External Rhinoplasty (Open Approach)

The unique challenge of rhinoplasty in facial surgery

The nose performs primary functions, irreplaceable for the integrity and proper functioning of the respiratory system. In addition to the sense of smell, the nose warms, humidifies, and filters inspired air, and possesses vital immunological functions. For these reasons, plastic nasal surgery is not conceivable in purely aesthetic terms: form and function closely intertwine in this sense organ, whose remodeling is always a challenge for the specialist.
To meet this challenge, Dr. Pietro Palma has dedicated his entire professional life to rhinoplasty. He has been former President of both the European Academy of Facial Plastic Surgery, and the International Federation of Facial Plastic Surgery Societies, both considered to be the most important organizations of plastic and facial surgeons in Europe and internationally. He has also been serving as Consultant and Clinical Professor at of the Department of Otorhinolaryngology and Head-Neck Surgery at the University of Insubria Varese, Italy.

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The inseparable entanglement of form and function in nose surgery

Several factors can alter the delicate balance of the nose, in which the relationship between form and function is of primary importance. Malformations, trauma, inflammatory pathologies, previous unsuccessful or partially successful surgical interventions all indicate aesthetic and functional problems that can and must be corrected by rhinoplasty (correction of the external nose) or septorhinoplasty (combined correction of the external and internal nose).
The complexity of the organ and its uniqueness require an accurate anatomical and functional diagnosis, a sophisticated aesthetic analysis of the external nose, and a deep appreciation of the psychological and emotional state of the patient before surgery. Based on this approach, Dr. Palma can minimize post-operative failure or dissatisfaction, as well as possible complications that can lead to revision or secondary rhinoplasty.

Rhinoplasty: different techniques based on specific objectives and conditions

As each patient is unique, rhinoplasty and septoplasty feature endless intricacies, variables, and pitfalls. We cannot appoint one technique as “the best”. Traditionally, we subdivide nasal surgery into external rhinoplasty (or open rhinoplasty) and endonasal rhinoplasty (or closed rhinoplasty). The training and aptitude of the surgeon determine the functional and aesthetic evaluation of the nose and guide him or her to prefer one or other technique.
Function and shape are always interconnected. Septoplasty, is an operation that has a key role in determining both the shape and the function of the nose. The first phase of septorhinoplasty, this operation can be highly complex in cases that require extensive reconstruction. To reduce hypertrophic turbinates, minimally-invasive methods are usually enough: these include laser, radiofrequency under endoscopic control, and motorized instruments (debriders). Surgical turbinoplasty allows the combined correction of bone and turbinates. Finally, to correct and reconstruct the nasal valves, the surgeon frequently employs support grafts, also known as structural rhinoplasty.

Open or closed rhinoplasty? Pros and cons of two different surgical approaches

In open rhinoplasty, the entrance incision between the two nostrils, on the skin of the columella, allows the surgeon to raise a flap of skin and soft tissues. The opencast vision of the nose skeleton (cartilage and bones) offers significant operational advantages, especially in complex interventions requiring high precision. Very popular in the past 2 decades – even among less experienced operators -, external rhinoplasty became the primary choice for relatively common problems that would not have required nose deconstruction.
However, the external approach to rhinoplasty is not entirely devoid of disadvantages, including:

  • generally longer operating and healing times;
  • soft tissue swelling that may persist for months;
  • stiffness of the external nose;
  • less natural result due to the possible permanence of the columellar scar – however remote when relying on rhinoplasty specialists.

Closed rhinoplasty (endonasal technique) focuses above all on the “reduction” of bone and cartilage, with entry incisions inside the nose. The procedure is scar-free. Despite its faster healing times, the endonasal surgery also presents some disadvantages:

  • reduced visibility of nose skeleton, involving potentially less precision in surgical manoeuvres for less experienced operators;
  • possible inadequacy in complex revisions involving reconstruction of nose bridge and tip.

To sum up: on the one hand, open rhinoplasty allows greater precision in remodeling and cartilage suture. Sometimes preferable in high-precision interventions, despite requiring longer operating and healing times, it implies the risk of visible scars and technical complications in revision cases. Finally, the need to resort to cartilaginous grafts, often taken from other sites (ear, ribs), may involve further complications in sites other than the nose.
On the other hand, closed rhinoplasty requires more advanced skills to the operator. It is usually more conservative as it causes fewer alterations in the anatomy of the nose and the overall balance of the face, and is noted for its shorter operating and healing times.

YOUnique Rhinoplasty™: the advantages of open and closed rhinoplasty in the exclusive hybrid technique developed by Dr. Palma

Through years of anatomical studies and intense practice dedicated solely to nose surgery, Dr. Pietro Palma has developed a hybrid procedure. This versatile technique described in the Archives of Facial Plastic Surgery (2010) combines the advantages of the two methods which had hitherto been considered mutually exclusive. Hybrid rhinoplasty™ allows the surgeon to adapt surgical techniques to the specific expectations and anatomical characteristics of each patient.
The incisions are inside the nostrils as in endonasal (closed) rhinoplasty, but site and number may vary according to needs, anatomy, and surgical target. The technical advantages include:

  • the typical precision of open rhinoplasty;
  • faster healing times without external scars, such as in closed rhinoplasty;
  • minimal invasiveness and greater respect for the anatomy of the nose, that recreate a natural and balanced harmony between the various aesthetic units of the face.

Hybrid surgery is an option that the experienced surgeon can always consider, both in extensive reconstructions of septum and tip, and in complex surgery with dorsal cartilage grafting. The “third way” is also a valid alternative in revision cases where external rhinoplasty usually gives higher rates of success.
The hybrid endonasal technique can be adapted to many different situations, reducing the frequency and extent of subsequent remodeling by about 30%.

Rhinoplasty in Milan with Dr. Pietro Palma

Among the leading experts in rhinoplasty both in Italy and internationally, Dr. Pietro Palma has refined his specialization by committing himself solely to nasal surgery (corrective, functional, plastic). In its most successful form, rhinoplasty is an art. Mastery of any form of art requires complete and unconditional dedication.
Due to his diligence and thorough approach, Dr. Palma distinguished himself as an authority in the field by developing a tailor-made method, called YOUnique Rhinoplasty™: versatility and predictability, empathy and precision are central features of his approach. With over 25 years of practice focused on a single organ, Dr. Pietro Palma is available for non-binding interviews with patients who have the desire or the need to undergo surgical nose remodeling.
An interview with Dr. Palma can be requested either at the Clinica del Viso (Piazza Repubblica, 21 – Milan, Italy info@pietropalma.it) or at the Casa di Cura La Madonnina (Via Quadronno, 29/31 – Milan, Italy cup.cclm@grupposandonato.it), both easy to reach from all overItaly and abroad.


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