Dr. Kanodia’s Closed Rhinoplasty Philosophy
It seems that virtually any modern day patient can be a very well informed rhinoplasty patient within a matter of hours. Despite this, there is still a shortage of information with regard to rhinoplasty and the various approaches rhinoplasty surgeons use to improve a patient’s cosmesis. Little distinction and attention is given to fact that there are two main ways in which surgery can be performed, and this very lack of information can easily lead a future rhinoplasty patient into having a more traumatic and unnecessary surgery if she doesn’t do enough homework.
Dr. Raj Kanodia in Beverly Hills, California has been performing closed rhinoplasty, in his practice for the past 37+ years, and worries that soon, it is going to become extinct. “Closed rhinoplasty”, commonly referred to as “finesse” rhinoplasty, is a unique surgery whereby corrections and enhancements of the nose are made internally through the nostrils, avoid the need to inflict a scar at the bottom of the nose. Enhancing and beautifying the nose without visible scarring is the premise upon which Dr. Kanodia practices rhinoplasty surgery. Closed rhinoplasty surgery is also ideal for the majority of patients having cosmetic nasal surgery for the first time since there is much decreased post operative swelling, bruising, and pain. Most patients recover very quickly, which is important, because statistically speaking these patients are young, energetic, and very social. This enables them to perform activities of daily living usually on post operative day two, and return to social events by day seven. Upon removal of the cast, most patients don’t show evidence of having had surgery and this accommodates the needs for busy patients who need to return to work, school, and can’t take extended time away from their responsibilities. Scarless surgery coupled with decreased healing times, are a few of the many advantages of having closed nasal surgery.
In general, most rhinoplasty surgeons offer open approaches to their patients. Very few surgeons perform only “closed rhinoplasty” but the overall benefits of scarless surgery overshadow the risks of any other approach and Dr. Kanodia wishes more women knew this before having surgery. The learning curve for closed rhinoplasty is invariably higher than it is for the open technique and fewer surgeons are being taught how to do it. Which is unfortunate since the majority of patients having surgery are ideal candidates for closed surgery but don’t realize that this is even an option. Most requests made by patients can be addressed using the closed technique but since a growing number of American plastic surgeons haven’t been trained to perform it, most patients aren’t offered the choice. The declining number of practicing surgeons and the trend towards more “academic” medicine is making the closed approach a less well known procedure. Still, the number of patients having closed surgery persists in Dr. Kanodia’s practice, he performs up to 300 surgeries per year, more than triple the amount averaged by most plastic surgeons. But this doesn’t mean that there isn’t a huge discrepancy between the women actually having closed surgery and the women who should be having closed surgery. If a surgeon plans to unnecessarily inflict a scar on the face, the patient should be told that she has a less invasive alternative. Dr. Kanodia understands that most educated patients, given the option, would unequivocally choose the closed approach one hundred percent of the time. If given the opportunity, most women would not accept scarring, prolonged swelling, and bruising if they were told other options were available.
Nonetheless, over the past two decades, a paradigm shift has occurred, such that rhinoplasty surgery is now more commonly performed using the “open” technique. This approach allows for a more comprehensive view of the nose and is ideal for the purposes of training in teaching hospitals. It originated from the need, by surgeons, to expose the entire nasal structure during difficult revision rhinoplasty where abundant exposure was necessary to complete surgery. Severely difficult noses that were traumatized, deformed, or obstructed weren’t amenable to closed techniques and an incision on the outside of the skin was created to facilitate surgery. Soon thereafter, the approach became more popular in the 1980′s, and more surgeons opted to use this technique on simple, straight forward cosmetic cases as well. Now, numerous patients suffer from having had open surgery needlessly and Dr. Kanodia regrets this. He suggests that open rhinoplasty compels surgeons to perform grafting and structural changes beyond what are cosmetically necessary. These changes often alter the character of the patient’s face and leave a permanent scar. The motivation to create the “perfect” nose skews a surgeon’s judgement, whereby alterations are made that don’t suit the patient’s face.
Physicians in training and students still benefit enormously from viewing open rhinoplasty surgery and it is an essential part of rhinoplasty training. The major drawback to open rhinoplasty surgery is the external incision that is made just under the tip of the nose. The rhinoplasty surgeon uses this incision to gain access to the framework of the nose and alterations are made accordingly. But external incisions on the nasal skin, in his opinion, inherently defeat the purpose of performing aesthetic surgery. A patient shouldn’t have to sacrifice aesthetics for the elective use of an incision that causes noticeable scarring. But Dr. Kanodia realizes that patients, even the most informed ones, don’t understand the ramifications of open surgery. These days, external incisions have gained acceptance within mainstream cosmetic surgery and patients don’t know that superior alternatives exists. There are many plastic surgeons that have never even witnessed closed rhinoplasty surgery, and Dr. Kanodia wonders if they wouldn’t perform it if given the proper training.
