**5. Basic techniques in rhinoplasty**

#### **5.1. Incisions**

Open approach rhinoplasty needs two basic incisions namely, skin incision and rim incisions. These two incisions are connected to each other and skeletonization is started.

### **5.2. Skin incisions**

The skin incision is placed in the mid-columellar skin. An inverted-V (Figure 2) or stair-step (Figure 3) design will provide a longer incision line and logically better healing and less visible scar. On the other hand, the geometric incision may help the surgeon return the flap to its exact position thus, distortion or deformities are prevented.

**Figure 2.** Inverted-V incision

**Figure 3.** Stair-step incision

### **5.3. Rim incision**

The rim incision is an intranasal incision along the caudal edge of the lower lateral cartilages (Figure 4).Care should be taken to remain close to the cartilage edge. In this way a proper incision will follow the normal anatomy of the lower lateral cartilages. For this reason, the incision line will be close to the nostril margins in the dome area and will move caudally as it is continued along the border of the lateral crural cartilage.

**Figure 2.** Inverted-V incision

752 A Textbook of Advanced Oral and Maxillofacial Surgery Volume 2

**Figure 3.** Stair-step incision

#### **5.4. Skeletonization**

Skeletonization is usually done to gain access to cartilaginous and bony framework of the nose. To do so, columellar and marginal incisions are connected to each other and with delicate scissors the skin flap is reflected gradually. Care is usually taken to move close to the cartilage and bone during dissection (Figure 5). A deeper plane will provide a skin coverage that will conceal subtle irregularities while intradermal dissections may lead to color changes or surface irregularities.

#### **5.5. Tip-plasty**

Tip-plasty is a combination of many reductive, suturing and grafting techniques that are done to refine or shape a malformed asymmetric tip. Basic techniques are usually enough in most cases. Though in some complicated noses such as revision or cleft noses some advanced methods may be applied that require skill and training.

**Figure 5.** Skeletonization is completed.

**Figure 6.** Cephalic trimming.

#### **5.6. Cephalic trimming**

In this technique, a narrow strip of lateral crural cartilage is marked, incised and separated from underlying skin. The main purpose of cephalic trimming is to refine the tip and make enough space for tip rotation (Figure 6). [11].

#### **5.7. Salient points**

This technique is potentially destructive and may weaken the tip. Vigorous cartilage resection may result in severe pinch deformities and external nasal valve incompetency. As a rule all respective techniques must be done conservatively and is best avoided in narrow or weak lower lateral cartilages.

#### **5.8. Tip spanning suture**

Tip spanning suture is a mattress suture that is done on each dome. This suture will make a sharper dome on each side and as result more definition of the tip will be apparent (Figure 7).

**Figure 7.** Tip spanning suture

#### **5.9. Common mistakes**

Big suture bites over the dome area or over-tightening of the tip spanning suture may lead to a pinch deformity or tip destruction. Gentle tightening of sutures and use of delicate suture material (PDS 6-0) is enough to shape the structure of the lower lateral cartilages.
