Surgery Spotlight: Primary Closed Rhinoplasty: Personal Experience-Surgery Spotlight: Primary Closed Rhinoplasty: Personal Experience

Surgery Spotlight: Primary Closed Rhinoplasty: Personal Experience

Video Transcription

Hi, I'm Dr. Jober Skavitz, and I'm president of the Rhinoplasty Society, and I'm going to show my personal technique for a closed rhinoplasty approach.  This is going to involve a cephalic trim, showing some techniques to prevent over-resection. It'll show removal of the dorsal hump and then a tip graph that you take from the distal  hump to put into the tip, and then it'll end with perforating osteotomies and a green stick fracture that are done internally, and then finally, alar wedges.  So this is going to be the closed approach. We've marked the patient ahead of time. I talked about analysis previously.  And basically, we've marked, injected, and coconized the nose. In Minnesota, anyway, most people have large, lower, inferior turbinates, and so we're  going to go in with a bipolar and just cauterize them a little bit, usually put this on a setting  of 35, and then we'll take a boy's elevator, and I'll fracture the turbinate laterally called lateralization of the turbinate.  I keep the strings on my cotinoids long so that you don't lose track of them in the back of the throat.  I put the caliper for women to five and men to six and mark it with a little marking pen. You can see I want to mark right along the edge of the lower lateral cruise on the lower  aspect, and then I tattoo where I'm going to do my cephalic trim incision. This would be called an intracartilaginous incision, so now I've got five millimeters  preserved inferiorly towards the points of my thumb hook. So I go up into the domes, and one of the biggest problems is you don't go way up far  enough into the dome to resect a sufficient amount and you end up with a boss afterwards. So with a 15 blade, I'll cut right along where I want to do my trim.  I'll turn the knife around and cut back up into the dome area. To get way up in there, make sure we get every little bit of cartilage.  So the part that's on your left is the part that's going to be removed for the cephalic trim. At this point, you want to undermine the cartilage from the overlying soft tissue.  If you have a real thick skin nose, you might consider taking a little soft tissue with this cartilage, but at this point, I'm going right on the cartilage.  A pair of scissors probably works best here. If the knife seems to be working well, I'll just keep going with that, otherwise I'll change to a scissors.  And I like to use a blunt hook when I can because I've seen a number of patients in town who've had little dents along the visual border of their alar rim that fit exactly  like a sharp double hook. So and then now we're going on the side of the endonasal mucosa, taking that off with a scalpel.  And you want to be very careful, if you can, avoid perforating the mucosa. It's nice to get this out in one piece, it doesn't always happen that way, but the main  thing is you get it all. And then down inferiorly, I want to, inferiorly towards the inside of the nose, I sweep, I  want to sweep a little bit up to preserve just a little bit in Webster's triangle so that they don't get collapsed to the internal valve. So now this piece is coming out nicely.  Looks like we'll get a pretty good donation today.  And then I like to include the scroll area, in particular if they have an ultra-projecting tip to break these attachments to allow the tip to drop back.  So, removing part of the scroll and then the whole cephalic trim intact.  See that coming out like so.  And then you want to go, think in terms of going side to side. So there's the cephalic trim intact. And then the same thing ultimately is done on the other side.  At this point, I'm thinking in terms of a transfixion incision, and so we wanted to set this patient's tip back, so I did a full transfixion incision, meaning I went all the  way through on both sides. If I don't need to set the tip back, then I'll make a hemitransfixion incision, and  the way I'm using that term is that it's made on just one side, but instead of just one side here, we'll poke through, and we'll be releasing the medial crura of the lower lateral  cartilages completely along the septum. So once I've got that through and through, I like to just spread the tissue bluntly with  a male and release the tip attachments to the caudal septum.  Then, if you need access to the nasal spine, this would be the time to go in there and clean off the spine and release the depressor nasae septi if you need to.  We won't be doing that in this situation. So now I go to the septal angle and spread with a Joseph scissors, and we're looking to skeletonize the dorsum.  Once I've got the cartilage undermined with the scissors, then I'll go with the rasp, whatever your favorite tool is to undermine, not the rasp, but the dissector, and then  I'll trim the distal cartilaginous septum. I like to use a scalpel, or you can use a septal scissors, that's probably safer.  Anything's good here as long as you're cognizant if you're using the blade to stay away from the skin on the opposite side.  And the Obergweiser elevator, what I brought out before, was used to undermine the bone, so it went in with an Osteotome and took off the proximal bony hump, and you can see that  comes out like so. At this point, I'll inject the osteotomy sites, and I'm going to show another view of that hump removal in a moment so you get a different angle on it.  That went kind of quick. I always sharpen my osteotomes before I use them, I didn't sharpen the elevator.  And use 10 strokes on each side at 30 degrees, 45 degrees, and then a very fine stroke for one little whisper at 60 degrees.  And most people prefer a rasp for the bony dorsum, so again this is the exact same thing we just did, but I'm showing the side view.  And then I'll use a little guarded up toward the radix area where it narrows out. But probably it would be better to start with a rasp, and if you do, I prefer a push rasp.  The problem with a pull rasp is it's been reported any way you can avulse the upper lateral cartilages.  So the hump I remove is monoblock, and it's taken out like so, I can get the darn thing  out of there. I had trouble from the other view as you saw too, it's the same exact maneuver, again just from a different angle with a second camera.  But again customarily, people would prefer to maybe use a scissors for the cartilaginous dorsum and a rasp.  Now to polish things off, again I mentioned I had trouble with the keystone area over the years. That's where my biggest revision rate is, I'll do a little push rasp, then I'll look  at the distal cartilaginous septum and see if there's just a whisper, and I mean a whisper, just you're taking down fractions of millimeters.  Now since we have the hump intact, I'm going to trim the cartilaginous portion and use that as a sheen or shield graft that I'll insert into the tip area.  I really like tip grafts in general, I think it's nice if you have them to the point where they're thinned down.  One of the problems is they can displace, so you want to make a very precise pocket. So I'll trim the tip graft up, and then since I do want to do a tip graft, and the cephalic  trim doesn't have much support, it avoids going into the septum. So I'll make a little incision here with the 11 blade, that's maybe four millimeters long.  I'll go in with the angle weck scissors, and I've drawn my pocket as precisely as I think I can, preoperatively, meaning in the surgery room, in the OR, but before we started,  and before I injected. And again, you want a very precise pocket. It's easy to make the pocket bigger, so we'll try the graft in there and see if it fits or not.  