Open Rhinoplasty (Structural rhinoplasty)

This is also called open incisional two- or three-section rhinoplasty, though more commonly it is referred to as open rhinoplasty. Conventional surgery is performed by creating an external incision at the bottom of the columella to completely release the intimately connected ligament and fiber tissues between the nasal tip skin and deep cartilage framework, thus making the skin more distensible for nasal tip remodeling. In addition, the intranasal cartilage and osseous structure should be clearly visualized to perform the reduction of the lower lateral cartilage, dome suturing of the nasal tip, correction of the septal deviation (septoplasty), and correction of the nasal bone distortion (corrective osteotomy of nasal bone). Moreover, the autologous nasal septal cartilage or ear cartilage can be harvested to sculpt the nasal tip, which effectively narrows and elongates the nasal tip and solves tricky problems such as nostril exposure, an upturned snub nose, or various bulbous noses. Besides autologous tiplasty, nasal bridge augmentation is not different from general rhinoplasty and uses various materials and models of nasal implants or even total costal cartilage (autologous or allogenic rib) to elevate the overall nasal bridge, thus meeting the patients’ expectations.

open rhinoplasty performed by Dr. Chuang emphasizes on the following surgical characteristics:

• Nasal septal cartilage is preferred to traditional ear cartilage for the nasal tip graft
  In general, the nasal septal cartilage is thicker than the ocular cartilage, which provides stronger support for the tip structure. It also has a large amount and high rigidity, which is abundant for nasal tip sculpting or columnar elongation and is more likely to reshape an upturned nose. Moreover, as the septal cartilage is thick and less likely to be absorbed by the body, with the loss rate estimated to be only approximately 10%, it effectively sustains stable results for a long time and addresses prior drawbacks such as an excessively soft ear cartilage.
• Nasal tip triangle reconstruction and reduction
  The nasal tip triangle expands from the nasal tip to the bilateral alar feet, which contains the nostrils and columella. Plastic surgery in this area constitutes the essence of open rhinoplasty. Surgical conditions comprise the reduction or partial removal of the inferior alar (lower lateral) cartilage, concentrated suturing of the bilateral alar cartilage, support and elongation of the columella, reduction of the nostrils and lateral ala nasi, and most importantly, transplantation of the septal cartilage to the columella and sutured with bilateral inferior alar cartilages to support the nasal tip. As long as the above-mentioned procedures are properly performed, the appearance of the nasal tip will be completely changed from the “gabled” or “round” shape to the “cone” or “triangle” shape, thus achieving the results of obviously reduction of the nasal tip and relatively structures like columella and nostrils.
• Composite nasal tip surgery
  Either type I or L nasal implant can be applied for nasal bridge augmentation in open rhinoplasty, but the results are slightly different. General type I implant surgery must completely rely on autologous cartilage to support the nasal tip, but as the cartilage (particularly the ear cartilage) demonstrates structural softening or absorption, the results are compromised over time and the nasal tip commonly become droopy. To provide the long lasting result, Dr. Chuang refines traditional practices using the modified short type L implant for his open rhinoplasty, where the L strut of the prosthesis is embedded into the deep nasal septa and fixated with bilateral alar cartilages, and the removed nasal septal cartilage is stacked on the nasal tip and columella and stitched to the prosthesis. Such a structure buries the type L implant in the autologous cartilage like a sandwich and effectively enhances the buttress of the nasal tip cartilage to offset autologous absorption of the cartilage, thus sustaining long-term and stable results.

