Open Access Rhinoplasty: Can You Count On A Nice Nose?

All modern surgeries, and even plastic surgery, tend to be minimally invasive and reduce trauma. The access is literally made through punctures and a very large area can be accessed. Of course, in a jewelry store like nose plastic surgery, closed surgeries quickly gained popularity. With all due respect to advanced technologies, however, conservative methods are essential.

Open nose jobguarantees the highest accuracy and predictable results even in the most difficult and atypical cases, as the surgeon has full access to the tissue and visual control of the surgical field. And this is the guarantee that the business will be crowned with success and the nose will be given a pre-planned shape, without unpleasant surprises.

The guarantees are good, but many patients are confused by the long recovery time and the prospect of a visible post-operative scar on their face. But everything is not as scary as it seems: finding out when such an access is really necessary, how traumatic it is and whether it leaves such noticeable marks.

Indications for an operation

With an open (external) rhinoplasty, the incision runs not only from the inside along the mucous membrane, but also through the columella - the septum between the nostrils, i. e. outwards. In addition, all of the soft tissue is lifted and the osteochondral base of the nose is exposed, allowing the surgeon to see the entire surgical area directly. This approach is particularly indispensable when performing complex operations, including reconstructive operations. With its help, the following is corrected:

• congenital pathologies - curvature of the septum, cleft lip and palate, too narrow nasal passages, different variants of turbinate hypertrophy;
• The consequences of injuries are cartilage displacement, fragmentation or curvature of the bridge of the nose, disorders that lead to atrophy of the mucous membrane.

An open method of rhinoplasty is indispensable when several anatomical structures of the nose are involved in the surgical process at the same time. For example, changing the wing is almost never an independent task - it is usually just one of the stages of a complex operation. Reducing the fullness of the tip of the nose also requires a series of surgical interventions that, in one way or another, affect the adjacent tissues and cartilage. And, depending on the task at hand, even a tip correction can be an indication of open intervention - to change, raise, straighten or narrow the incline of the dome. Arguments for one or the other rhinoplasty method can be found on the Internet, but they usually require explanation and cannot be considered generally valid: It depends on the specific problem of the respective patient.

For aesthetic reasons, the technique is used for:

• narrowing of the bridge of the nose, its orientation;
• Cutting the length;
• Insertion of implants;
• Decrease in the height of the bridge of the nose;
• Asymmetry correction, dome improvement;
• Re-rhinoplasty - eliminating unsatisfactory results from previous operations.

The choice is also due to the anatomical features of the organ: weak cartilage, too thick skin, the need for serious osteocorrection - these factors make the use of a closed access difficult and sometimes completely impossible.

Age restrictions

• In children under the age of 18, plastic surgery is generally not shown, including rhinoplasty. In adolescence, the formation of the nasal cartilage is still going on. Exceptions are only special cases if the operation is necessary for medical reasons: for example in the case of injuries or congenital malformations.
• The optimal time for an open rhinoplasty is 25-40 years. At this age, people usually get rid of congenital and acquired aesthetic defects of the nose.
• The most common surgery for patients over 50 is to remove age-related asymmetries and what is known as the "beak" - an unsightly change in which the tip elongates and curves downward, and to solve problems with snoring or breathing difficulties. You need a particularly thorough preoperative examination, but doctors do not set an upper age limit - the main thing is that you are in good health.

advantages and disadvantages

The main advantages of the open method:

• the surgeon's ability to visually follow every step of the operation, all his actions and to work as accurately as possible (this is especially important, for example, when suturing the arches of the alar cartilage, where the slightest mistake can cause a noticeable curvature);
• when working with implants - the ability to safely and correctly fix them.

In comparison, closed nasal surgery is considered more difficult because the surgeon has very limited access through incisions in the mucous membrane in the nostrils. There are no visible postoperative scars, but at the same time the doctor is forced to work blindly and literally orientate himself by touch, which significantly increases the risk of inaccurate adjustment of the nasal structures, asymmetries and other complications.