If it doesn't, we'll go back and enlarge it a little bit. Now this dissection is right down on the dome area, it's not superficial, it's not under the skin.  And I go in with a freer or any kind of elevator just to see if the pocket's got any areas in it that I missed with the scissors.  And then with a little double hook, excuse me, we'll clean off the edge there and then pop that graft in, I usually hold it with a little mosquito, pop it upward, downward.  And if it doesn't look good, just take it out and start over. Now I'm going to show the same exact maneuver from the second camera.  So again, we make a little incision with the 11 blade, we go in with the weck scissors again and fashion our pocket as such.  Again one of the problems with the sheen graft in the tip is you can see irregularities so you want to make sure your graft is very smooth and it can displace over time.  If you want to, you can bring the tip graft into the pocket with a mattress suture of chromic. You only need one needle but you can go in through the tip skin, come out the incision  with the needle, go through the graft on one side, back through the graft on the other and then come back out the skin and pull the graft into the pocket and tie that loosely  over the skin to hold it into place. So pop that back in there, seemed to go in pretty well. The biggest problem is you want to make sure the base of the graft is centered exactly  in the midline so you don't have it cockeyed after surgery and crooked. Then I like to feel and make sure it's in good position.  I close this entry site with interrupted 6-0 Nylons or Fast Guts, good too. Probably use Fast Guts actually more than the Nylon but I use Nylon in this case.  So here's the Osteotome, 10 strokes at 30 degrees on each side. Turn it over, now 10 strokes at 30 degrees.  This is on a whetstone, this is Arkansas Blackstone that I got, you can get them online or whatever you want.  Then 10 strokes on each side at 45 degrees. Then finally go up to about 60 degrees and just a little whisper just to clean off the edge.  And this thing is razor sharp, you should be able to feel that through your glove as being extremely sharp.  Now we'll do the internal perforating osteotomy through the endonasal approach. I want to leave a little triangle of bone down at the base of the piriform aperture  laterally called Webster's Triangle to avoid collapse of the external valve. So with the internal perforating osteotomy I'm going along each of those little marks  that I put with the marking pen and perforating just like a postage stamp. I suppose if I've had trouble fracturing this then I'll go back to a continuous technique  and use a guarded osteotome or I'll go percutaneous with the 2mm. And then usually I can get a nice green stick fracture, I like a green stick fracture because  it stays in place but even with that I overdid this one, you can see it's dented in a little bit so I'm going to pop that back out ever so carefully with the handle of the bayonet.  And then we close the transfixion incision, excuse me, remember again I want to keep this transfixion incision, don't need to put a lot of support on it because I want to drop  the tip back. So you saw my nurse was pushing down on the tip while I put in the transfixion incision.  And then to make sure the endonasal mucosa is approximated correctly we'll put in some interrupted 5.0 chromics.  Now these are my two pieces of cephalic trim that we took out earlier, I just wanted to show you those, we have both those out intact.  And now to finish up we're going to do ailer wedges, I usually set the caliper at variable settings but generally it's at 3.  I have trouble with ailer wedges making them symmetrical and the same so I really pay attention  to my angle of the blade, I think it's a left hand right hand thing a little bit, sometimes I angle the blade a little bit too much on the right side and end up flattening what  I bring together so I really watch out for that. So I try to cut as best as I can at 90 degrees with the visual border and not skive one way or the other with the blade.  Now if the aperture is large you'll want to take out more of a trapezoid shape and go inside the nose to make the opening smaller.  For this patient we just wanted to narrow the nostrils and I don't want to decrease the aperture or impair airflow in any way.  And then I use any kind of scissors at this point to take out that little triangle of tissue.  If there's a lot of bleeding I'll cauterize a bleeder or so but at this point it didn't seem to be under undue tension so I decided not to use a deep suture, I had my splint  on for a week to hold things in place. And I prefer to close these with 6-0 nylon because I feel I can get better approximation.  First thing I do is start with the border or the aperture right along the nostril sill. So I set the nostril sill first and my second stitch goes at the other side to prevent any  dog ear action along the alar cheek groove. Next I put in three sutures so after this we'll probably put one in the middle.  Now that we've done our alar wedges we'll put on an aquaplast gel foam steri-strip splint. There's all different ways to splint the nose, just showing my preferred method, push that  down with your fingers to flatten it and put the steri-strips on. I use a little mastisol sometimes right at this point and then put a melted, molded should  say warmed aquaplast splint on there. And if you take a real towel, a real OR towel and wet it with cold water that will set that splint up in a matter of about 5 seconds.  I like to use marcaine blocks at the end of the rhinoplasty especially if I haven't gone in the septum you can pretty much help people become roughly pain free for 8 to 24 hours.  So go along the greater palatine area and then along each area where the angular artery comes in. Now this shows the patient pre-op and post-op.  She wanted tip definition and narrowing of the nostrils, she objected to her nasal hump. We preserved her nasal abial angle but you can see her tip was a little relaxed there  which is nice, gives her a little more of a pleasing curve. She has a smooth dorsum with pleasing dorsal aesthetic lines on 3 quarter and side view  and you can see she has a very nice tip defining point, super tip break and infralobular break or a double tip break with a take off right at her lash line.  So very pleasing aesthetics externally. Avoiding the transcalumellar open incision, nice triangulation on base view and inconspicuous scars.  Now a few tips, one of the tips to prevent over section is you can actually undermine the endonasal mucosal along the lower lateral cartilage up and down.  So we got the scroll area on your left, caudal edge on the right, tattoo that at 5mm and then take that out directly.  We like to use an extra mucosal dissection of the nasal hump because you absolutely want to preserve the internal valves, that's one of the criticisms of the closed approach.  So we preserve that endonasal mucosa underneath and then resect the hump keeping the internal valve intact.  And if you want to do medial osteotomies you can, but you can see here there's another patient who had a removal through an open approach of a large hump but the endonasal  mucosa in the internal valve is preserved. See I'm pulling away what's left of the lower lateral cartilage out laterally away from  the septum and you can see that mucosa from the extra mucosal dissection is preserved. I know that the open rhinoplasty approach is much more common than the closed rhinoplasty  approach so if you feel you have patients that you want to do the closed approach on, I hope you found this tape to be very helpful for you. Thank you.

