Surgical techniques


 

Open or closed technique?

This technical term relates to the small incision made underneath the tip of the nose or the abandonment of it. 

1. Closed technique:

The incisions are only made underneath the nasal wings and on the inside of the nose. The entire operation takes place in a small tunnel.  A decrease in size of the right and left side of the nose is done through the right and respectively the left tunnel. This is why a comparison of the symmetry of the trimmed cartilage is not given through direct view. The surgeon ultimately judges the final shape through palpation of the nasal bridge and tip of the nose. But due to the surgery these are swollen and delicate asymmetries are not visible any longer.

2. Open technique:

The only and essential difference is in the approximately 6mm long additional incision at the narrowest part of the columella. Through this method, the entire skin can be lifted off the tip of the nose and nasal bridge and a complete view on the entire cartilages and cartilaginous-bony nasal bridge is possible, which is an enormous advantage! A common problem of the closed technique is that once the swelling has fully subsided 2 or 3 years post-surgery, small bumps and asymmetries appear. The open technique is trying to avoid this problem.

With the open technique of the rhinoplasty the bridge of the nose can be grinded down, respectively reduced under vision. So called spreader grafts – miniature cartilage splints harvested from the nasal septum for straightening of the bridge of the nose or for functional improvement of the ventilation of the nose – can be fixated. Frequently occuring nasal tip asymmetries can be corrected under direct vision and tip shields, septal extension grafts and columella struts for stabilisation and shaping of the tip of the nose can be stitched upon. 

So In a lot of cases this additional small incision does allow for a better display of the operation field and will lead to a better outcome. Opinions among rhinoplasty surgeons vary a lot in respect to this. In 2014 a congress was held in italy, in which the controversial opinions of supporters of the open teqnique vs. Defenders of the closed technique were acridly but barrenly discussed. I perform both techniques – depending on the desired change of the nose. The ratio for first-time rhinoplasties is 85% closed vs. 15% open technique. 

I do use the open approach in 90% of the revision-rhinoplasty cases. Advantages of the open technique are not only improved visualization of the cartilaginous and bony structeres, but also the more precise suture and graft placement that is often need on the tip of the nose.  The downside is the increased postoperative swelling of the nasal tip that possibly persists for a longer time.The closed technique causes less swelling, but with the decreased display of the tip of the nose, this technique is dramaticall limiting the surgeon in his/her operative abilities and precision. Which technique I decide on depends on the characteristics of your nose. I’m well trained in both techniques , but based upon my surgical experience I prefer the open approach.

Visibility of the scar

Many patients ask if the scar will be visible later on. In my experience after one to four month the small scar on the columella is invisible in 80% of the postoperative patients. In approximately 15% die redness within the fine scar persists up to circa 6 months. Only in about 3% of the cases need a small scar revision via CO2-Fraxel Lase one year postoperatively. 2% receive a small scar correction under local anaesthesia. The acceptance of this little additional incision is very high and the benefits of an open technique like higher precision and better symmetry leading to better longterm results are obvious

The wellbeing of the patient has the highest priority. Usually I don’t place classic nasal packing, but so called doyle-splints, which leaves the nasal access open to allow patients to breathe through their nose right after the operation.

I operate in a hospital in Frankfurt as well as in a private operation center with specialist doctors for anaesthesiology- either in a so called twilight sleep or general anaesthetic.

Postoperative care takes place in my office, for the first 14 days we will monitor your healing closely. In all these years of my surgical work I have learned the though the operation is a critical step towards success and the desired change, the right and closely monitored postoperative care with check-ups of the healing process are just as important to ensure the desired results.

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