The main disadvantages are:

• Injury operation with an external cut. Severing the columella damages the vascular bundles that supply blood to the tip of the nose. Because of this, it takes a long time to heal.
• The presence of a scar that is visible from the side, looks unaesthetic and "reveals" the operation performed.

The fact that an open nose job is more traumatic is a common misconception. During closed work, almost the same volumes of tissue are corrected and, accordingly, injured, the only difference is that the doctor cannot fully assess the consequences of his actions, while with an external incision it is possible to visually monitor the progress of the operation. Accordingly, the surgeon acts as gently as possible without touching other tissue and reduces the risk of complications to zero. And in this regard, an open operation can be seen as even more economical.

Also about the visible scar is the not entirely correct statement, too bloated by the supporters of the closed method. From the side, the seam area can only be guessed by a very careful, meticulous examination. Until the patient points a finger himself - they say, "I had plastic surgery, but a scar" - no one will ever advise it. And now imagine that on one side of the scale there is a guaranteed success of the operation and the achievement of all the planned goals with a scarcely noticeable scar, and on the other hand there is a complete absence of external traces, but not a particularly predictable result. Which of the following would you choose?

Either way, your plastic surgeon will help you weigh the pros and cons. He estimates:

• Respiratory anatomy;
• the presence of bone and cartilage defects and the extent of the intervention required (cutting off the bone, using a graft, reducing or expanding the air sinuses, etc. );
• the general complexity of the surgical intervention - the number of manipulations and their specific localization (tip of the nose, bridge of the nose, midsection of the back);
• the presence of such operations in the past and their effectiveness.

And already with a complete picture, he decides whether an external incision is necessary or the procedure can be carried out in a closed manner.

Types of open rhinoplasty depending on the problem

External access surgery is suitable for any part of the nose. Let's take a closer look at the most popular options:

What should be done	How it is done
Tip correction	As a rule, it is aimed at sharpening and aligning the nasal dome in relation to the back, as well as eliminating the effect of "sagging" or, on the contrary, excessive snub nose. During the operation, the pterygoid cartilage is loosened, excess tissue is removed, sutured and the desired shape of the tip is made. With such manipulations, it is very important to achieve perfect symmetry, so an open technique is quite appropriate here, as it guarantees the maximum accuracy of the surgeon's actions.
Removal of the hump	It begins with the exposure of the nasal skeleton. In the case of small defects, it is sufficient to grind with a rasp. In other cases it is necessary to cut off some of the cartilage and bone tissue. Next, the gap is closed - either by suturing parts of the back or with an implant.
Correction of the shape of the nostrils	They can be: too wide or too narrow; short or long; rounded "meaty", which gives the shape of a potato; high or low wings; with decreasing effect. As a rule, plastic surgery of the nostrils does not require extensive surgical interventions and can certainly be performed closed. An open technique is used when such correction is performed as part of a more complex operation to correct multiple errors at the same time.
Length reduction	One of the most common ways to shorten the nose is to remove part of the septum, which will cause the tip to blur upwards. Often the same effect can be achieved by shortening the lower lateral cartilage.
Placement of grafts	You can resort to prosthetics for almost all of the above tasks. And in this case, performing open-access surgery is the best option. The most common autochondrod transplants used are those made from the patient's own cartilage tissue. The extraction points can be the auricles, ribs or the nasal septum. You are hired for: Modeling the bridge of the nose; Tilt correction; Strengthening the tip to avoid drooping as it ages.

How's the operation going?

