour grafts are placed along the alar
rim margin in a vestibular pocket18 (Fig. 17). [See
Video, Supplemental Digital Content 5, which dis-
plays placement of alar contour grafts. This video
is available in the “Related Videos” section of the
full-text article on PRSJournal.com or at http://
links.lww.com/PRS/D541. (From Rohrich R, Afrooz
P. Rhinoplasty refinements: The role of the open
approach. Plast Reconstr Surg. 2017;140:716–719.)]
A hook is placed in the nostril apex and gently
retracted. Using a pair of iris scissors, a vestibular
pocket is dissected along the alar rim toward the
alar facial junction. A cartilage graft measuring 2
to 3 mm wide and approximately 15 mm long is
fashioned and placed within the vestibular pocket
along the alar rim.
Alar Base Surgery
Alar base surgery is performed to address
alar flaring, large nostril size, excessive width
of the nasal base, and alar base or nostril
asymmetries.19,20
Alar Flaring
In patients who exhibit alar flaring with nor-
mal nostril size, the alar base excision is designed
to address alar flare only, without extending into
the nasal vestibule. Three types of alar flaring have

Fig. 16. Lateral crural transection and overlap. (From Afrooz PN, Car-
boy JA, Mendez BM, Rohrich RJ. Cephalic rotation of the nasal tip. Plast
Reconstr Surg. 2019;143:734e–743e.)

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 Volume 144, Number 1 • Primary Open Rhinoplasty

Video 5. Supplemental Digital Content 5, which displays place-

ment of alar contour grafts, is available in the “Related Videos”
section of the full-text article on PRSJournal.com or at http://
links.lww.com/PRS/D541. (From Rohrich R, Afrooz P. Rhinoplasty
refinements: The role of the open approach. Plast Reconstr Surg.
2017;140:716–719.)

been described along with excision design for cor- junction. A wedge resection is designed, and skin
rection19 (Fig. 18). The superior extent of the inci- and fibrofatty tissue are excised. The incision is
sion is routinely kept below the alar groove. The closed using a 6-0 nylon suture using the halving
posterior incision is designed within the alar-cheek principle.

Fig. 18. Alar flare classification. (From Rohrich RJ, Malafa MJ, Ahmad J, Basci DS. Managing
alar flare in rhinoplasty. Plast Reconstr Surg. 2017;140:910–919.)

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Alar Flaring, Large Nostrils, and Wide Alar
Base
To treat alar flaring, large nostrils, and a wide
alar base, the alar resection is designed to incor-
porate a portion of the nasal vestibule.20 In a simi-
lar fashion, the posterior incision is placed within
the alar-cheek junction. The incision extends into
the nasal vestibule incorporating the nasal sill
(Fig. 19). The width of the vestibular or sill exci-
sion is dependent on the desired amount of nos-
tril circumference reduction or alar base width,
respectively. The excision is performed incorpo-
rating skin, fibrofatty tissue, and a small portion
of alar musculature. At the nostril sill, the bevel
of the blade is angled to create a slight medi-
ally based flap of tissue. This medially based flap
ensures wound eversion during closure to ensure
a graceful transition across the nasal sill, and
avoidance of a depressed scar. Externally, the exci-
sion is closed with 6-0 nylon. The vestibular por-
tion of the excision is closed with 5-0 chromic gut.
Closure
The transcolumellar incision is closed with
meticulous realignment using 6-0 nylon inter-
rupted sutures. Within the vestibule, the infra-
cartilaginous incision is closed using interrupted
5-0 chromic gut sutures. The infracartilaginous
incision is best exposed by placing a double hook
using slight eversion similar to the exposure used
in making the incision initially. Generally, three
interrupted sutures are placed in the lateral aspect
of the incision. Medially, two or three interrupted
sutures are placed. Suture placement near the
soft-tissue triangle and nostril apex is avoided, as
Fig. 19. Incision design to address alar flaring and a wide nasal
base. This excision design incorporates the alar flare excision
design with extension across the nasal sill and into the vestibule.
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Plastic and Reconstructive Surgery • July 2019
these sutures frequently distort the contour of the
soft-tissue triangle, nostril apices, and alar rim. As
a general rule, the suture bites within the infracar-
tilaginous incision are made as small as possible to
avoid distortion or retraction of the alar rim.
Splinting
Following meticulous closure, mupirocin-
coated Doyle splints are placed within the nostrils
and sutured in place using a 3-0 nylon horizontal
mattress suture through the membranous septum.
The nasal skin is cleaned, and Steri-Strips (3M, St.
Paul, Minn.) are placed in an overlapping fashion
along the dorsum and to the level of the supra-
tip breakpoint. A metal splint is then placed over
the Steri-Strips. Finally, a Surgicel (Ethicon, Inc.,
Somerville, N.J.) hemostatic wrap is cut into several
pieces approximately 4 × 4 mm in dimension. Sev-
eral pieces are coated in mupirocin ointment and
packed within the nostril apices to provide internal
support and splinting of the nostril apices and soft-
tissue triangles during the acute healing phase.
POSTOPERATIVE REGIMEN
Primary rhinoplasty patients receive intraop-
erative antibiotics, followed by 24 hours of postop-
erative antibiotics. Patients are instructed to clean
incisions daily with dilute hydrogen peroxide in
the postoperative period, followed by application
of antibiotic ointment. Columellar sutures are
typically removed at 7 days. If alar base surgery is
performed, these sutures are usually left in place
for 10 to 14 days because of dynamic activity at the
alar-cheek junction and the potential for wound
dehiscence. Internal and external splints are
removed at 7 days, followed by nighttime taping of
the supratip area with Steri-Strips for 4 to 6 weeks.
CONCLUSIONS
The open approach in primary rhinoplasty
facilitates accurate visualization of the underlying
anatomy to precisely correct anatomical deformi-
ties and enhance nasal shape and function. Grati-
fying results begin with meticulous preoperative
analysis of the deformities in conjunction with a
clear understanding of the patient’s goals. Once
realistic expectations are set, thorough preopera-
tive preparation is essential to operative execu-
tion. Although the level of complexity among
rhinoplasty patients is highly variable, the prin-
ciples and techniques herein are fundamentally
comprehensive, and will serve as a solid founda-
tion for the rhinoplasty surgeon.
 Volume 144, Number 1 • Primary Open Rhinoplasty
Paul N. Afrooz, M.D.
777 Arthur Godfrey Road, Suite 300
Miami Beach, Fla. 33140
paul.afrooz@gmail.com
Twitter: @DrAfrooz
Instagram: @dr.paul.afrooz
Facebook: PaulAfroozMD
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