Open rhinoplasty had its resurgence in the mid 1980’s to help surgeons perform techniques that they found too hard through the lining—the way it had been done for a hundred years.  The open procedure was originally simple: the same closed operation, but through an external columellar incision.

The principal was this: If the surgeon can see the skeleton perfectly, he or she can create a perfect shape.

Unfortunately, that is not true because the skin has its own intrinsic shape.  It is not just a passive tablecloth.  So the surgeon can make a wonderful skeletal shape and still have a poor result if the skin cannot adapt.

Soon, surgeons added sutures and columellar struts.  The proven ways of reconstructing the nasal valves did not seem to work well any more, consequently new ways to support the airways were designed.  However, no clinical studies yet prove that they work.

The alar walls, which were dissected for exposure, became abnormally arched or distorted after surgery, so strips of cartilage were added to brace them.

Then surgeons noticed that the nostril rims adjacent to the tip (the so-called “soft triangles”) began to distort, so more grafts were added.  But how should they be performed?  Should they be sutured?

The real question ought to have been, why are we making these deformities?

In my next blog I will give you a better solution.