Open rhinoplasty is performed under general anesthesia. The dosage of the drug, its administration and the subsequent exit of the patient from drug-induced sleep are controlled by the anesthetist. The duration of the surgeon's activity depends on the number and complexity of the tasks he is faced with. Let's analyzethe procedure using the example of hump and nose tip correction:

• The surgeon makes an incision along the inner surfaces of the ala, along the edge of the lower lateral cartilage, with the intersection of the columellar skin.
• Soft fabrics are removed with a special crochet hook. Then the cartilage is separated from them - sharp scissors are used for this.
• The cartilaginous part of the cusp is cut off with a scalpel. If necessary, a protruding bone is excised with a special instrument - an osteotome.
• An osteotomy is performed on both sides of the back to move the bone structures and close the "lid" of the nose. The graft can also act as the latter.
• The surgeon removes portions of the lower lateral cartilage, then sutures their domes to symmetrically narrow the tip of the nose.
• The skin returns to its place. If necessary, the shape and size of the nostrils are corrected.
• Cosmetic sutures are made, narrow curves are inserted into the nasal passages, the back is fixed with plaster of paris (Denver splint).

On average, such an operation takes 2-3 hours, after which the patient is transferred to a ward under medical supervision, where it may be necessary to spend a day or two until the condition is fully stabilized.

recreation

The last phase of hospitalization is a check-up. If everything is okay, the surgeon will let the patient go home according to his results.

There is a misconception that the nose is covered with gauze turundas for several days after a rhinoplasty. I think such long-term tamponing is unjustified, it only slows recovery. In our clinic, we use a gentler method to stop bleeding - with the help of soft turundas, which are removed the next day after the operation. There is no point in keeping them longer and tormenting the patient with it.

The first stage of rehabilitation - 10-12 days after the operation

The nose can bleed easily for several days. Inside, uncomfortable dry crusts form. During this time, it is recommended that you flush your sinuses with salt water. Breathing is a little difficult due to swelling. Many patients report tearing and sore throats for 2-3 days.

In addition, the immobilizing bandage also causes some discomfort on the face. Today, plaster of paris is used less and less to fix the nose after operations, as it has many disadvantages - the quality of its hardening is unpredictable, it is brittle, it crumbles easily. The tissue can be fixed with metal clips with minimal correction, but these are not very reliable, which is why I personally prefer to use artificial fiberglass materials. They are light in weight, keep their shape perfectly and cause a minimum of discomfort to the patient. This bandage can be easily removed after 10 days. After that, you can finally see your new nose, although it is still distorted by edema and far from its final shape.

Recommendations and limitations in the initial phase of rehabilitation after open nose surgery:

• Take drugs prescribed by your doctor - anti-inflammatory, analgesic, antibiotics.
• No activity, no sport! Do not lift anything heavy or make sudden head movements.
• No alcohol - it thins the blood, provokes edema and disrupts tissue regeneration. You have to avoid spicy or spicy food and drinks.
• Only sleep on your back - you can put pillows on the sides so as not to turn over in a dream.
• Eyeglass wearers have to temporarily switch to contact lenses: even light frames press on the bridge of the nose and can deform an unhealed nose.
• Avoid swimming in public places - bodies of water, swimming pools - because of the risk of contagion.
• You can wash your head, but without tilting it down, on the contrary, tilting it back slightly, like in a hairdressing salon.
• With the doctor's permission, you can use bruise resorption gels to speed up the resorption of bruises.

I also advise you not to forget to use a nasal moisturizer that contains normal sea water. After the operation, dryness appears on the mucous membrane, crusts form, which interfere with nasal breathing and can lead to increased bleeding. Regular rinsing with salt water maintains the required moisture, softens the mucous membranes, and cleanses and makes breathing easier.

The first stage of rehabilitation is considered the most important, and all the recommendations of the doctor must be strictly followed! In this case, there should be no healing problems and the nose will become exactly as you initially imagined.

Second stage - next 3 months

The plaster of paris and threads are removed - the patient already feels like a person. Breathing is still a little difficult, but after 1-2 weeks it will practically recover. The contours of the nose are getting closer to the shape they have come to love every day and will soon be almost perfect. Almost - because the end result should be evaluated after six months at the earliest. Even so, within a month and a half after the operation, the patient gets a completely presentable appearance - in any case, it will be possible to appear calmly in public without dark glasses and loads of foundation.

