Rhinoplasty of the Nasal Tip - Open Vs Closed Approach

By far, the most challenging aspect of rhinoplasty surgery is in the nasal tip. As the nasal tip is probably the greatest variable in appearance amongst individuals and one of the most defining parts of the nose, precision in nasal tip changes during rhinoplasty is of critical importance. Therefore, good access to provide adequate visualization and workability of the nasal tip cartilages is key.

Rhinoplasty, by its history, has been traditionally done through a closed or endonasal delivery technique. By this approach, the nasal tip cartilages are delivered without using a skin incision at the columella. In the 'right' nose, I personally prefer this technique as it is simple, produces consistent results, and has a low rate of the need for revisional surgery. It also offers the bonus of less prolonged swelling of the nasal tip after rhinoplasty. Good patients are those that have fairly thin nasal skin, strong stiffer cartilages, and have never had rhinoplasty surgery before. The only problem with the closed approach to rhinoplasty is that it requires more finesse in delivering and suturing the cartilages than an open approach.

Open structure rhinoplasty, where the entire nasal tip is widely exposed, is done by making a incision across the columella (skin between the nostrils) and lifting the skin off of the nasal tip. With such exposure, manipulation of the nasal tip cartilages is much easier and symmetry between the sides better appreciated. For this reason, open rhinoplasty is the most common way rhinoplasty surgery is done today and, in most surgeon's hands, produces more reliable results. It certainly is the way to go in revisional rhinoplasty (of the tip area) and in primary rhinoplasty where the patient has thick skin, nasal tip asymmetries, or weak cartilages. The fear over a columellar scar is largely unfounded as they heal nearly imperceptably. The biggest problem with gloving the nasal skin through an open approach is that some patients will have some prolonged swelling of the nasal tip, particularly those with really thick skin.

The debate between open vs. closed rhinoplasty isn't really a debate anymore. It is more about what type of nose does a patient have and the plastic surgeon's experience with each rhinoplasty technique. When considering rhinoplasty (nose reshaping) surgery, talk to your plastic surgeon in depth about your goals and how he or she is going to meet them. Ask if your rhinoplasty surgery will be done open or closed... it shows you have done your homework.

Dr Barry Eppley is a board-certified plastic surgeon in private practice in Indianapolis, Indiana at Clarian Health Systems. (http://www.eppleyplasticsurgery.com) He writes a daily blog on plastic surgery, spa therapies, and medical skin care at http://www.exploreplasticsurgery.com

Hyperpigmentation in Cosmetic Laser Procedures

Hyperpigmentation means the abnormal darkening of skin, usually in a specific area of the body. This may be due to an injury, such as a burn, or from inflammation, such as an infection (e.g. a skin infection that was treated). Normal pigmentation is from melanin which is produced by melanocyte cells in the skin. Anytime there is an inflammatory stimulus, melanocytes might be triggered to produce extra melanin as part of the healing process. Increased melanin production by the melanocytes occurs in response to thermal changes and inflammation. It usually goes away but may last anywhere from a few weeks to many months. It is different from scarring. Scarring means that there is increased collagen production in the area and that the texture of the skin has changed. Hyperpigmentation causes no textural change of the skin, just a change in color.

Laser treatment of the skin can also occasionally lead to hyperpigmentation. Any laser transmits light into the skin. If there is heat generated or cells damaged, inflammation and thereby hyperpigmentation may be stimulated. The ideal in most cosmetic laser treatment is to target specific elements within the skin, such as hair or age spots, and avoid thermal damage to surrounding structures. This kind of targeted approach is usually successful in avoiding hyperpigmentation.

In published research, it has been shown that darker-skinned patients are more likely to be affected by hyperpigmentation when treated for laser hair removal. Darker skin types may have a 10 times risk versus the lightest skinned patients. In hair removal, some lasers have a lower risk of hyperpigmenation than others. The diode laser, for instance, has a much lower risk than the ruby. For this reason, the ruby is no longer commonly used for hair removal.

THe main treatment for hyperpigmenation has been hydroquinone. It varies in strengths from 2% to 4% or much higher. Hydroquinone works by blocking the tyrosinase enzyme which is important in the making of melanin. It is not recommended for long term use but may be very useful in the short term to prevent hyperpigmentation in patients prone to it who are receiving laser hair removal or other laser procedures. It may even be used as pre-treatment in darker-complexioned patients. There are many natural alternatives to hydroquinone, such as kojic acid, azelaic acid, and licorice extract. Their effectiveness in comparison to hydroquinone has not been well-tested.

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