Video Summary

Dr. Jober Skavitz demonstrates his technique for closed rhinoplasty, emphasizing a cephalic trim to prevent over-resection, dorsal hump removal, and a tip graft using cartilage from the removed hump. The procedure includes internal perforating osteotomies and alar wedges to achieve desired nasal aesthetics without external scarring. Key steps involve marking, injecting, and coconizing the nose, as well as handling large lower inferior turbinates common in Minnesota patients through bipolar cauterization and lateralization. Dr. Skavitz highlights the importance of maintaining precise incisions to avoid irregularities and displacement, ensuring symmetrical alar wedges, and preserving the internal valves through extra mucosal dissection, an essential consideration for the closed approach often criticized for internal valve disruption. The tutorial concludes with post-operative management, including the application of an aquaplast splint and a showcase of pre- and post-op patient outcomes. Tips for avoiding over-resection and handling endonasal mucosa are shared to aid those interested in performing closed rhinoplasty.

Asset Caption

This video shows a primary closed rhinoplasty.

Surgeon Joseph Gryskiewicz, MD This product is not certified for CME.

Keywords

surgery spotlight

Surgical Videos

Aesthetic

Joseph Gryskiewicz MD; Memben

closed rhinoplasty

cephalic trim

dorsal hump removal

internal perforating osteotomies

bipolar cauterization

aquaplast splint