In WiSH clinic, open rhinoplasty can be extensively applied and concurrently performed with the following surgeries:

• Nasal bone reduction (lateral osteotomy of nasal bone)
  This is commonly called “knocking-off” the nasal bone. Because the nasal bone is the foundation of the nose, if it is deviated, the nasal bridge also shifts after rhinoplasty. Therefore, if such a problem is detected prior to the operation, nasal osteotomy will also be simultaneously performed to ensure that the nasal bridge is properly aligned. Another purpose of this surgery is to narrow the original broad base of nasal bridge to remodel a delicate or an exquisite nose. A small incision is made inside the nostril, so it is frequently conducted along with open rhinoplasty.
• Nostril reduction (Alarplasty)
  This is also called alar base reduction. In light of the golden ratio, the bilateral width of the ala nasi should not exceed the distance between the medial canthus (inner corner) of both eyes. Otherwise, the ala nasi would appear hypertrophic and flared, and the nostrils would also be enlarged especially in smiling. In particular, as local patients mostly have broad and hypertrophic nasal tips and wide ala nasi, nostril reduction should be frequently conducted along with augmentation rhinoplasty to reduce the frontal visual area of the nasal tip and restore the oval appearance of the round nostrils. Both internal (scarless) and external incision methods are available, but Dr. Chuang will offer suggestions of proper method based on the patient’s conditions and requirements.
• Nasal fat shaving
  For patients with a wax apple-shaped or bulbous nose, apart from the procedures of concentrated suturing of the lower lateral (alar) cartilage and supporting of the nasal tip with autologous cartilage graft, intranasal excess fats and soft tissues should also be appropriately removed to effectively reduce the volume of the nasal tip. Such a surgery should be conducted from the dorsal side of the skin and can therefore only be performed in open rhinoplasty. Nevertheless, attention should be paid to maintain blood circulation to prevent complications such as nasal tip atrophy or hypersensitivity due to excessively thin skin. Moreover, some patients may suffer from intranasal scar proliferation after nasal fat shaving, which may result in secondary nasal tip enlargement or hypertrophy; therefore, if necessary, traces of steroids will be intranasally injected to inhibit scarring.
• Nasal fat padding
  This is also called nasal fat supplementation or nasal tip skin padding. This surgery is mainly conducted because the thickness of the nasal tip skin is associated with the durability and naturalness from rhinoplasty. In particular, for a minority of patients with a congenitally excessively small tip or thin skin, multiple rhinoplasties, or even those with an upturned nose (short nose) and exposed nostrils, if only the nasal tip cartilage is elongated disregarding the limitation of nasal tip skin, patients may show nasal tip blushing, overt sharpness, or even nasal fat atrophy due to overextension of the nasal tip skin by cartilage grafts, and those in a severe condition will need to undergo revision surgery. To avoid such problems, Dr. Chuang recommends autologous fascia transplantation of the nasal tip in conjunction with open rhinoplasty by grafting the dermal fat tissue from the buttock to the thin nasal tip to provide a buffer between the skin and grafted cartilage, thus effectively improving the nasal tip thickness and naturalness from rhinoplasty and also avoiding the disturbances of an excessively sharp or constricted nasal tip.
• Septal deviation correction
  Nasal septal deviation is a common problem in patients who have undergone rhinoplasty, so it can be corrected along with augmentation rhinoplasty. Dr. Chuang first extracts a partial septal cartilage for later use at the nasal tip and then conducts transfixion suturing within the defective area of the nasal septum (septoplasty) or concurrently performs deep osseous septal osteotomy (septorhinoplasty) to smooth the external airway blocked by the deviated nasal septum and restore the relatively normal respiratory functions. Such a surgery will also correct the crooked nose appearance in patients with a saddle nose or an S-shaped deformed bridge.
• Glabellar augmentation
  The glabella, which is the space between the bilateral eyebrows and nasal root (nasion), refers to the area from the starting point of the nasal bridge upward to the eyebrow horizontal line. Congenital depression or an overt smooth forehead causes the post-rhinoplasty nasion to be too acute or form horizontal shadows at the bottom of the nasion, thus leading to unnatural and artificial results. To avoid such problems, Dr. Chuang recommends emplacing a piece of Gore-Tex at the nasal bridge superior to the nasal implant to augment the glabella, which will smoothly connect the eyebrow ridge and nasal bone and make the forehead and nasal bridge a perfect Y-shaped curvature to set off the soft lines of a female nose. This surgery is frequently performed along with two-section augmentation rhinoplasty; therefore, it is also called three-section rhinoplasty.

Comparison between ear cartilage and nasal septal cartilage