Advances in Plastic & Reconstructive Surgery

© All rights are reserved by Dr. Marcos Quispe Jorge Luis, et al.

Research Article ISSN: 2572-6684

Semi-open Rhinoplasty: Getting together the best of both, Open and

Closed Rhinoplasty
Marcos Quispe Jorge Luis1, Marcos Quispe Mirek Fernando2, Marcos Quispe Henri Armando1, Benavides Rubio
Jacqueline1
1Plastic Surgery, Vitalis Clinic.
2Facial Plastic Surgery, Vitalis Clinic.

Abstract
Summary: Rhinoplasty is one of the most common procedures of our surgical practice. According to the approach, it can be open or
closed; however, the semi-open approach has been recently incorporated. Semi-open rhinoplasty allows the dissection and complete
exposure of the alar cartilage, similar to the open approach, but the incision is limited to the nasal vestibule without a transcolumellar
scar, just as in the closed approach.
The objective of this work is to describe the surgical technique and show the outcomes.
Material and Methods: We evaluated 376 patients who underwent primary and secondary rhinoplasty with the semi-open technique,
performed between June 2016 and June 2019.
Results: In this period, we performed 376 rhinoplasties with the semi-open technique; 340 (90.4%) patients underwent primary rhino-
plasty and 36, secondary; most of our patients were women (73.1%), both, in primary (72.4%), as in secondary rhinoplasty (80.6%). To
address the nasal tip, we performed mainly domal suture and columellar graft in 48.9% of the patients, followed by domal suture,
columellar graft, and nasal tip graft in 30.3%, and in 20.8%, we shaped the tip with domal sutures.
Conclusion: The semi-open technique provides a wide exposition of the nose, to successfully address and modify the osteocartilaginous
nasal structure, especially the nasal tip, thus obtaining predictable results.
Keywords: Rhinoplasty; Semi-open rhinoplasty; Primary Rhinoplasty; Septorhinoplasty.

Introduction
Rhinoplasty is one of the most common procedures of our surgical
practice. According to the approach, it can be open or closed. The
open rhinoplasty provides a wide exposure of the nasal structures, to
clearly identify defects, and correct them under direct vision. However,
the transcolumellar scar can alter the final aesthetic results, especially
in non-caucasian patients. On the other hand, the closed rhinoplasty
limits the incision only to the nasal vestibule without a visible scar.
Thus, this narrow exposure of the osteocartilaginous vault, makes
difficult the handling of the structures, especially those of the nasal
tip.
Semi-open rhinoplasty technique allows wide exposure of the alar
cartilage, as in open technique, with the incision placed in the nasal
vestibule with no transcolumelar scar. This technique, previously
known with another nomination, was published in 1990 by Dr. Gue-
rrerosantos [1], as a technique of "Open rhinoplasty without skin-
columella incision," later Holmstron in 1996 [2], and Bravo & Schwarze
in 2008 [3] published a similar technique with a slight variation in shape
*Address for Correspondence: Dr. Marcos Quispe Jorge, Plastic Surgeon,
Manuel Olguín Street N° 970 – 19, Santiago de Surco, Lima, Perú. Postal
Address: 15023, E-mail: jmarcosq@icloud.com drjorgemarcos@gmail.com
Received: April 24, 2020; Date Accepted: May 29, 2020, Date published:
June 01, 2020.
and length of the incision in the columellar skin. Also, Sevin et al. [4],
Bruschi et al. [5], Cardenas et al. [6], Kamburoglu et al. [7] published
successful results with the technique described. The term semi-open
rhinoplasty was introduced by Inchingolo et al. [8] in 2012, who
reported some cases he operated on, using the technique published by
Guerrerosantos.
In 2014 we began performing this approach for the primary
treatment of the nasal tip, instead of the “delivery" technique; soon it
became our first surgical option for both, primary and secondary
rhinoplasty, choosing the closed one with intracartilaginous incision for
some select primary cases, and the open for particular secondaries. The
objective of this work is to present the surgical technique and show our
results.
Material and Methods
We evaluated 376 Patients who underwent primary and seco-
ndary rhinoplasties, with the semi-open approach, from June 2016 to
June 2019, patients having only closed or open rhinoplasty were
excluded. The database was checked to obtain the list of patients
operated on with the technique described and collected their medical
records and the photographic album.
Surgical Technique
With the Patient under intravenous sedation, we block, the infra
and supraorbital nerves with lidocaine and epinephrine1/200000 with
local troncular anesthesia, we continue the tumescent infiltration into

