Anatomic basis and clinical implications for nasal tip support in open versus closed rhinoplasty

Successful rhinoplasty depends on nasal tip support and its influence on nasal tip projection. The factors involved in nasal tip support are numerous; however, the role of the anterior septum versus the lower lateral cartilages has been debated in the literature. The purpose of this study was to quantitate, using fresh cadavers, the critical elements for nasal tip support with open versus closed rhinoplasty techniques. Multiple nasal manipulations, including cephalic trim, cephalic trim and interruption of the lower lateral cartilages, dorsal hump resection (1 to 4 mm), submucous resection of the septum, and complete septal removal, were performed using fresh cadaver heads and using both the open and closed rhinoplasty approach. Changes in nasal tip support were recorded. In comparing similar procedures, the mean loss of tip projection for the open approach was 3.43 mm versus 1.98 mm for the closed approach (p < 0.001). There was a significantly larger loss of tip projection in open versus closed procedures for cephalic trim, cephalic trim and interruption of the lower lateral cartilages, and cephalic trim with interruption of the lower lateral cartilages and septum removal (p < 0.001, 0.001, and 0.001, respectively). We attributed the differences between the open and closed approaches to the increases in ligamentous disruption and skin undermining that occur when using the open approach. Septum manipulation in general resulted in larger losses in tip support in both the open and closed approach. We conclude that the open approach for rhinoplasty results in a significantly increased loss of tip projection when compared with the closed technique due to the larger disruption of ligamentous support. Contrary to previous data, septal manipulation resulted in significant losses of tip projection, most likely secondary to lowering the nasal septal angle, and this effect may be more significant in closed rhinoplasty. The apparent clinical implications are that active measures, such as columellar struts and/or suture techniques for adding or maintaining nasal tip support during rhinoplasty, are indicated, especially when using the open approach and when any anterior septal alteration is performed using the open or endonasal approach.