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Techniques in Rhinoplasty

Nasal access:

During plastic surgery, access inside the nose is secured, either with the open rhinoplasty technique or the close rhinoplasty technique. 

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The distinct characteristic of an open rhinoplasty is that incisions are made inside the nose, close to the outer part of the nostrils, and that another incision is performed on the columella (the vertical part of the nose, located between the two nostrils). The plastic surgeon, through these incisions, can reveal and have direct visibility to almost all the nasal skeleton. 

Moreover, skeletal correction maneuvers are greatly facilitated, especially when nasal implants need to be used, a procedure which is a lot easier and precise when the surgeon has good visibility. 

At the end of a nose job, sutures are applied where there are incisions. After some time, the parts that are located inside the nose are not visible, while the incision on the columella usually heals very well, in a manner that makes it barely visible at all. 
  
In closed rhinoplasty, usually more incisions are made in comparison to the open one, but these incisions are on the inside of the nose. Through these incisions, the surgeon corrects the nasal skeleton. The visibility is more limited compared to the open rhinoplasty and, thus, the surgeon works mainly through palpation.  

There is certainly some visibility of the parts that form the nasal skeleton, but it is obviously rather limited, compared to the open rhinoplasty. Also, there is no direct line of visibility of the nose tip. The advantages of this method are that the operative time is shorter, the postoperative edema (swelling) is less, and there is not that little scar, which is formed on the columella during open rhinoplasty.

While in previous years rhinoplasty was based more on the removal of the problem, in recent years this philosophy has changed. Rhinoplasty is now based on the rebuilding and sculpturing of the nose. This is achieved using grafts, such as cartilage and fascia (part of connective tissue) and stitching the cartilage of the nostrils. This is why many plastic surgeons opt for the open rhinoplasty, because it provides higher visibility of the inside of the nose, better maneuvering techniques and the result is usually more predictable compared to the closed rhinoplasty.

Shaping the nose:

The plastic surgeon, after detaching the skin, exposes the nasal skeleton and starts shaping it. Depending on the kind of the problem, the appropriate corrections will be made using grafts. These grafts are cartilage, taken from other parts of the nose, usually the septum. 
Also, some specialized techniques of stitching the lower cartilage that forms the nostrils and the tip of the nose can be used, in order to narrow a broad nasal tip, to rotate the nose upwards or lower the nostrils. Sometimes, some osteotomies (fractures of the nasal bones) have to be performed, so that the nose looks narrower and more aligned.

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Septoplasty:

Septoplasty is the surgery of correcting the septum. The surgeon separates the septum cartilage from the mucous membrane. Afterwards, he detaches the septum from the bone, where it is attached. This separation helps the septum get free from the parts that hold it in a wrong position, so it can freely shift to the right one. A small part of the cartilage or the bones is usually removed. Most of the times, through this action alone we are able to bring the septum back to the right position. Sometimes, follow-up procedures have to be performed. 

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Turbinoplasty:

On the inside of the nose there are some structures, which are called turbinates. In some cases, the turbinates can be hypertrophic and block nasal airflow. In these cases, many different techniques of turbinate reduction can be applied. Extra caution is needed because if the turbinates are completely removed, this will cause additional breathing problems in the future.


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