The positive aspects of closed rhinoplasty far outweigh the risks when compared to the open approach, yet eighty percent of American plastic surgeons choose not to perform it. This translates into more women unknowingly and unnecessarily having invasive plastic surgery. If more information was made available to patients contemplating surgery, the reality is that most would choose to have closed rhinoplasty, but would their surgeon be able to accommodate them?
Dr. Kanodia’s New Thoughts : Ever evolving concepts of finesse rhinoplasty (with no scars)
(Audio version of Dr. Kanodia Speaking about finesse rhinoplasty)
I am on a mission to revive my passion; the almost extinct art of closed rhinoplasty. Everybody talks about plastic surgery as an artistic endevour, but not much is taught about this in our surgical training. The emphasis is mainly on anatomy, technical skills, and surgical techniques but I want to seriously inject art into this discipline. Artistic vision is critical if this is going to be your career. After years of attending many rhinoplasty conferences, I have observed the lack of emphasis and conversation about the design element in rhinoplasty. Absence of this artistic philosophy just leaves rhinoplasty as a basic surgical procedure that lacks the beauty element and leads to rhinoplasties that look technical or mechanical. The nose is the center of the human face and the feature perhaps most closely associated with what we call “character.” Any alteration in its shape must be handled with great care, subtlety, and artistry, for no form of cosmetic surgery will so influence that way a face is perceived. In my 37+ years of rhinoplasty experience, after performing over 9,000 closed rhinoplasties, my experience has been that overwhelming majority of patients, approximately 90%, want subtle refinements to their nose with a desire to preserve the natural character. As restoring a Rembrandt does not require major alteration, neither does the beautiful nose that simply needs subtle refinements. Most noses have attractive features which should be identified and left untouched. Even if there were such a thing as a “perfect nose” it would be of no use in practice. A well executed rhinoplasty is simply a series of subtle brushstrokes leaving the patient a more refined version of herself or himself. It is one which fools the human eye, where no one is able to discern the specific alteration, yet can appreciate the enhancement. Appropriate selection of patients with compatible vision of the final outcome is paramount. I urge you not to impose the reconstructive mentality of revision rhinoplasty and inflict it upon a beautiful nose. My desire is that all students of rhinoplasty should once again consider and re-evaluate this almost extinct art of closed rhinoplasty, despite its difficulty teaching and its longer learning curve.
Rhinoplasty is about finesse, NOT change. During consultation, I review the nose in 9 categories:
- Internal Nasal Valves
- Length of nose
- Tip configuration
- Width and asymmetry of nasal bones
- Width and contour of nostrils
Upon review, I normally discuss which of the above categories are in harmony and which ones need some refinement. Preserving parts of the nose in its original form keeps the integrity and character of the nose. This is an extremely important concept to fully comprehend. Amongst rhinoplasty surgeons, there is a wide range of techniques, philosophies and surgical results. Most surgeons employ an “ideal nose strategy” for rhinoplasty. These surgeons have a vision of a perfect nose and focus their rhinoplasty efforts toward creation of their ideal nose for every face. Unfortunately, the “ideal nose strategy” has a few flaws. First of all, this strategy assumes that all parts of the nose which do not meet the criteria of this ideal nose need to be changed. I contend that there is a wide range of features which may be attractive and must be considered in the context of the remainder of the face and nose. Surgeons who ascribe to the ideal nose strategy will often employ more extensive radical procedures with extensive grafting in an effort to impart more dramatic changes to the nose. While the surgeon may be able to achieve his goal in changing one aspect of the nose, it often comes at the expense of unintended changes in the remainder of the nose. Another downside of the one nose fits all strategy is that it may lead to imbalance between nose and the corresponding facial features. A successful rhinoplasty operation is a marriage between the face and nose so that not only is the appearance of the nose improved, but the remainder of the facial features are enhanced.
During the initial consultation, an understanding between the surgeon and patient is necessary to see if the patient and surgeon have a shared goal of what can be achieved. Patients are prepared with Vitamin K 5mg twice daily and Arnica montana preoperatively for 1 week. Patients are forbidden to take Asprin, Motrin or any blood thinning products for two weeks prior to surgery. Caffiene, alcohol, and smoking is also limited during this time. One hour of preoperative icing is performed on all patients. Ice acts as a natural and powerful vasoconstrictor of the nose, which significantly reduces edema and bruising. All surgeries should be performed under general anesthesia as this allows greater control of the patient’s blood pressure, which is a direct contributor to the amount of intra-nasal bleeding.
A vasoconstricted, bloodless tissue plane is needed for appropriate visualization and methodical, rhythmic execution of all steps. To accomplish this, one should hydro-dissect the septal mucosa from the bony and cartilaginous septum and the whole skin envelope from the framework of the nose. Approximately 10-15cc of ropivicaine and lidocaine is injected 25 minutes before the 1st incision is made.
