1. External rhinoplasty
Specific indications for the external approach in rhinoplasty include:
1. Congenital deformities such as the cleft nose;
2. Extensive revision surgery;
3. Severe nasal trauma;
4. Elaborate reduction & augmentation procedures;
5. Marked tip deformities;
6. The need for extra tip rotation;
7. The correction of extreme overprojection;
8. Situation where assessment of the exact pathology is difficult.
9. It has been advocated for nasoseptal perforation repair.
Anatomy of nose
Anatomical subunit of nose, which are conveniently divided into thirds.
1. The bony pyramid consisting of the nasal bones with their articulation to the
ascending(frontal) process of the maxilla & bony septum constitutes the upper third.
2. The paired upper lateral cartilages insert just under the caudal end of the nasal bones &
their fusion with the midline cartilaginous septum in a T type confuration forms the middle
third(vault).
3. The scroll attachment of the caudal aspect of the upper lateral cartilage to the cephalic
aspect of the lower lateral cartilages forms the boundary to the lower third of the nose. The
paired lower lateral cartilages form the nasal tip & are traditionally divided into the lateral,
intermediate & medial crurae.
The dome & tip forming points lie within the intermediate crus.
The medial crural footplate extend to the lower aspect of the columella & lie just anterior to
the caudal aspect of the nasal septum.
Principles of external rhinoplasty
A mid-columella( transcolumellar) incision is connected to bilateral marginal incision. Subsequent
dissection in the subperichondrial & subperiosteal plane leaves as much soft tissue as possible on
the skin flap. Thus prerserving its viability. In this way the lower & upper lateral cartilage together
with the bony dorsum can be exposed to the nasofrontal angle in their undisturbed postions.

2. Division of the medial crural tissue offers access to the caudal septum& premaxillary spine, it should
be left intact if exposure is not indicated, as this intercrural attachment is one of the support
mechanisms for the nasal tip.
By dividing the upper lateral cartilage from the quadrilateral cartilage, the whole of the septum is
accessible from the cephalic as well as the caudal aspect, allowing treatment of nasal valve
problems, dorsal septal deviations & septal perforation repair.
External rhinoplasty , therefore, provides very extensive exposure for both septal & rhinoplasty
surgery. Others benefits are
1. Binocular vision
2. Use of both hands;
3. Control bleeding with diathermy
4. Precise placement of & suture of strut, battens, shield grafts.
5. Intercartilagenous incision are not used, the valve area is preserved.
Disadvantage ; the disruption of the skin soft tissue envelop from the lower lateral cartilage &
division of medial intercrural ligamentous fibrous tissue leads to loss of some of the minor tip
support mechanisms, & therefore some tip ptosis should be anticipated in all cases.
Surgical technique
Incisions
The broken transcolumellar incision is most coomonly used , inverted V configurations. If the
columella is deemed too short in relation to the intended tip projection as is particularly the case in
the cleft lip rhinoplasty, a V incision made at the base of the columella to perform a V-Y lengthening
procedure may be indicated.
Mid columella incision should be situated above the level of the medial crural footplates to ensure
adequate support. It is essential to protect the integrity of the caudal end of the medial crura just
beneath the incision to prevent post-operative notching in this area. This may be done by initially
making only a relatively superficial columellar incision; then the vertical columellar parts of the
marginal incisions are then placed 1.5 -2mm inside the vestibule & joined by careful undermining
with scissors of the columella skin. These scissors can be used as a guard upon which the columella
incision is completed.
To obtain adequate exposure of the nasal skeleton, the marginal incision should be extended at least
halfway along the lateral crura.
Dissection of the soft tissue envelope
Dissection of the soft tissue envelope in the right surgical plane is desirable to ensure minimal
bleeding. This starts in the subperichondrial plane in the domal area. Dissection should be continued

3. in a lateral direction up to the hinge area, hugging the lower lateral cartilage with further extension
in a cephalic direction to the scroll area.
It can be helpful to vertically incise the perichondrium at the caudal end of the cartilaginous vault in
the midline, after which subperichondrial dissection can proceed from medial to lateral & in a
cephalic direction. A potential complication of the external approach is prolonged supratip odema &
occasionally a soft tissue pollybeak as a result of dissection in the wrong plane disturbing the
integrity of the transverse nasal muscle.
To access the bony nasal pyramid:Dissection of the soft tissue of the bony pyramid in a
subperiosteal plane should start 2-3mm parallel to & above the caudal end of both nasal bones. It is
of great importance to palpate the edge of the nasal bone before making the incision, to prevent
separation of the upper lateral cartilage from the bony pyramid,( a pitfall that can only be corrected
with a camouflaging onlay graft).
To access the nasal septum: by dividing the tissue between the medial crurae of the lower lateral
cartilages.( although alternative exposure can be gained through a separate hemitransfixion or
Killian’s incision. If medial crurae are separated, tip projection can be maintained by a columella
strut that strengthens the leg of the tripod formed by the conjoined medial crura. The graft is placed
in a well-defined pocket between the crura & extends from 2mm above the anterior nasal spine to
the angle between the medial crura & intermediate crura. The sandwich construction is fixed by
mattress sutures which must not be placed above this angle in order to prevent loss of the
columella-lobular (double break) angle.
Closure of the transcolumellar incision
Meticulous closure is imperative with slight eversion of the wound edges. The authers prefer a fine
nonabsorbable suture material (6/0 ethilon or prolone). To prevent tension, it can be helpful to
place an initial subcutaneous absorbable suture,although this is not usually necessary. The skin
sutures are removed five to seven days post-operatively. The use tissue glue has also been shown to
be effective alternative method of closure.
The following operation can be done by external rhinoplasty incision
1)The bony pyramid in external rhinoplasty
Exposure of the upper third of the nose allows more accurate diagnosis & precise correction of
dorsal abnormalities thus avoiding irregularities that can arise from a closed procedure.
The subperiosteal dissection should not extend more than halfway along the nasal bones.
A direct systematic examination is possible of the individual components of the bony vault . The size,
shape & position of both nasal bones & bony septum as well as the thickness of the overlying skin-soft
tissue envelope in the region of the rhinion & nasion, are assessed individually & in relation to
their effect on the nasofrontal angle & the width , height, dorsal profile contour of the upper third.
The open approach allows the use of a burr or reduction of the soft tissue envelop at the nasion to
deepen the nasofrontal angle. Conversely , the angle can be deepened or set in more cephalic

