Dr. Pablo Vaquero
All surgical notes

Approach, choice of technique and undermining — The two prior decisions and their cost in support

The choice between preservation and structural technique, the catalogue of incisions ordered by the support each costs, when the external approach is justified, undermining plane by plane and the general sequence of the operation.

Content intended for healthcare professionals. It does not replace clinical assessment and is not written as patient information.

Key points

  • Before the first incision there are two decisions: preservation or structural, and open or closed approach. They answer to the anatomy of the case rather than to a preference of school.
  • Every incision is paid for in tip support. The operative question is not which route offers better vision but how much support is sacrificed and how it will be replaced.
  • The external approach is not a routine method: it is reserved for situations that require it, whether primary or secondary.
  • The correct plane is supraperichondrial over cartilage and subperiosteal over bone. Departing from it produces irregularities and healing disturbances.
  • The extent of undermining determines the degree of cutaneous retraction, so it is matched to the type of nose: minimal in small noses without cutaneous excess, wide in large, ptotic or thick-skinned noses.

The first decision: preservation or structural

With facial analysis complete — developed in Facial analysis: lines, angles and proportions — the first decision affects the whole operation. The structural technique resects the hump and then reconstructs the dorsum, which requires restoring the internal valve and allows correction as the operation proceeds. Dorsal preservation lowers the dorsum while conserving its surface, with fewer reconstructive manoeuvres and lower risk of late irregularity, at the cost of a narrower margin for intraoperative correction. The choice depends on the anatomy rather than on the currency of either technique. For explaining it in consultation, the patient-facing article on preservation rhinoplasty may help.

Preservation or structural

Is the hump harmonious, of mixed bony-cartilaginous predominance and without marked tip deformity?

YesCandidate for dorsal preservation: the dorsum is lowered en bloc preserving the keystone area, with fewer manoeuvres and lower risk of late irregularity.
NoContinue: the amount of reconstruction required must be assessed.

Is there significant deviation, sequela of previous surgery or need for structural grafts?

YesStructural: resection of the hump and reconstruction of the dorsum with spreaders. Preservation leaves little margin for intraoperative correction.
NoConventional structural technique with detailed planning. Both routes are valid and the choice answers to the anatomy.

The second decision: the incision and support

The incision is the route of access, but choosing it already constitutes a surgical decision about the tip. It may be internal, in the mucosa, or external, in the skin, and the choice depends on the regions to be addressed. What each alters deserves stating. Extending an incision into the membranous septum to reach the dorsum and septum eliminates two of the major mechanisms of tip support: the adhesion of the medial crura to the caudal border of the septum and the support of the medial crura on the anterior nasal spine. This is not an avoidable side effect but a consequence inherent to the access, so it falls to anticipate it in the plan and replace it with the appropriate grafts and sutures, as developed in Grafts and implants.

The incisions and the support each compromises

IncisionLocation and accessCost
HemitransfixionAt the lower border of the membranous septum, on one side only. Access to the caudal septum, medial crura and nasal spineIt does not alter the major support system of the tip. In exchange it hinders access to the opposite side of the septum and may heal asymmetrically
TransfixionThe same, joining both sides. It may extend to the nasal spine, and to the nasal floor where greater projection is soughtIt eliminates the support of the medial crura on caudal septum and spine. It requires replacement
IntercartilaginousBetween the lower border of the upper lateral and the upper border of the alar cartilage, in the valve area. It gives access to tip and dorsum, and to the alars retrogradelyIt lies in the valve: cicatricial retraction may alter its physiology. It must not be joined to the entry of the internal osteotomy, and the lateral end of the alars must be preserved
TranscartilaginousIt crosses the alar cartilage, parallel to its cephalic border at 3-5 mm according to the planned resection. It may involve mucosa alone or mucosa and cartilageLess trauma than the intercartilaginous and, above all, it lies caudal to the valve, so it does not compromise its physiology. Dividing only the mucosa and elevating it on both sides allows comparison of how much cartilage to resect
Marginal or infracartilaginousParallel to the caudal border of the alar cartilages, guided by the transition between hair-bearing skin and mucosa. It allows removal of fibrofatty tissue from the tip and weakening of cartilageIt is the one always used in the open approach. Combined with the intercartilaginous it allows the alars to be exposed as a bucket-handle chondromucosal flap
TranscolumellarIn the skin of the columella, joining both marginal incisions. It is placed at the transition or flare of the feet of the medial crura, and extends towards the domes 2-3 mm from the skin edgeIt exposes the skeleton completely. Placed closer to the face, it risks a depressed or visible scar for want of cartilage to resist the tension of healing

Releasing or not releasing the alar cartilages

This is the division that truly separates the approaches, more than the labels open or closed. Those that do not release the alars — intercartilaginous, transcartilaginous — work on them retrogradely and preserve support. Those that do release them — double incision with bucket-handle mobilisation, or complete elevation of the covering — provide direct vision and greater control of symmetry, at the cost of altering the major support mechanisms. The practical consequence is that exposure is justified where there is something to analyse: asymmetry, or alterations of shape, position or consistency of the alars. In the absence of those findings, exposure adds cost without adding information.