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 Marcos Quispe JL, Marcos Quispe MF, Marcos Quispe HA, Benavides Rubio J. Semi-open rhinoplasty: Getting together the best of both, open and closed
rhinoplasty. Adv Plast Reconstr Surg, 2020; 4(2): 327-330.

the submucosal plane of the nasal vault, and xxx the subcutaneously the
nasal tip and base. We wait for the anesthesia effect for 10 minutes
and proceed with the infracartilaginous incision 1 mm from the lower
margin of the alar cartilage: from medial to lateral in the lateral crus,
from top to bottom at the edge of the medial crus along the columella,
and the incision is completed at the level of the domes, carefully to
avoid injuring the area of the soft triangle [Figure 1].

Figure 3: The semi-open technique shows up widely the alar cartilage; to trim
and reshape the nasal tip by placing sutures: ix Interdomal, transdomal,
intercrural, septocolumellar. (left) If needed, we caninterdomal
use a columellar graft; it is
placed between the medial crurato provide support and projection to the nasal
crura to
tip (right).

Figure 1: Semi-open rhinoplasty showing infracartilaginous incision (left). Local

anesthesia with IV sedation, tumescent infiltration of lidocaine with epine-
phrine 1/200000. The procedure with minimal bleeding (right).

With fine-tipped scissors, we dissect the alar cartilage; from the

incision, heading superiorly on the supracartilaginous plane to free
the nasal cartilages from the nasal skin. Then, to perform this step, we
put a traction stitch with non-absorbing 2/0 suture, placed symmetri-
cally at the height of the domes to pull the alar cartilage downwards,
and easily dissect the upper half of the nose [Figure 2]. We proceed to
dissect the alar cartilage, upper lateral cartilage, the caudal edge of the Figure 4: The semiopen approach allows grafting the tip with a shield to
septum, when this is done, we put the Aufritch retractor to visualize improve definition, and dome asymmetry (left). We can place mixed grafts
the osteocartilaginous structure completely, determine the amount of (right), gull wings grafts, transpose lateral crura cephalad, reinforce lateral
resection and proceed using a chisel or scalpel. crura with fixed or articulated laminar graft, and many other options.

Results
In the period studied, 376 rhinoplasties were performed with the
semi-open technique: 340 (90.4%) were primary rhinoplasties and 36
cases secondary, the majority of them in women (73.1%); both:
primary rhinoplasty (72.4%), as secondary (80.6%), as referred in
[Table 1]. To address the nasal tip, we performed mainly domal
sutures and cartilaginous graft (columellar and or nasal tip) in 79.2%
of all our patients. Only in some of them 20.8% we used exclusively
domal sutures.
Table 1:Demographic features and nasal tip procedures performing semi-
Figure 2: To facilitate dissection and handling, we link the domes with black open rhinoplasty. when performing
silk 2/0, to pull them to correct osteocartilaginous defects (Left). Thus, we
Primary Secondary
laterally retract the alar cartilage, and with the double hook, we expose the Rhinoplasty Rhinoplasty
cartilaginous back to inset spreader grafts (right). Total
posterior aspect of the cartilage,and insert spreader grafts Men Women Men Women
Next, we check and do the corrections needed, trim the dorsum,
Cases 94 246 7 29 376
and go back to the nasal tip; according to the surgical plan, we first
place spreader grafts [Figure 2], go on with the resection of the cephalic Age 17 - 52 y 15-53 y 23-62 y 21-57 y
edges of the lateral crus, then we put transdomal sutures with 5/0
prolene, remove the traction stitch from the domes. We evaluate the
Domal Suture 23 51 0 4 78
shape and projection of the domes in their natural position; then we
transfer the markings to the other nostril. In that position, we put a
Domal Suture + 57 117 2 8 184
columellar graft [Figure 3] or a septal extension graft, according to Columellar strut
the individual nose evaluation, it is fixated with stitches. Then, we
Domal Suture + 14 78 5 17 114
proceed with intradomal, transdomal, and or interdomal suture Columellar strut +
[Figure 4], and at the end of this step, xxxxxx
we put nasal tip grafts if needed Nasal Tip Graft
place
[Figure 4]. Finally, we perform internal and or external osteotomy
using 2mm chisel, suture the nasal mucosa with chromic catgut 4/0,
and xxx
we end with splinting.