4. position by precise application of soft tissue onlay grafts of temporalis fascia or autogenous
cartilage.
The principles & techniques of bony dehuming together with lateral , medial oblique & intermediate
osteotomies are the same for both the endonasal & open approach.
It can be easier, however, to remove medial bony wedges in a trapezoid bony vault with an open
approach.
2)The middle nasal vault
The nasal valve area is the smallest cross-sectional area in the nasal airway.it is boundary is formed
by the caudal end of the upper lateral cartilage, the head of the inferior turbinate, the floor of the
nose, nasal septum & the intervening tissue surrounding the pyriform aperture.
Rhinoplasty can compromise the nasal valve, particularly in patients with short nasal bones, a high
bony-cartilagenous hump & weak upper lateral cartilages. Frequently , there is an additional
corresponding aesthetic defect of a sunken or pinched-in middle third.
The placement of cartilaginous strips or spreader grafts to open up the nasal valve area & angle
was initially described via an endonasal approach, thereby improving both function & cosmosis.
The external approach allows easier & more precise placement & suture fixation of such spreader
grafts minimizing the risk of displacement.
3)Nasal tip surgery
Altering the tip position & rotation by remodelling the alar cartilages is based on the tripod theory.
This theory states the structural framework of the nasal tip is based on two lateral crura & the
conjoined medial crura, each forming one leg of the tripod. This allows an understanding of the
effect on the tip position by altering the size & position of the medial crura & lateral crura.
For instance, if the medial crura & lateral crura are reduced in length, the tip is deprojected,
whereas if they are augmented projection is achieved. Superior rotation is achieved by shortening
the lateral crura or alternatively, by lengthening the medial crura causing rotation at the hinge
region.
4)The deviated nose
For example, if the nose deviates to the right, first step is to mobilize the left nasal bone & reposition
it in its normal position; the next step is to position the bony septum in the midline; finally the right
nasal bone is repositioned in its normal position.
When the lower two-thirds of the nose are deviated following corrective septoplasty this is usually
due to a C-shaped dorsal deviation of the nasal septum possibly complicated by the previous
surgery,which may have disrupted the union of the upper lateral cartilage to the septum. In mild
cases, the dorsal aspect of septum is shaped on the convex side & sutured to the upper lateral
cartilage, together with cross hatching on the concave side if necessary. If this is not sufficient to
correct the deviation, a unilateral spreader graft is placed between the dorsal septum & upper
lateral cartilage. The spreader graft act as a stent as well as opening the nasal valve area. Any
residual deformity is corrected by an onlay graft.

5. 5)Tension nose
Cottle’s nose description of the term tension nose denoted a high nasal dorsum with stretching of
the overlying skin & soft tissue, together with a highly arched & narrow nasal vault. There is an
overgrowth of the quadrilateral nasal septum along both the dorsum & caudal aspects, which exerts
a pedestal effect by pushing the lower lateral cartilages in a forward & downward direction, causing
a blunting & anterior displacement of nasolabial angle & shortening of the upper lip, since anterior
nasal spine is commonly also long.
Johnson describes a method of tip deprojection-
1. by excision of excessive elements of the nasal septum & anterior nasal spine,
2. followed by reprojection of the domes using tip grafts & suture techniques,
3. Modifications can be performed with precision using the open approach.
6)Septal perforation repair
Contemporary techniques of septal perforation repair rely on mobilization of mucoperichondrial
flaps to allow individual closure usually with an intepositional graft. Such dissection are laborious &
challenging& the external approach may be undoubtedly facilitating particularly in the repair of large
septal perforations. It allows unique exposure of the septum both from the cephalic & the caudal
aspect & also aids any required conjunctive rhinoplasty.
7)Nasal dermoids
The poor cosmesis associated with a vertical midline scar required in total excision of a nasal
dermoid may be avoided by use of the external rhinoplasty approach & its use has been advocated
widely.
Conclusion
1. It allows the analysis of skeletal abnormalities with direct binocular vision.
2. It enables the correction of deformities with bimanual manipulation & direct suturing of
graft material.
3. Correct incision placement, dissection in the right surgical planes & meticulous suturing will
prevent unnecessary sequlae of this approach such as prolonged supratip oedema &
aesthetically unacceptable transcolumellar scars.
Best clinical practice
1. The rhinoplasty surgeon should be adopt the least traumatic technique to resolve the
specific abnormalities.
2. Externa rhinoplasty technique are preferred in difficult traumatic, congenital & revision
surgery& with complex nasal tip deformities.

6. 3. A broken transcolumellar incision , carefully closed, gives the most inconspicuous scar.

7. 3. A broken transcolumellar incision , carefully closed, gives the most inconspicuous scar.