Which approach to choose

Is it necessary to analyse and modify the alars for asymmetry, shape, position or consistency?

YesApproach with cartilage release: bilateral marginal plus transcolumellar, or double incision with bucket-handle mobilisation. Vision and symmetry are gained at the cost of support.
NoContinue to the next point.

Is it sufficient to work on the cephalic portion of the alars?

YesTranscartilaginous, which offers control equivalent to the intercartilaginous with less trauma and lying caudal to the valve.
The dorsum and septum must also be addressedExtend into the membranous septum, accepting the loss of medial crural support. The hemitransfixion preserves it at the cost of more limited contralateral access.

The design of the transcolumellar incision

  • The original design was a direct transverse line. Current forms — stepped or with a middle triangular flap — allow precise closure, conceal the scar and prevent transverse contracture.
  • The points of the design are marked before incising: the symmetry of the scar is decided in the drawing, not in the suture.
  • The incision ends in the nasal mucosa and not in the skin: that is where it continues into the marginal incision on each side.
  • The lateral extension is performed with fine scissors, drawing both nostrils superiorly with a double retractor.

Preparation before the incision

  1. PositionSupine with the head slightly raised above heart level, which favours venous return and reduces oedema
  2. MarkingBiological ink — methylene blue, gentian violet or a dermographic marker — to avoid the tattooing produced by conventional markers, applied with a stick or fine sterile brush
  3. InfiltrationAlways, whether the anaesthetic is general or local with sedation. Anaesthetic solution with adrenaline: it reduces bleeding and facilitates anatomical dissection
  4. Territories to infiltrateDorsum, entering through the mucosa between lateral crus and upper lateral; tip, above the intermediate crus in the subcutaneous plane; columella and anterior nasal spine; septum, by direct puncture of its mucosa; marginal area, where the incision will lie; and inferior turbinates if turbinoplasty is planned

Undermining: a different plane in each territory

Undermining consists of separating the skin and soft tissues, fat and muscle, from the skeleton on which the work will be done, and the plane changes with the nature of the substrate. Over cartilage, both at the tip and on the dorsum, work is carried out in the supraperichondrial plane, and departing from it produces irregularities and healing disturbances. Over the bony skeleton one moves to the subperiosteal plane with the periosteal elevator. A documented objection to this last point deserves recording: some authors hold that the nasal periosteum is scarcely elevated at all and that what is actually done is to displace it superiorly to the frontonasal suture. The manoeuvre remains justified nonetheless, because it avoids injuring the periosteum with the rasp, a described mechanism of postoperative osteoma.

The extent of undermining is determined by the skin

It is one of the few parameters in rhinoplasty that admits an explicit rule: the extent of the dissection determines the degree of cutaneous retraction. Hence it is lesser in small noses, where there is no cutaneous excess to redistribute, and wider where skin is in excess — large, long or ptotic noses. Two further situations require wide undermining: the ptotic tip in which substantial superior rotation is sought, because the covering must redistribute and retract postoperatively, and thick skin, by the same mechanism. And one exception in the opposite direction: over the ascending processes of the maxilla lateral undermining should be avoided, since that intact periosteum holds the fragments after the lateral osteotomy.

The sequence of undermining

  1. From the lateral incisionApproach the superficial surface of the upper laterals with a 15 blade or fine scissors and elevate them to the lower border of the nasal bones, joining the dissection of both sides
  2. In the external approachAscend along the medial crura to the level of the domes and, at that point, identify the subperichondrial plane precisely before extending the dissection laterally, sliding over the alar cartilage. Countertraction with a fine hook
  3. Over boneChange to the subperiosteal plane with the periosteal elevator, as far as the radix and the medial canthus. Once bone is palpated, a cold blade eases identification of the plane
  4. The transitionSeparate the upper laterals from the nasal bones taking support on the former, recalling that the upper laterals pass beneath the nasal bones in the keystone area
  5. LaterallyMinimal dissection, limited to what the planned reduction in height requires, and meticulous: it is what prevents adhesions of the skin to the bone of the dorsum

