CEDARS-SINAI MEDICAL CENTER

Department of Surgery
Division of Plastic Surgery and Division of Otolaryngology

Advances in Multi-Specialty Aesthetic and Reconstructive
Plastic Surgery Symposium
featuring
The Bernard G. Sarnat, MD Lectureship

September 12-13, 2009

Endonasal Approach to Revision Rhinoplasty

BY
William J. Binder, MD, FACS
Assistant Clinical Professor
Department of Head and
Neck Surgery
David Geffen School of Medicine
at UCLA, Los Angeles, CA

Due to the positive reception to his 2008 address at the Cedar Sinai Medical Center, rhinoplasty specialist Dr. William J. Binder reprises his lecture on the endonasal or closed rhinoplasty approach in revision rhinoplasty.  In recent years, this approach has given way to the less difficult, but more invasive "open" rhinoplasty approach but not without its drawbacks. Dr. Binder lays out the immediate and long-term benefits to patients and surgeons of his updated endonasal revision rhinoplasty.

Rhinoplasty has shifted from the traditional "reductive" approach focused on making the nose smaller to a "structural" approach aimed at bringing the nose in harmonious balance with the rest of the face while maintaining and enhancing structural integrity.  Open rhinoplasty, where an incision is made across the columellar allowing the interior structure of the nose to be exposed and visible to the surgeon, was developed to apply structural preservation and support techniques.  The new technique, while making the rhinoplasty procedure easier for the surgeon to learn and master, came with some costs in longer operative time, increased swelling, bruising and recovery time and potential loss of nasal tip support, scarring and other issues.

Partly because of his many years revising or correcting primary rhinoplasty procedures, Dr. Binder has found that in addition to the possibility of causing significant scarring on the outside of the nose, the open technique also has an increased potential for skin shrinkage and is generally more unpredictable than the closed structure technique.  Also, sometimes the nose simply can’t be "opened" for the 3rd or 4th time without an increased risk of complications. 

In addition to decreasing operative and recovery times, scarring and other complications, Dr. Binder believes the endonasal approach has distinct advantages   Profile adjustments are generally easier to judge if the soft tissue around the nose is undisturbed.  Also, by integrating structural concepts into the endonasal rhinoplasty, a skilled closed rhinoplasty surgeon is able to achieve better and more predictable results; including  postoperative tip position and projection, stabilization of the middle and lower cartilages and compensating for weakness and asymmetries.

In short, a very skilled rhinoplasty surgeon with a thorough understanding of nasal dynamics and use of modern techniques for cartilage grafting and support can effectively utilize the closed or endonasal technique to alter the nasal anatomy and create an aesthetic and beautiful nose with the least amount of trauma, healing time and scarring.

Rhinoplasty is arguably the most artistic and technically difficult operation in plastic surgery and it requires a dedicated surgeon with a true understanding of the nose, its anatomy, and its response to surgical maneuvers.  Ideally, a skilled rhinoplasty surgeon is well versed in all of the above techniques and will diagnose the aesthetic and/or functional problems for each patient's nose. Based on his expertise, he will then choose the most appropriate method to obtain the best results with the least amount of swelling for every patient.