Incisions and Approaches

Incisions are methods of gaining access to the bony and cartilaginous structures of the nose, and include transcartilaginous, intercartilaginous, marginal, and trans-columellar incisions. Approaches provide surgical exposure of the nasal structures including the nasal tip and include cartilage-splitting (transcartilaginous incision), retrograde (intercartilaginous incision with retrograde dissection), delivery approach (intercartilaginous + marginal incisions), and external (transcolumellar and marginal incisions) (Table 1). Based on an analysis of the individual patient’s anatomy, appropriate incisions, approaches, and tip-sculpturing techniques may be selected.^3-5

I. Trans-cartilaginous incision or cartilage-splitting approach – technical considerations

As demonstrated in the accompanying figures, use a two-prong retractor and the middle finger of the non-dominant hand to expose the lower lateral cartilage (LLC). Locate the caudal and cephalic margins of the lateral crura. (The surgeon must identify the cephalically positioned lateral crus when it is present prior to executing this incision.) Make an incision through vestibular skin only 5 to 8 millimeters cephalic to the caudal margin of the lateral crus of the LLC incision. With scissors, dissect free the vestibular skin in a cephalic direction to just beyond the cephalic edge of the lateral crus (Figure). Then, incise the lateral crural cartilage and free the cephalic portion (to be removed) from its remaining soft tissue attachments by dissecting superficially to it in the supra-perichondrial plane. Use a skin hook to retract the caudal vestibular skin and another skin hook to retract the nostril margin. An assistant may hold the skin hook that retracts the nostril margin, while the surgeon grasps the cartilage to be removed and completes the excision by dividing any last soft tissue attachments with scissors (Figure). ^3-5

II. Delivery approach – technical considerations
A. Intercartilaginous Incision

Using a two prong retractor, evert the caudal margin of the nostril and, by applying pressure with the middle finger of the non-dominant hand, present the gap between the caudal margin of the upper lateral and the cephalic margin of the lower lateral cartilages. With a scalpel, make an inter-cartilaginous incision in this location (Figure). ^3-5

B. Marginal Incision Using a two prong retractor, evert the caudal margin and, by applying pressure with the middle finger of the non-dominant hand, define the caudal margin of the lower lateral cartilage. Pressing cephalad on the nasal dome will cause the caudal margin to present itself laterally. Remember that the non hair-bearing area is a guide to the caudal margin of the lateral crus. Furthermore, palpation of the cartilage edge with the handle of the scalpel can be helpful before cutting. Using the two prong retractor to obtain proper exposure, make the marginal incision just caudal to the caudal edge of the lower lateral cartilage (Figure). Great care must be taken as the lateral incision nears the midline. Make sure that the incision follows the cartilage edge and does not take a “short-cut” along the alar rim, which can damage the facet area. Great care must be taken not to cut across a narrow dome or intermediate crus. ^3-5

C. Delivery of lower lateral cartilages

Re-insert the two prong retractor into the nostril with the intercartilaginous and marginal incisions and re-present the caudal margin of the lower lateral cartilage with the aid of pressure from the third finger of the non-dominant hand. Use a slightly-curved, fine-pointed dissecting scissors to lift and dissect the soft tissues from the surface of the lower lateral cartilage (Figure). Perform this dissection by inserting scissors into the marginal incision laterally, and then separate the perichondrium of the lower lateral from the overlying external skin and soft tissue with a spreading motion. If this is difficult, caudal traction on the vestibular skin underlying the lower lateral cartilage, with a fine two prong hook, will facilitate this maneuver (Figure ) by pulling the lateral crus into the vestibule and thus opening up the potential dissecting plane. Avoid damaging the overlying muscle and nasal vasculature.^3-5 Do not work too far laterally. The lateral one quarter of the lower lateral cartilage should be avoided by the surgeon in nearly all cases.

Place the hook end of a Nievert (or other similar) retractor through the inter-cartilaginous incision and draw the now-free lateral crus down, like a visor, until it presents outside of the vestibule. It can be held in this position by the Nievert, or by another suitable instrument (Figure). Examine the lower lateral cartilages for unique anatomical features and asymmetries.

III. The external (open) rhinoplasty approach

Background
The external rhinoplasty approach to the nose provides maximal exposure of the lower lateral cartilages, upper lateral cartilages, middle nasal vault, and bony nasal vault. ^3,6-13. The incisions used in this approach include a transcolumellar incision connected to bilateral marginal incisions. The actual configuration of the transcolumellar incision is not as critical as the placement of the incision. The incision should be made at the level of the midcolumella where the caudal margins of the medial crura lie close to the skin and can support the incision to help prevent a depressed scar. An inverted -V incision, or some other “broken-line” incision, is used to break up the scar and lengthen it to minimize scar contracture. (SEE BELOW FOR 4 EXAMPLES OF OPEN RHINOPLASTY SCARS) The surgical dissection must be performed in the proper areolar tissue planes to minimize tissue damage and scarring, maintain hemostasis and maximize redraping of the skin-soft tissue envelope. Dissection in proper tissue planes will help preserve vascular structures of the flap, insure flap viability, and minimize bleeding, postoperative edema, and scarring.²

Before and after Revision Rhinoplasty - OPEN

Before and after Primary Rhinoplasty - Open

Before and after Revision Open Rhinoplasty

Before and after Rhinoplasty - Open

A. Marking the trans-columellar incision. Begin by outlining the transcolumellar incision used in the external rhinoplasty approach with a marking pen. Mark an inverted-V transcolumellar incision at the level of the midcolumella (Figure). The midcolumellar incision should be marked midway between the top of the nostril and the base of the columella, where the caudal margin of the medial crura lie just beneath the skin to provide support for the incision. The midcolumellar incision will be connected to bilateral marginal incisions which are placed just caudal to the caudal margin of the lateral crura (Figure). The marginal incision should not be made along the rim of the nostril (rim incision). The marginal incision may be marked with a marking pen as well.