Adv Plast Reconstr Surg, 2020 Page 328 of 330

Marcos Quispe JL, Marcos Quispe MF, Marcos Quispe HA, Benavides Rubio J. Semi-open rhinoplasty: Getting together the best of both, open and closed
rhinoplasty. Adv Plast Reconstr Surg, 2020; 4(2): 327-330.

Above all the patients, 340 underwent primary rhinoplasty, which

represents 90.4%. Note that it was more frequent in women (72.4%).
In this group, the average age was 25.2 years in women and slightly
superior in men (26.1y). The procedures required for reshaping the
nasal tip in all patients were the inset of domal sutures: interdomal,
transdomal, intercrural, and or septocolumellar; and in 78.2% we
insert a cartilaginous graft: in the columella (51.1%) and the nasal tip
(27.0%). Note that 78 patients (21.8%) required only domal sutures.
Secondary rhinoplasties represented 9.6% of total cases, with more
frequency in women (80.6%), and the average age, in both sexes, is
higher than those of primary rhinoplasties. Concerning the treatment
of nasal tip, the domal sutures were used in all patients, associated
with cartilaginous grafting in 88.9% of these cases: in the columella
(27.8%) and de nasal tip (61.1%). Note that the nose tip grafting was
the most frequent procedures used both, in women (58.6%) and men
(71.4%), as shown in [Table 1]. Also, only 11.1% of these cases
required only domal sutures.

Figure 6: Male patient, 26 years old. Primary septorhinoplasty was performed

with semi-open technique: resection of the osteocartilaginous hump, the
resection of the
cephalic edge of the lateral cruraxxxxxxxx
resection, correction of the prominent nasal
spine. Also, septoplasty was performed to correct the septal deviation and
obtain cartilage necessary to perform spreader graft and columellar strut. The
enough
handling of thecartilage
nasal tip was completed with transdomal and interdomal
sutures. Results at six months postoperative: the frontal view shows
correction of the asymmetry in the cartilaginous back and nasal tip (Figure
A); the lateral visa shows an aesthetic back, with adequate rotation and
view
projection of the nasal tip, proper nasolabial angle, and elongation of the
upper lip (Figure B); all reflected too in the oblique view (Figure C).

Figure 5: Female patient, 42 years old. Primary semi-open rhinoplasty: resection

of a dorsal hump, upper border resection of the lateral crura, and caudal edge
of the septum. The nasal tip was reshaped with sutures: projection septocolu-
mellar, intercrural, transdomal, and interdomal. Results at two months
showing shortening of the nose in front view (Figure A), Side (Figure B) and
oblique (Figure C). the

Discussions
xx Discussion

The selection of the best surgical technique in rhinoplasty is

permanently one x discussion because the results depend on factors
concerning both, patient and surgeon. [9]. However, it is possible to
achieve excellent results with open or closed rhinoplasty. Although,
many authors consider that open rhinoplasty has many advantages for
the treatment of patients with delicate nasal tips, the full exposure of
the cartilages and its correction under direct vision, it is necessary to
make an incision through the columella that leaves a visible scar.
The semi-open rhinoplasty technique, in our concern, is an
excellent surgical option because it gets together the best of both
"classic" techniques: open and closed. Thus, it allows us to deliver the
alar cartilage similar to the open technique, but with only a single scar
limited to the nasal vestibule, just as in the closed approach, avoiding
the disruption of the columella. Although the term semi-open
rhinoplasty was introduced by Inchingolo et in 2012 [8], who operated
few cases of rhinoplasty using the surgical technique, it was published
by Guerrerosantos [1] in 1990 and named "semiopen rhinoplasty."
Figure 7: Female patient, 34 years old. High dorsal hump, hanging tip, acute
nasolabial angle, short columella, and slight alar retraction. Primary rhinoplasty
was performed with infracartilaginous incision, xxxx with subperichondrial and
subperiosteal dissection of the back, resection of the osteocartilaginous hump,
the cephalic edge of the lateral crura and the caudal edge of the nasal septum.
Septoplasty to harvest cartilage for spreader graft, columellar strut. The
management of the nasal tip was completed with transdomal and interdomal
sutures, sheens and pecks graft, finally we did alar contour graft. Postoperative
results after six months, front view (Figure A), side view (Figure B), and
inferior view (Figure C). Sheen and Peck grafts
The infracartilaginous incision used in this technique, allows
adequate exposure of the alar cartilage through the nostrils, their
features are completely visible, and precise surgical corrections are
proposed, using sutures and graft techniques. If greater exposure is
necessary, this original incision can be extended to the base of the
columella, as referred by Holstrom [2] and Kamburologlu [7], and