Pitanguy’s ligament: a decision, not an inertia

On ascending along the medial crura in the external approach, the dermocartilaginous ligament appears, and two documented positions exist on its management with published results on both sides. Some authors divide it, at times ligating it together with the interdomal ligament, because separating the alars eases the subsequent approach to the septum. Others preserve it systematically and consider it determinant for the supratip. In the absence of established superiority, what is pertinent is to record that a decision is being taken: preserving it confers supratip definition, dividing it confers access. What is not appropriate is to divide it without having decided. Its anatomy is described in Applied nasal anatomy.

Precautions during undermining

  • In the open approach, undermining of the tip demands particular care: the skin covering the medial crura is thin and the continuity of the alars is easily interrupted.
  • In secondary surgery the plane may be hard to identify because of fibrous tissue and irregular previous dissections. Generous infiltration in the correct plane appreciably eases the undermining.
  • On elevating the perichondrium of the upper laterals towards the pyriform ligament, perforating vessels appear, which must be anticipated and cauterised.
  • When turbinoplasty is performed, its usual position in the sequence is after septoplasty and before the osteotomies. Direct division with scissors increases bleeding compared with radiofrequency reduction or simple outfracture.
  • The turbinate performs a conditioning function on inspired air, and its excessive cauterisation is associated with dry rhinitis. That is the argument that sustains restraint in its management.
Figure pendingParasagittal section of the nose with the catalogue of incisions marked: transfixion, hemitransfixion, intercartilaginous, transcartilaginous, marginal and transcolumellar.
The catalogue of incisions on a parasagittal section: transfixion and hemitransfixion, intercartilaginous, transcartilaginous, marginal and transcolumellar, with the support each compromises.

The general sequence of the operation

  1. 1. Anaesthesia and approachInfiltration by territory, inverted-V transcolumellar incision plus marginal incisions, and dissection until the subperichondrial plane is identified
  2. 2. ExposureAscent along the medial crura to the dome, lateral extension over the alars and subperiosteal elevation of the nasal bones to the radix
  3. 3. Septum and turbinatesBilateral perichondrial elevation, upper and lower tunnels and septoplasty respecting the L-strut, with a zigzag suture of mucosa and septum. Turbinoplasty if indicated. See Septoplasty and the nasal valve
  4. 4. Dorsum and osteotomiesComponent reduction, bony regularisation and medial oblique and lateral osteotomies. See Dorsum and osteotomies
  5. 5. Internal valveClosure of the open roof by spreader flap or spreader graft. This step is not optional after addressing the dorsum
  6. 6. TipCephalic resection of the lateral crus, domal and interdomal sutures and support with a septal extension graft or columellar strut. See The tip
  7. 7. ClosureLigamentous repair if indicated, skin closure with 6/0 monofilament, mucosa with 5/0 absorbable suture, and final assessment of the alar base with calipers

References

  1. 1.Arquero P. Preparación. rinoplastia.eu.
  2. 2.Arquero P. Incisiones. rinoplastia.eu.
  3. 3.Arquero P. Despegamiento. rinoplastia.eu.
  4. 4.Pitanguy I. Surgical importance of a dermocartilaginous ligament in bulbous noses. Plast Reconstr Surg. 1965;36(2):247-253.
  5. 5.Pitanguy I, Salgado F, Radwanski HN, Bushkin SC. The surgical importance of the dermocartilaginous ligament of the nose. Plast Reconstr Surg. 1995;95(5):790-794.
  6. 6.Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg. 1987;80(2):161-173.
  7. 7.Toriumi DM, Mueller RA, Grosch T, Bhattacharyya TK, Larrabee WF. Vascular anatomy of the nose and the external rhinoplasty approach. Arch Otolaryngol Head Neck Surg. 1996;122(1):24-34.
  8. 8.Saban Y, Andretto Amodeo C, Hammou JC, Polselli R. An anatomical study of the nasal superficial musculoaponeurotic system. Arch Facial Plast Surg. 2008;10(2):109-115.
  9. 9.Daniel RK, Palhazi P. The nasal ligaments and tip support in rhinoplasty: an anatomical study. Aesthet Surg J. 2018;38(4):357-368.
  10. 10.Saban Y, Daniel RK, Polselli R, Trapasso M, Palhazi P. Dorsal preservation: the push down technique reassessed. Aesthet Surg J. 2018;38(2):117-131.

Related specialty: Rhinoplasty

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