Fundamental terms, considerations, and approaches in rhinoplasty.

It is essential to appreciate the healing dynamics in rhinoplasty patients that occurs over a period of months. It is for this reason that long-term analysis and follow-up are essential for the surgeon to fully realize and understand the final effects of the effort. Discussion of important patient selection considerations, review of standard terminology, review of incision and approach choices, and brief review of alar cartilage procedures were presented. The importance of performing minimal surgery that would be capable of predictably producing the desired changes is stressed. In the majority of rhinoplasty cases, use of nondelivery or limited-delivery approaches, limited transfixion incisions, and conservative alar rim strip techniques seems to offer maximal predictability. These considerations, however, must be balanced with the improved exposure and teaching opportunity allowed via open rhinoplasty. The decision of which approach to use must be based on a thorough understanding of the problems presented by each case, and the techniques available within a surgeon's armamentarium. Excellent exposure and control of symmetry in the open structure approaches has led many teaching institutions to rely solely on that approach. It is the author's opinion that nasal reconstruction in more complicated secondary rhinoplasty, severely distorted, or congenitally deforms noses, or complex combinations of anatomic structure requiring grafting or lengthening should be performed via open rhinoplasty. It is believed, however, that an effective rhinoplastic surgeon should be able to successfully accomplish most nasal correction via any of the standard approaches discussed. With more conservative nondelivery approaches comes the probability of reduction in surgical trauma, decreased scarring, and increased relative predictability necessary for cosmetic surgical cases. Unfortunately, limitations of exposure and access are often difficult for even very experienced surgeons. It is not acceptable that all patients have to be exposed to only one type of exposure or technique based solely on the individual's original training experience. Rhinoplasty offers an ongoing learning experience, with a variety of elements. It remains perhaps the most challenging and demanding of the procedures in cosmetic and reconstructive surgery.