Despite the popularity of open rhinoplasty, very little has been written about its complications. In 2002, a published series indicated that secondary deformities following open and closed procedures differed in number and type. The purpose of this study was to extend that work and document the procedures used to correct deformities following either access route.
Methods/Technique:
The charts of 100 consecutive secondary rhinoplasty patients were reviewed. Photographs and operative reports generated tallies of the deformities and their corrective procedures. Only endonasal access was used for reconstruction.
Results/Complications:
Eighty women and 20 men were studied. Seventy-four percent of the patients had undergone open rhinoplasties; 26% had been treated endonasally. Open rhinoplasty patients were older (mean age 43 vs. 38 years) and had undergone more surgeries than their endonasal counterparts (3.7 vs. 1.5 rhinoplasties). The open rhinoplasty patients had more preoperative deformities (5.8 versus 3.6 per endonasal patient), and thus required more individual corrective procedures (5.6 per open patient vs. 3.6 per endonasal patient).
Open rhinoplasty patients had more preoperative deformities in their middle vaults, nasal tips (97% vs. 21%), columellae (84% vs. 23%), alar rims (82% vs. 31%), and more obstructions at their internal (81% vs. 50%) and external valves (62% vs. 23%) than patients treated endonasally. Endonasal patients only tied their open counterparts in the prevalence of dorsal deformities (92% vs. 88%).
There were correspondingly large differences in corrective procedure complexity: open patients underwent more spreader grafts (93% vs., 65%), alar wall grafts 94% vs. 50%), and corrections of hanging columellae (44% vs. 19%) than prior closed patients. However, endonasal patients required more dorsal grafts than open patients (92 % vs. 81%). The two groups required the same number of tip grafts (96% open vs. 92% closed).
There were qualitative reconstructive differences between the two groups. Eighty-two percent of open patients required columellar grafts for retractions or deformities, compared to 12% of endonasal patients; 45% percent of open patients needed composite grafts for alar rim defects vs. 4% of endonasal patients; and 44% of open patients required columellar excisions (to correct widening or contour distortions), whereas none of the endonasal patients did.
Perhaps most striking was the lack of correlation between the number of previous rhinoplasties and the number of preoperative deformities, regardless of access route. Ten patients in each group who had undergone only one rhinoplasty had 6.5 deformities (open) and 4.5 (closed), and 10 patients in each group who had the most prior operations had 7.1 vs. 4.5 deformities (open vs. closed, respectively).
Conclusion:
A new review indicates that open rhinoplasty patients have a significantly higher prevalence of secondary deformities in the middle vault, tip, alar rims, columellae, and external valves than endonasal patients and require more corrective procedures, including some (like composite grafts and columellar excisions) that are rarely needed for endonasal patients. However, patients who have undergone only one prior rhinoplasty have almost as many impairments as those who have had multiple operations, regardless of the access route used, which suggests that rhinoplasty is poorly understood by many practicing surgeons.
The scatter of open rhinoplasty deformities clustered around the nasal base (alar rims, columella, external valves, and nasal tip) relates directly to anatomical structures that are most easily distorted by the open approach. The prevalence of hanging and widened columellae is explained by the difficulty of recreating normal basal relationships when struts are needed and columellar anatomy has been disrupted.
Therefore, aside from vascular and patient safety considerations, which are considerable in secondary rhinoplasty, it is also logical to conclude that when postoperative deformities are created by the limitations of a given access route, their required corrections will be best achieved by a surgical exposure that does not carry the same limitations.