The restrictions are noticeably fewer:

• You can already start non-aggressive physical activity - walking, light stretching. At the end of the 3rd month, let's say a pool. But still no sudden jerks, lifting weights, jumping. Nothing that could somehow provoke the displacement of the fragile structures of the nose.
• Bathing saunas are still forbidden, as is a shower that is too hot or alternating showers.
• No extreme temperature fluctuations - avoid excessive heat or frost. Protect your face from direct sunlight.
• Glasses are acceptable in very light frames and preferably away from the bridge of the nose.

The third phase is the last, from 3 to 7 months

This period is still considered the recovery period. The last remnants of edema disappear, the nose assumes its final shape. It is already possible to draw conclusions about the result of the operation and, if necessary, to plan additional corrections. Although needed in extremely rare cases, this is the beauty of open rhinoplasty.

Until the end of the 4th month, it is better to continue to lead a more or less moderate lifestyle in order to avoid excessive physical exertion and temperature fluctuations. From around the second half of this period almost all restrictions are lifted - however, this should only be carried out by the surgeon who operated on you based on the results of a routine examination.

Contraindications for an open rhinoplasty

In essence, it is a classic operation with anesthesia, incisions and some blood lossit cannot be done if the following factors exist:

• chronic diseases and the risk of their exacerbation after surgery;
• dermatological problems on the face, pronounced inflammatory rashes;
• Viral and infectious diseases;
• Internal organs pathology;
• Oncology;
• Violation of the blood picture, diabetes mellitus;
• Cardiovascular problems;
• Age under 18 years.

Specific contraindications are the presence of the slightest cold or condition immediately after a cold while sinus swelling persists. For some other operations it would be possible to close your eyes for this, but in preparation for a rhinoplasty, the condition of all ENT organs (especially the nose) is assessed and it must be optimal.

Possible complications and side effects

The undesirable consequences of the operation are divided into functional ones that directly affect the patient's health:

problem	Reason and solution
Feeling constipated and loss of smell	Don't worry, this is a swelling and is temporary. Soon the nasal passages will be free, breathing will be easier and you will be able to distinguish smells again.
Profuse bleeding	See your doctor, he will prescribe vasoconstricting medication
Tissue necrosis	The reason is poor blood circulation. Symptoms are paleness or even blue discoloration of the local skin area, pain on touch. Immediate medical advice is required. A new plastic may be necessary.
Wound infection, abscesses (accumulation of pus in the tissue)	Drainage and an antibiotic regimen are required. Symptoms are redness, severe swelling, itching, fever.
Narrowed nasal passages	It occurs when the bone structures are shifted. Additional correction will most likely be needed to widen the sinuses.

and aesthetically, they only affect the external result of the operation:

problem	Reason and solution
Keloid scarring	Depending on the individual characteristics of the patient's skin. In the initial stages (up to six months), it is corrected less often with steroid injections - with ointments and plasters for scars. Cosmetic resurfacing will be possible in the future.
Raising or lowering the tip of the nose, different shapes or sizes of the nostrils	Probably a misjudgment by the doctor. Surgical correction is required.
Curvature of the bridge of the nose, its excessive narrowing or width	Another mistake by the doctor. And the same solution is corrective surgery.
Adhesion dent	Not scary, you just need to do a dissection. The procedure is quick and painless and is performed under local anesthesia.

One of the complications of open rhinoplasty is the subsequent manifestation of the vascular network - the so-called rosacea. One of the factors in its development is free subcutaneous cartilage graft. However, the enhancement of the microvascular pattern on the skin surface after a rhinoplasty occurs in very rare cases and usually disappears over time.

Another complication that is often feared on the Internet is permanent loss of smell. This situation is only possible in theory, it does not happen in practice. 99. 9% of people who suffer from lack of smell got sick from the flu, head injuries, or birth trauma, but that's a whole different story and the surgery has nothing to do with it.

In the case of open rhinoplasty, all cases with a serious violation of the aesthetics or functionality of the nose are the exception to the rule. And they are linked either to the patient's failure to comply with the recovery regime or to the doctor's illiteracy. If all is well with these two factors, the risks are minimized and only a predictable result remains.