Aesth. Plast. Surg. 30:155158, 2006 DOI: 10.

1007/s00266-005-0125-x

Closed Rhinoplasty with Marginal Incision: Our Experience and Results

Stefano Bruschi, M.D., Maria Alessandra Bocchiotti, M.D., Maurizio Verga, M.D., Nicola Kefalas, M.D., and Marco Fraccalvieri, M.D.
Department of Plastic Surgery, University of Turin, via Cherasco 23, Turin 10100, Italy

Abstract. Supporters of traditional rhinoplasty and promoters of open rhinoplasty have debated their approaches for many years. From among dierent possible techniques, a surgeon must always choose the approach that provides the best aesthetic result. The surgeons experience and artistic sense are essential for the closed technique, whereby most of the corrections are performed without exposing the nasal frame. The open technique allows a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. This report highlights the marginal technique, described in 1990 by Guerrerosantos, which uses a twosided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach, together with the extramucous technique, permits complete exposure of the skin and nasal septum without a columella incision. Therefore, the marginal technique is suitable for primary rhinoplasty cases in which complex modeling of the nasal tip and an excellent aesthetic result are required. Key words: Closed rhinoplastyExtra mucous techniqueMarginal techniqueOpen rhinoplastyTraditional rhinoplastyTwo-sided circular incision

Supporters of traditional closed rhinoplasty and promoters of the open rhinoplasty technique have debated their approaches for many years. From among dierent possible techniques, a surgeon must always choose the approach that provides the best aesthetic result.
Correspondence to M. Verga; email: maurizioverga@ yahoo.it

A surgeons experience and artistic sense are essential for the closed technique, in which most of the corrections are performed without exposing the nasal frame. The open technique, with the incision made in the columella, allows the nasal skin to be lifted o the tip of the nose, permitting a greater operating range with a direct view of the nasal structure, resulting in improved precision in modeling the cartilages. However, the absence of intact skin cover exposes the surgeon to a less precise overall aesthetic evaluation. For this reason, we believe it is not the skin scar on the columella, which usually is hardly visible, that deters the use of open rhinoplasty, but rather the reduced ability for intraoperation evaluation of the proportions of the nose [7]. According to the preceding description, the surgeon should not choose to use open rhinoplasty for all patients. However, if nasal shattering is massive, it may be necessary to forego an optimal aesthetic evaluation in favor of good nasal tip modeling. This can be the case with posttraumatic noses, cleft lip and palate, and complex secondary rhinoplasties in which the open method has been the primary technique. In this report, we highlight the marginal technique, described in 1990 by Guerrerosantos [5]. The marginal technique uses a two-sided circular incision permitting complete dissection of the alar cartilages and the overhead skin cover of the columella. This approach together with the extramucous technique makes it possible to visualize the entire cartilage frame of the tip and nasal septum without a columella incision. The marginal incision negates the use of open rhinoplasty in the case of borderline noses. In these borderline cases, there are signicant anatomic alterations of the tip, but these are not suciently severe to require the use of the open technique. Therefore, the marginal technique is indicated for

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Closed Rhinoplasty with Marginal Incision

Fig. 1. Case 1. Deviated nose with nasal obstruction corrected by functional and aesthetic rhinoplasty using the marginal incision technique. Preoperative and postoperative frontal and lateral views are shown.

primary rhinoplasty cases in which complex modeling of the nasal tip and excellent aesthetic evaluation are required.

tip modeling techniques, according to the corrections that need to be made. Discussion

Materials and Methods For the past 7 years, we have used the marginal incision technique in rhinoplasty to treat 107 patients (46 men and 61 women) with a mean age of 42.3 years (Figs. 1 and 2). Surgical Technique The marginal incision starts at the medial crux at the caudal columella level and proceeds along the margin of the columella to the medial crux up to the dome, where the incision is placed a few millimeters inside the margin. The incision then follows the border of the lateral crux up to its caudal pars. Detachment of the mucous from the body of the medial and lateral crux continues until the triangular cartilage is shown. The detaching is extramucous and under the submucosal aponeurotic system (SMAS), freeing the alar cartilage arch from the vestibular mucous. Through this incision, it is possible to expose the cartilage frame of the tip and the septum because the medial crux is separated such that the edge of the septum is exposed and dry from its perichondrium (Fig. 3). This permits a wide variety of possible choices among