B. Midcolumellar incision. Using an 11 blade with a “sawing motion,” follow the mid-columellar markings to complete the midcolumellar incision. Proceed medial to lateral on one side of the columella, and then the other. Take special care to keep the blade perpendicular to the skin edges, thereby preventing bevelling of the skin edges. (Bevelling of the skin edges may lead to a “trapdoor” deformity with evemntual unacceptable scar). As one incises laterally, be careful to stay superficial to avoid damage to the caudal margin of the medial crura. Use a 15 blade to make the columellar extension of the marginal incision on both sides of the columella, 1 to 2mm behind the leading edge of the columella (Figure). This incision is made along the caudal margin of the medial and intermediate crura. By minimizing the dissection over the medial crus, damage to this cartilage can be avoided.

C. Marginal incision. Beginning laterally, make a light incision through vestibular skin 1 to 2 mm caudal to the caudal margin of the lateral crura. Follow the caudal margin of the lateral crura as you extend the incision medially.

D. Define the columellar flap. Using angled Converse scissors, or another suitable dissecting scissors, elevate the thin vestibular skin of the flap that covers the medial crura. Insert the scissors beneath the columellar extension of the marginal incision and dissect medially in the correct plane of dissection, below the musculoaponeurotic layer (Figure). Repeat this maneuver on the opposite side. The scissors should then pass superficial to the caudal margin of the ipsilateral and then contralateral medial crus (Figure). Guide the scissors through the opposing columellar extension of the marginal incision. During this dissection, take special care to avoid damaging the flap. Use the scissors to spread the tissues in the plane of dissection (Figure).

E. Flap elevation. Use the Converse scissors to complete the mid-columellar incision without bevelling the incision or damaging the medial crura (Figure). Take special care to avoid bevelling this incision. Use a narrow double prong hook to retract the flap. The paired columellar arteries typically need to be cauterized with bipolar cautery (Figure).

F. Three-point countertraction. To elevate the skin soft tissue envelope over the nasal tip, 1) place a wide double prong hook along the margin of the nostril rim caudal to the lateral crus, 2) place a small double prong hook on the columellar flap, and 3) place a small double prong hook on the vestibular skin side of the intermediate crus (Figure). Then, use Converse scissors to dissect the columellar flap from the caudal margin of the medial and intermediate crus as the counter-traction acts to expose the areolar tissue plane. The scissors are used to expose the caudal aspect of the lateral crus as well. Then, the dissection advances cephalically over the surface of the lateral crus. As the dissection continues along the surface of the lateral crus, soft tissue is elevated leaving only perichondrium on the cartilage. As dissection proceeds laterally along the lateral crus, cut the vestibular skin along the caudal margin of the lateral crus, thereby completing the marginal incision. Make small, calibrated cuts under direct vision to avoid inadvertently cutting through the lateral crus. Limit dissection of the lateral crus to the areolar tissue plane deep to the muscle. A cotton tip applicator can be used to complete the dissection of the lateral crus once the deep aerolar tissue plane has been identified. A portion of the dissection on the opposite side was performed when you undertook the cartilage delivery approach; nevertheless, repeat these maneuvers on the opposite side to complete elevation of the skin-soft tissue envelope over the nasal tip.

Retrograde approach
An alternative approach to this dissection is to begin dissection through the marginal incisions (retrograde dissection).14 In this approach, identify the proper tissue plane and elevate the skin-soft tissue envelope off of the lateral crus. Then proceed medially with scissor dissection toward the domes and intermediate crura. This maneuver is performed bilaterally to achieve elevation of the skin-soft tissue envelope.

Retrograde dissection is helpful in cases where the surgeon is having difficulty following the caudal margin of the intermediate and lateral crus. This is not unusual in cases where there is buckling of the intermediate crus or domes. Retrograde dissection may not be the approach of choice for secondary rhinoplasty when the lateral crura has been excised or previously resected. However, the retrograde approach can be extremely helpful in secondary rhinoplasty cases in which the primary surgery was performed via an external approach, when the medial crura dissection is hindered by excessive scarring.

G. Midline dorsal dissection. Divide fibrous connections in the midline near the surface of the domes to release the flap and allow dissection cranially. Do not dissect tissue from between the domes; otherwise a midline band of tissue may be left on the flap. Shift the dissection to the midline where the anterior septal angle is identified with a spreading action of the Converse scissors or other suitable dissecting scissors. Once the blue hue of the cartilaginous middle-third of the nose has been identified, create a midline tunnel over the cartilaginous middle vault. Then use a cotton tip applicator to bluntly dissect the soft-tissue envelope cranially and laterally (Figure). This maneuver will frequently expose sizable blood vessels that can be spared as they are dissected laterally. Depending on the degree of exposure that is needed, some fibrous connections may need to be cut near their attachment to the cartilaginous nasal vault. Muscle and vessels can be spared by dividing tissues close to the surface of the cartilages.

H. Closure of columellar incision For the transcollumellar incision, it is important to have a tension free closure. Consider using a deep suture if there is any tension. Evert skin edges, pay meticulous attention to proper skin edge alignment, and be careful to avoid notching. Be careful not to BEVEL the incision to avoid a “trap-door” abnormality.