The Art of Revision Rhinoplasty using the Closed Technique

The art of revision rhinoplasty has been revised over 35 years of performing this type of surgery using the closed technique.  The open technique limited the surgeon in many aspects of revision surgery.  The open technique does not allow certain degrees of finesse in placing cartilage grafts in exacting locations in order to correct deformities that are found in revisional rhinoplasties.  In my experience, using small incisions and taking cartilage from the septum or the ear, you can accurately place small millimeter-type grafts into various locations throughout the tip, the dorsum, and sides of the nose and spare the patient extensive surgical intervention, which is the case when open technique is used.  The open technique distorts the normal anatomical attachments of the skin to the nasal bones and nasal cartilages, further complicating the surgeon’s ability to perform a natural revision rhinoplasty.

            After harvesting cartilage from the nasal septum or the ear, and occasionally the rib, small incisions are made inside the nose in order to accomplish the reconstructive aspects of this rhinoplasty procedure. Anesthetic used is local in the nose plus intravenous sedation.  Intubation and deep general anesthesia is avoided and, therefore, much less nose bleeding is encountered during the procedure, allowing for even further improvement in technique because of the limited amount of blood loss.  The small cartilage grafts are placed where the surgeon marks the external aspect of the nose with ink in order to allow for exacting placement of the reconstructive cartilage grafts.  The patient is seen in the treatment room preoperatively and in the upright position.  The surgeon has direct communication with the patient prior to surgery, and exact locations for cartilage grafts are discussed and agreed upon by both the patient and the surgeon.  Once the various ink marks are made on the external part of the nose, the patient is then taken to the operating room and given intravenous sedation, avoiding all narcotics and anesthesia gases, which help very significantly in reducing postoperative nausea.  There is very little discomfort to the patient postoperatively, since packing is never used, and nausea after surgery is a rare event.  Discomfort and pain are absolutely minimal because the open technique has been avoided, which prevents unnecessary incisions and unnecessary dissection throughout the nose area.  The exact appearance of the nose is noted right after surgery, and minimal swelling takes place postoperatively.  This avoids the long two to three-month delay in seeing the final result when the open technique is used.

            In conclusion, excellent results are obtained with minimal patient discomfort and quick recovery using the above-described technique.