Alar Cartilage Approaches
Dr. Sam Rizk, a board certified facial plastic surgeon and New York Rhinoplasty specialist has established and will summarize certain contouring techniques for the nasal tip during tip rhinoplasty. Contouring with volume reduction of the alar cartilages can be classified into 3 categories:
1. Cephalic cartilage volume reduction with preservation of an intact complete caudal cartilage strip.
2. Cephalic cartilage volume reduction with caudal complete strip preservation with a shape change induced by sutures or by cartilage attenuation techniques.
3. Cephalic cartilage volume reduction with vertical dome division and/or lateral crus, medially or laterally.
To achieve alar (lower lateral cartilage) cartilage contouring, one must choose an approach based on the anatomy encountered and the degree of exposure required to satisfactorily effect a pleasing contour modification.
Dr. Sam Rizk customizes his rhinoplasty procedures and believes that one technique or approach is not adequate for all patients. Dr. Rizk has developed a graduated approach to endonasal tip surgery versus open nasal tip surgery. Using the endonasal approach can progress from less invasive to more invasive. The endonasal less invasive approaches can be classified into either nondelivery approaches to the lower lateral cartilage or delivery approaches to the lower lateral cartilages. Of course, the more aggressive open approach are a last resort but are indicated in situations where major tip support and definition is needed and especially in revision rhinoplasty patients where the anatomy may not permit an endonasal approach in some revision rhinoplasty patients. As such, Dr. Rizk feels a true rhinoplasty surgeon is an artist and should not limit his techniques to only "open" or "closed" rhinoplasty. A true artist has an open mind and will change his techniques and instruments used to adapt to a new situation or to achieve a more superior result.
In Nondelivery approaches, it requires minimal dissection disturbance of the alar cartilages and generally ensures more symmetric healing and produces fewer risks of unpredictable healing. Since tip surgery constitutes a bilateral operation where ultimate symmetry is very important, minimal disturbance to an already asymmetric tip makes operative sense. Although believed by some to be technically more difficult, Dr. Rizk finds little difficulty in employing this nondelivery minimally invasive approach. Dr. Sam Rizk states he prefers nondelivery minimally invasive rhinoplasty approaches in some primary rhinoplasty surgeries where patient anatomy permits its use.
Additional virtues of the nondelivery rhinoplasty approaches include:
1. relative resistance to cephalic rotation
2. A single endonasal incision
3. Preservation of existing tip projection
4. Relative resistance to tip retrodisplacement and postoperative tip ptosis.
Dr. Sam Rizk believes that the endonasal minimally invasive tip rhinoplasty with the nondelivery approach has a recovery of only a few days with no bruising and is best used in situations where a subtle finesse rhinoplasty is needed.
In Transcartilaginous (cartilage-splitting) approaches, Dr. Rizk believes this approach is excellent in patients in whom a conservative tip sculpture is indicated and minimal tip rotation is desired. Advantages include a single incision, diminished tip edema and scarring, complete preservation of facets, and if a complete strip is preserved, a relative resistance to cephalic rotation in patients where tip position and projection is already anatomically correct or requires only minimum rotation. Postoperative tip ptosis or retrodisplacement is largely avoided. Properly performed in selected anatomic situations, predictable healing with preservation of symmetry and support is consistently achieved. Cephalic tip rotation is likely if an interrupted strip is fashioned; varying degrees of loss of tip projection may be expected as well. In patients demonstrating abnormal divergence of the intermediate crura, with a wide intercrural distance, the cartilage-splitting approach is insufficient for proper repair, since in these patients the domes must ordinarily be exposed and sutured together for satisfactory narrowing.
In the retrograde, or eversion approaches, Dr. Rizk believes this approach is an alternative to the transcartilaginous approaches and is useful in patients requiring conservative tip modeling. In reality the two approaches are interchangeable. After retrograde undermining of the vestibular skin, conservative sculpturing of the lower lateral cartilage is accomplished bilaterally. The advantage to this approach is that it eliminates undesirable scarring or asymmetric healing in already pleasing caudal alar cartilages. Also, since minimal tissue void is created, more cartilage is preserved and scar contracture is minimized. Tip rotation is therefore avoided if a complete strip is preserved. Dr. Sam Rizk, a NYC facial plastic surgeon and rhinoplasty specialist, prefers to use the retrograde and transcartilaginous approaches for patients requiring only moderate tip refinements with minimal volume reduction, little ti rotation, and where thin skin coupled with wide or thick alar cartilages demands maximal alar cartilage preservation for support and tip symmetry. Dr. Rizk further states that if the alar cartilages diverge unaesthetically, then a delivery approach is perferred.
