Secondary rhinoplasty via transcolumellar incision

The inverted Batman incision: a new incision in transcolumellar incision for open rhinoplasty

Columellar and nostril shapes often present irregularity after transcolumellar incision for open rhinoplasty, because of the contracture of the incised wound. The present study introduces a new technique to prevent this complication, and verifies its efficacy in improving cosmetic appearance. In our new method, a zig-zag incision with three small triangular flaps is made on the columella and in the pericolumellar regions of the bilateral nostril rims. Since the shape of the incision resembles the contour of an inverted "batman", we term our new method the "Inverted Batman" incision. To verify the effectiveness of the Inverted Batman incision, aesthetic evaluation was conducted for 21 patients operated on using the conventional transcolumellar incision (Conventional Group) and 19 patients operated on using the Inverted Batman incision (Inverted Batman Group). The evaluation was performed by three plastic surgeons, using a four-grade scale to assess three separate items: symmetry of bilateral soft triangles, symmetry of bilateral margins of the columella, and evenness of the columellar surface. The scores of the two groups for these three items were compared using a non-parametric test (Mann-Whitney U-test). With all three items, the Inverted Batman group patients present higher scores than Conventional Group patients. The Inverted Batman incision is effective in preserving the correct anatomical structure of the columella, soft triangle, and nostril rims. Hence, we recommend the Inverted Batman incision as a useful technique for open rhinoplasty.

Differing characteristics in 100 consecutive secondary rhinoplasty patients following closed versus open surgical approaches

Open rhinoplasty has unquestionably become more popular during the past two decades because of the putative diagnostic and technical advantages that direct transcolumellar access offers. To test the hypothesis that patients initially treated by the opened or closed approaches differed in the secondary deformities that developed, a retrospective study was conducted of 100 consecutive secondary rhinoplasty patients (66 women and 34 men) operated on by the author before February of 1998. Sixty-four percent had previously undergone closed rhinoplasties and 36 had undergone open rhinoplasties; the incidence of prior open rhinoplasty had increased steadily over the survey years, from 21 percent in 1996 to more than 50 percent in 1998, 1999, and 2000 (p < 0.05). The data generated indicate the following. First, the open rhinoplasty patients had undergone more operations (3.1 versus 1.2) and had more presenting complaints (5.8 versus 2.6) than the closed rhinoplasty patients. Second, although the most common presenting complaint among prior closed rhinoplasty patients was an overresected dorsum (50 percent) or tip (33 percent) or internal valvular obstruction (42 percent), prior open rhinoplasty patients complained more frequently than the closed rhinoplasty patients of these problems and also external valvular obstruction (50 percent, p < 0.0001), short nose (39 percent, p < 0.001), wide columella (36 percent, p < 0.001), narrow nose (31 percent, p < 0.001), columellar scar (25 percent, p < 0.001), and symptomatic columellar struts (19 percent, p < 0.001). Only excessive nasal length was more prevalent among closed rhinoplasty patients (20 percent, p < 0.01). Third, ranking of deformities differed significantly (p < 0.0001) between the two groups, so that complaints related to the nostrils, nasal tip, nasal length, or columella were more common among the open rhinoplasty patients than among those previously treated endonasally. Fourth, the relative frequencies of surgical complaints also differed: whereas patients previously treated endonasally were 6.7 times more likely to complain of long noses, patients previously treated by open rhinoplasty complained more frequently of the following: excessive columellar width (open approach, 36 percent of patients; closed approach, none), hard columellar struts (open approach, 19 percent of patients; closed approach, none), external valvular obstruction (4.5 times as frequent with the open approach as it was with the closed approach), alar/nostril distortion (four times as frequent), and narrow nose (3.9 times). Although the most common complaints among all postrhinoplasty patients remain the overresected dorsum, tip, or (internal valvular) airway obstruction, the author's data suggest that patients previously treated by the open approach are more likely to have postsurgical deformities and complaints referable to those anatomic structures most easily reached by transcolumellar exposure and to techniques that can be performed more readily or aggressively through that access route.