A left hemitransfixion incision is made 5 mm posterior to anterior edge of the cartilaginous septum. Through this incision a full thickness mucosal flap is elevated to access the cartilaginous and bony septum. The obstructing portions of cartilaginous and bony Septum are removed to straighten the airway. Approximately 3cm long and 4mm high septal cartilage will be needed for spreader grafts. This is harvested from the floor of the cartilaginous septum, embedded in the vomer. We as surgeons must work extremely diligently to have 100% patent nasal airways on both sides.
When addressing the nasal tip, the intracartilaginous incision in the vestibular skin is made at the level which will facilitate the entry and then the removal of the excess cephalic strip of the tip cartilage. In order to prevent any post-operative pinching or collapse, no more than 50% of the cephalic strip should be removed. Here, comes the dilemma and limitation in an extremely bulbous tip. Delivering the tip cartilage, trimming and suturing the domes, can be accomplished through the closed approach, yet may have a better access through the open approach.
The nasal dorsum is skeletonized through the same intracartilaginous incision. Cartilaginous dorsum is adjusted with a 15-C blade. The bony dorsum from rhinion to nasion is addressed with a Rubin chisel to lower the bony dorsum as well as to open the roof of the bony vault. This cortical nasal bone has to be gouged because using the Rasp, not only fails to reduce the bony profile but also does not open the roof. The space thus created by opening the roof is absolutely mandatory to accomplish complete lateral osteotomies. The ease with which the nasal bones can be aligned in a more medial position is a direct result of creating this gouged open roof. This averts the need for medial osteotomies and transcutaneous transverse osteotomies to accomplish complete medialization of the nasal bones.
Lowering of the bony cartilaginous junction disrupts and tears the fibrous connections between the nasal bones and the upper lateral cartilages, often leading to medial migration of the upper lateral cartilages. This results in a cosmetic mid third pinch and functional crowding of the internal nasal valve. To avoid this unacceptable outcome, an appropriate placement of the Spreader Graft is the answer. Septal cartilage harvested earlier during septoplasty is straightened, sliced, and carved into 2 spreader grafts. They vary in length, height and thickness according to the individual need for correcting this mid third deformity and restoring the patency of the internal nasal valve. More than 1 spreader graft on the same side could be utilized to wedge and skew the cartilaginous nasoseptal pyramid for further straightening. The spreader grafts, once positioned to accomplished the desired results are immediately fixed into its desired position using a 3.0 chromic in a through and though mattress fashion.
Lateral osteotomies are performed in a LOW to LOW fashion from base to the top to medially displace the right and left nasal bones to recreate the nasoseptal pyramid. The ease with which the nasal bones come together is a direct result of our previously created space from gouge osteotomy on the nasal dorsum. Very rarely, if one or both bones are resistant to medialization, a Quisling osteotome is used. This is placed lateral to the reluctant bone and tapped into place for completion.
The dorsum is revisited for smoothness and finessed with sharp Maltz rasps if so needed. Once completely satisfied with the dorsal projection and smoothness, a small strip of gelfoam is introduced into the dorsum between the skin and the dorsal bony cartilaginous framework of the nose. The intracartilaginous incision is closed. The nose is taped and casted with moldable cast.
Please do not try to impose your vision of what is beautiful and in effect, take away natural features of the face. Alar grafts, batten grafts, radix grafts may have a place in secondary rhinoplasty, but in primary noses, they bulk up the nose. Furthermore, most grafts add a certain rigidity to the nose taking away its natural feel and look. Although they may be able to achieve the desired amount of projection or deprojection, they do so at the expense of the rest of the nose.
Knowledge of the nasal anatomy and steps performed in a closed rhinoplasty is critical to a successful operation, and during residency, we are taught exactly this. But we are NOT taught the art of rhinoplasty. We spend countless hours memorizing the ideal facial angles, ideal proportions of the nasal tip, and performing multiple surgeries using these concrete measurements as our measure of a successful outcome. But there is so much more that goes into rhinoplasty that cannot be taught using the standard textbook. Each patient is different and only when we look at the patient’s nose in the context of his/her face can we better understand this artistry. In fact, this skill of injecting art into your work is something that takes time to develop and I think that we need to start developing this skill in our training, while our minds are more fresh and malleable, before rigid dogma has stamped its imprint on our way of thinking about rhinoplasty. Every face and every nose is beautiful in its own way. As a true artistic surgeon, our job is to bring out those beautiful features even more while refining those areas that are not in congruence with the rest of the face. Subjecting every patient to an “ideal” nose is absolutely wrong. Given the entire context of a face, some noses look better with a sliver of a dorsal hump or with an alar width larger than the “ideal” intercanthal distance. These artistic decisions are made based on preserving the natural beauty in a person’s face. As a cosmetic surgeon, it is important to understand and see beauty in all aspects of life as this will better allow us to inject artistry into our craft of rhinoplasty.
Raj Kanodia, M.D.
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