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Marcos Quispe JL, Marcos Quispe MF, Marcos Quispe HA, Benavides Rubio J. Semi-open rhinoplasty: Getting together the best of both, open and closed
rhinoplasty. Adv Plast Reconstr Surg, 2020; 4(2): 327-330.

even extend it to the upper lip, as proposed by Bravo & Shcwaze [3].
However, we believe that it is not necessary to make such extensive
incisions, except in patients with small or constricted nostrils. In
addition, as this incision goes through the inferior aspect of the
nostril, we can address the deformities of the lower area of the medial
crura, simultaneously with the dome and lateral crura [1]. On the
other hand, the incision and dissection must be carefully executed so
as not to damage the soft triangle [10], nor tear the mucosa or
cartilage, especially at the level of the domes or medial crura.
As referred by Guerrerosantos [1], Bravo & Schware [3] and
Brushi et al. [5], we use this technique in primary and secondary
rhinoplasties, that requires handling of back and nasal tip; and, we
prefer the open technique in secondary rhinoplasties with significant
deformity and for the treatment of cleft nose. However, Sevin et al. [4]
and Holstrom [2] have also used it in cases of nasal crush. Likewise,
just as Kamburoglu et al. [7] and Holstrom [2], we have operated on
patients who require additional procedures such as septoplasty and
turbinectomy, in such patients, we prefer to perform septoplasty by
septocolumellar incision separated from the columellar incision.
We agree with the findings described by Zeid et al. [11] who
conducted a comparative study of closed rhinoplasty vs. semiopen
rhinoplasty. This work confirms that the semi-open technique offers
greater accessibility to the osteocartilaginous framework. However, it
is a fact that the extended operative time increase edema in the
immediate and late postoperative findings not only observed in our
cases but mentioned by Dr. Guerrerosantos [1] in his original article,
• Authors' contributions: All authors have contributed to this work.
• Ethics approval and consent to participate: Not applicable.
• Consent for publication: Not applicable.
• Competing interests: We have not conflicts of interest.
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new concept and classification of rhinoplasty. Plast Reconstr Surg.122: 944-950,
2008. [Crossref]
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this edema lasts approximately six months. It is mainly observed in 9. Tebbetts JB. Open and Closed Rhinoplasty (Minus the “Versus”): Analyzing
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thick and mestizo skin. Another disadvantage of this technique is, that
it requires an extended learning curve, to avoid misplacing the 10. Campbell CF, Pezeshk RA, Basci DS, Scheuer JF, Sieber DA, Rohrich RJ.
Preventing Soft-Tissue Triangle Collapse in Modern Rhinoplasty. Plast. Reconstr.
incision and careful dissection of the flaps to prevent damaging the Surg. 140: 33e, 2017. [Crossref]
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consider that potential damage such as necrosis of the mucosa could Rhinoplasty approaches, closed versus semiopen: a comparative study. Pan Arab J
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various maneuvers described.
Within this group, we can include the technique "delivery,"
considered a closed technique. This present technique characteristics
are similar to that described in the present work, since it exposes the
alar cartilage without an external incision. However, unlike what, it
was made through two parallel intranasal incisions, marginal and
intercartilaginous, which extend to the columella and nasal septum.
This double incision can easily develop abnormal scarring, disruption
of the internal nasal valve, due to the poorly executed
intercartilaginous incision [12] and defects at the soft triangle, due to
an inadequate incision and careless dissection [10]; All these reasons
support our preference for the semi-open technique, described in this
work.
In conclusion, the semi-open rhinoplasty provides the benefits of
both techniques: closed, because the incisions are limited only to the
nasal vestibule, without an external scar; and open, because the
technique widely exposes the nasal vault, in order to make all the
changes needed to the osteocartilaginous frame.
Declarations
• Acknowledgments: Not applicable.
• Funding: We have not received support funds.
• Availability of data and materials: The data and materials of this
study are available to interested parties.

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