Rhinoplasty alters the aesthetic appearance and functional properties of the nose with surgical manipulation of the skin, underlying cartilage, and bone. The incision chosen by the surgeon classies the rhinoplasty as open or closed. With open rhinoplasty, the surgeon makes a small incision in the columella between the nostrils. The skin drape is completely lifted up from the nasal tip, and then additional incisions are made inside nose. Closed rhinoplasty is characterized by incisions only in the interior of the nose so that skin drape remains unchanged and attached at the columella [2]. We stress the use of traditional rhinoplasty in primary aesthetic rhinoplasty, and limit the use of the open technique to more complex cases such as those involving cleft lip and palate, posttraumatic noses, and secondary rhinoplasty [12]. To obtain a wide view of the nasal cartilage structures and to avoid cutaneous scars, it is possible to use a marginal bilateral incision allowing complete subversion. In fact, open rhinoplasty allows a better view of the cartilage structures to the detriment of a better aesthetic evaluation. The main advantage of open rhinoplasty is that the surgeon can work on the nasal cartilages more easily in their natural position.

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Fig. 2. Case 2. Deviated nose with nasal obstruction corrected by functional and aesthetic rhinoplasty using the marginal incision technique. Preoperative and postoperative frontal and lateral views are shown.

Fig. 3. The marginal incision. The surgical procedure for exposing the cartilage frame of the tip and the septum is shown.

However, the direct relation between the cartilage structures and skin coverage is lost, limiting the evaluation between dorsum and tip projection [9]. The dierence between the open and closed techniques is simply the columella external incision permitting the surgeon to view the complete cartilage framework. The visible incision usually is across the columella and appears as a step or an inverted V, allowing the nasal skin to be lifted o the tip of the nose. The advantages of open rhinoplasty include direct exposure and assessment of the osseocartilaginous framework, with precise modication of the cartilage frame abnormality and more options for changing and stabilizing the framework. The disadvantages of the open technique include the transcolumellar scar, with the possibility of a hypertrophic reaction or columellar ap necrosis [6]. Various articles in the rhinoplasty literature describe valuable statistical analyses of large

rhinoplasty series managed with the closed approach. However, similar reports on open rhinoplasty are rare [8]. In a comprehensive statistical analysis of 500 consecutive rhinoplasty cases treated with the open approach, the transcolumellar scar was found to be unnoticeable in 97% of the cases, noticeable but acceptable in 2.2%, and unacceptable in only 0.8% of the cases, according to the patients subjective evaluation of the rhinoplasty [8]. Other authors in the literature quoted similar results [1]. The greatest disadvantage is the extensive dissection of the skin over the osseocartilaginous framework. This increases operative time, persistent postoperative nasal tip edema, and numbness and consequent scar tissue contraction, as compared with closed rhinoplasty. Thus, the columellar scar is not the principal deterrent to the choice of the open technique because it can be visible in varying degrees but usually is not noticed at conventional distances.

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In most cases, it is completely accepted by the patients [6]. Use of the marginal technique avoids the risk of interrupting the lymphatic and venous draining of the tip. This is reected in the absence of prolonged postoperative edema, which, according to some authors, characterizes open rhinoplasty. Furthermore, this technique eliminates the risk of mishap to the columellar ap, although this represents a rare complication when the cutaneous ap is detached from the cartilage according to the correct plan. However it can represent a serious complication for an inexperienced surgeon. The marginal incision presents numerous advantages over the traditional techniques (transcartilage or eversion). First, it allows a wide operating area and a direct view of the anatomic structures of the nasal tip and the base of the septum, which make modeling easier. Second, there is only one incision line, and it is not over the nasal valve. Finally, it allows greater predictability of the aesthetic proportions of the nose. Using the marginal incision technique, the surgeon has the ability to correct the alar cartilages with ad hoc suture stitches, especially when better tip projection is needed or a bulbous tip requires accentuation of the domes angle [13]. In the past, to obtain this projection, it was essential to interrupt the domes using the Goldman or Ponti techniques or inserting grafts [4,10,11]. The current practice tends to avoid these techniques for tip modeling, instead using nonabsorbable monolament stitches, which allow for a better aesthetic result and more natural tip conformation [3,1315]. With the marginal technique, the current practice in tip modeling mentioned earlier is possible. The nal aesthetic outcome is better because the relationship between the dorsal slope and tip projection can be optimized. This, in our opinion, is fundamental in obtaining an optimal aesthetic result.

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