1934, 1973 · Aurel Rethi, W. S. Goodman
Open (external) rhinoplasty
Approach. Incision across the columella plus incisions inside the nose; skin lifted to expose the whole framework
An incision across the columella joins incisions inside the nose so the skin can be lifted off the bone and cartilage. Aurel Rethi described a columellar incision in 1934. Goodman published the external approach in 1973. Gunter and Rohrich reported more than 100 external rhinoplasties with a stairstep columellar incision and no incision problems.[1][2][3]
Suits. Secondary, cleft and reconstructive cases. In one series of 100 rhinoplasties, 28% of primary, 62% of secondary and 80% of reconstructive cases were done open.
Trade-offs. Leaves a scar across the columella. In 77 patients at one year, scar-related quality of life did not differ between open and closed septorhinoplasty.
Closed (endonasal) rhinoplasty
Approach. All incisions inside the nostrils; no external scar
All incisions are hidden inside the nose, and the skin is raised through them to reach the bone and cartilage. In a meta-analysis of 12 studies, 528 closed and 539 open rhinoplasties had similar outcome scores, breathing scores, swelling, bruising, operating time and complications.[1][2][3]
Suits. Primary rhinoplasty. In one 100-case series, 72% of primary rhinoplasties were closed. Saban's preservation operations used an endonasal approach.
Trade-offs. No external scar. Outcomes matched open rhinoplasty in the same meta-analysis.
1984 · Jack Sheen, Dean Toriumi
Structural rhinoplasty with grafts
Approach. Cartilage grafts rebuild and support the middle vault and tip
Structural rhinoplasty repositions and reinforces cartilage instead of only removing it. Sheen's spreader grafts, strips of cartilage placed along the top of the septum, rebuild the roof of the middle vault after a hump is removed. Columellar struts and septal extension grafts both increase tip projection. Component dorsal reduction keeps the upper lateral cartilages and lowers the septum and bone in steps.[1][2][3]
Suits. Hump reduction that opens the middle vault, a weak or under-projected tip, and protection of the internal nasal valve.
Trade-offs. In 87 patients followed 4 years, septal extension grafts held tip position more stably than columellar struts.
Rib cartilage grafts
Approach. Costal cartilage carved into grafts for the dorsum, tip or septum
Rib cartilage is used when the septum cannot supply enough cartilage, as in complex revision and dorsal augmentation. A meta-analysis of 20 studies and 1,648 patients found warping in 3.05%, resorption in 1.2%, infection in 1.45%, contour irregularity in 1.53% and revision in 2.25%. At the chest, hypertrophic scar occurred in 2.08% and pneumothorax in 0%.[1][2][3]
Suits. Revision with depleted septal cartilage, and dorsal augmentation.
Trade-offs. Warping is the most common graft complication. Chest donor-site problems raised the overall complication rate by 22%.
2018 · Yves Saban, Rollin Daniel
Preservation rhinoplasty
Approach. The dorsum is kept intact and lowered as one unit
Instead of shaving the hump, the surgeon removes a strip of septum below the dorsum, cuts the bones around the nasal pyramid and lowers the whole roof. Saban reported 320 cases through an endonasal approach: push-down for humps under 4 mm and let-down, with a wedge of bone removed, for larger humps. The push-down method is attributed to Maurice Cottle.[1][2][3]
Suits. Selected primary patients. Push-down is used for humps under 4 mm.
Trade-offs. Across 30 studies and 5,967 patients, hump recurrence was 1.3% after push-down and 4.6% after let-down, and revision 0% and 5.0%. Known problems are radix step-off, hump recurrence, supratip saddling and a wider middle vault. Comparative data with hump resection are limited.
2016 · Olivier Gerbault, Rollin Daniel, Alan Kosins
Piezoelectric (ultrasonic) rhinoplasty
Approach. Ultrasonic inserts cut and sculpt the nasal bones under direct view
Ultrasonic instruments cut and shape bone after a wide subperiosteal dissection, so osteotomies are done under direct view. In 185 cases, 95 had the bony vault shaped without osteotomies, 11 (6%) had revisions and none needed revision for bone asymmetry, irregularity or overnarrowing.[1][2][3]
Suits. Shaping and narrowing the bony vault through an open or extended closed approach.
Trade-offs. A meta-analysis found less eyelid swelling and bruising in the first 7 days, less pain and less mucosal injury than chisel osteotomies. Operating time was longer, and swelling did not differ from chisel osteotomies done under direct vision.
1987 · Jack Gunter, Rod Rohrich
Revision (secondary) rhinoplasty
Approach. Second operation through scarred tissue, often with rib cartilage
Revision corrects shape or breathing problems after an earlier rhinoplasty. Gunter and Rohrich described the external approach for secondary rhinoplasty in 1987. In 700 revision patients treated with an extended closed approach and rib cartilage, symptom scores fell from 44.2 to 17.8 and 14.2% needed a further revision.[1][2][3]
Suits. A defined problem in shape or breathing after a prior rhinoplasty.
Trade-offs. The surgeon works through scar, often with little septal cartilage left. In 36 patients, soft tissue stayed thicker and swelling resolved more slowly after revision than after a first operation.
Septorhinoplasty
Approach. Septum straightened in the same operation as the reshaping
A deviated septum is straightened and the projections inside the nose reduced to improve breathing, in the same operation that reshapes the outside. In 567 patients, nasal obstruction scores and general quality of life improved through at least 24 months, with a small added gain when the inferior turbinates were also reduced.[1][2][3]
Suits. Nasal obstruction from a deviated septum, with or without cosmetic goals.
Trade-offs. A hole in the septum (perforation) is a rare complication that may not be correctable. An L-strut of at least 1 cm must be left to support the dorsum and tip.
Non-surgical (filler) rhinoplasty
Approach. Filler injected under the nasal skin; nothing removed
Filler, most often hyaluronic acid, changes the profile of the nose without surgery. A review of 30 studies and 9,657 patients found 96.76% were treated with hyaluronic acid and 99.08% were satisfied. The FDA lists injection of the nose as an unapproved use of dermal fillers.[1][2][3]
Suits. Patients who want a temporary change or to avoid general anesthesia, and irregularities after surgery.
Trade-offs. Complications occurred in 39.11%, mostly redness and swelling, and arterial occlusion in 0.27%. The nose was the site in 40.6% of 365 reported vision loss cases.