Endonasal (closed) Delivery Approaches to the nasal tip
Dr. Rizk further states that if there is gross asymmetry, marked bulbosity, excessive or inadequate projection, marked bifidity, soft tissue excess requiring resection, and tip revision are reasonable justifications for endonasal delivery of the alar cartilage with its attached vestibular skin or alternatively reverting to the open rhinoplasty technique if needed. Slightly more transient edema with potential for swelling is expected than non-delivery approaches. Preservation of symmetry or production of symmetry in tips with unequal cartilages is enhanced by delivery of the alar cartilages for contouring under direct vision.
External (Open) Rhinoplasty Approach
In 1934, the first account of the open rhinoplasty was described where and incision across the columellar-labial junction, transecting the columella, and liftiing the nasal tip to gain acces to the nasal skeleton, was described. This approach was revived in 1957 and modified. In 1957, the open approach was limited to the transcolumellar incision of skin only. The entire skin of the columella above the incision was then dissected free from the adherent alar cartilages and nasal skeleton, fully revealiing the anatomy of the tip structures. Many surgeons have since improved the open approach. In the past 3 decades, external or open rhinoplasty has established its usefulness in the surgical correction of a variety of nasal anatomic deformities. Dr. Sam Rizk feels that those surgeons who advocate its use in every rhinoplasty operation are indiscriminate, while those who never employ this approach fail to add another useful tool to their surgical endeavors. It is Dr. Rizk's belief that a true rhinoplasty experienced surgeon should be selective and employ a variety of techniques, tailoring each approach to the patient's specific anatomic findings, using whatever approach achieves the best outcome, whether open or endonasal. Dr. Sam Rizk has innovated and pioneered many techniques in 3d rhinoplasty in both endonasal and open approaches. The 3d high definition adjunct to rhinoplasty allows more precision sculpturing of the nasal skeleton with a less invasive dissection.
So, the proper and appropriate use of the open approach, like the endonasal approach should be selected based entirely on the nasal anatomy encountered. It is important to appreciate that the open rhinoplasty is really an alternative approach to gain access to the nasal skeleton. It is further evident that certain specific nasal anatomic features lend themselves to a better correction through the open approach. The advantages of the open approach include the surgeon's unparalleled ability to expose and diagnose deformities, abnormalities, and asymmetries of the nasal tip cartilages, the cartilaginous and bony pyramid, and the nasal septum. Asymmetries can be appreciated that may have been underappreciated with the endonasal approach. Another advantage is the ability to employ microcautery for exacting hemostasis if necessary, to directly sculpt the alar cartilages and correct asymmetries, to secure tip grafts or other nasal grafts better under direct vision. The disadvantage of the open approach is the transcolumellar scar. However, this scar is camouflaged easily, and in reality is not a common concern of patients prepared for its presence. The scar is created in irregular geometric closure which helps it to be camouflaged easily rather than simply a straight line. Another potential disadvantage is the possibility of prolonged tip swelling or edema in some patients but this can be limited by doing a limited open or external approach.
Dr. Rizk has combined a limited version of the open approach with endonasal approaches where he opens the columella simply to secure a graft and adjust the tip cartilages without completely lifting the flap off of the nasal tip and nasal dorsum. Dr. Rizk then used the 3d endoscopic approach to sculpt the nasal dorsum from internal incisions. Dr. Rizk also has pioneered the use of dermabrading powered instrumentation to custom contour grafts to be placed in the nose. By custom contouring grafts with this dermabrading powered instruments, this creates smooth contours and non-palpable edges versus the traditional method of sculpting grafts with the surgical knife which creates sharp, palpable edges on the grafts.
Finally Dr. Rizk uses tissue glues in the nose instead of the traditional nasal packing either with the endonasal or open approaches to minimize bleeding and seal small blood vessels. This decreases the healing process. Dr. Rizk believes that nasal packing after surgery is painful and also creates more swelling and bruising and a prolonged recovery, in addition to not allowing the patient to breathe after rhinoplasty. For these reasons, Dr. Sam Rizk does not use nasal packing after the rhinoplasty surgery.