Semi-open rhinoplasty: a new Maxillofacial technique

Background Rhinoplasty "open" represents a surgical technique to access to the internal structures of the nose; it is an alternative to more traditional "closed" rhinoplasty. However, both these techniques have some advantages and some disadvantages. In this work the authors describe a case that shows the steps of a new surgical technique: the “semi-open” rhinoplasty. Methods The "semi-open" technique is performed by making an incision to access on the mucosa of both the nostrils, and through this access we separate the cartilages of the columella from the alar cartilages, debriding them at the domus. With such access we can perform any type of rhinoplasty surgery with functional or aesthetic purposes. Discussions Traditional techniques have undoubtedly some advantages and some disadvantages. The "semi-open" technique has the several advantages of the open technique, and it does not involve the presence of post-surgical scars. Conclusions This innovative technique provides great predictability and minimal postoperative discomfort, with no aesthetic damage.


Introduction
Rhinoplasty "open" is a surgical technique that allows, through the transverse incision of the columella [1], to access to the osteo-cartilaginous structures of the nose and to make all appropriate changes course to achieve functional and aesthetic purposes, thanks to a direct and wide vision of surgical site. The technique "open" represents a surgical mode to access to the internal structures of the nose, an alternative to more traditional "closed" rhinoplasty, which is realized through incisions made inside the nostrils, in correspondence with the area to be treated.
Both these techniques have certainly some advantages and some disadvantages [2], therefore, the authors wanted to test a new technique that shows the advantages of "open" and "closed" procedure: this new technique is called "semi-open", and in this work the authors describe a case that shows the steps of this surgical technique.

Materials and methods
The "semi-open" technique is performed by making an incision to access on the mucosa of the nostril (Figure 1), and through this access we separate the cartilages of the columella from the alar cartilages ( Figure 2), the same operation is performed in the contralateral nostril, debriding them at the domus. Later, with the alar cartilages totally exposed ( Figure 3) we can perform any type of rhinoplasty surgery with functional or aesthetic purposes. With such access is also possible to completely detach the nasal septum, in order to then perform the preferred technique for correcting a deviation, or withdraw cartilage (Figures 4, 5, 6 and 7) .
The intervention lasts absolutely equivalent to the duration of the traditional techniques [3].
During The post-operatory period, the authors have treated the patients with local application of an antiphlogistic ointment and with the administration of bromeline pills in order to reduce the swelling [4].

Discussion
Traditional techniques have undoubtedly some advantages and some disadvantages [5]. The advantages of the "open" rhinoplasty are, for example, a greater intraoperative visibility, high precision in performing corrective action, symmetrical on both sides of the nose; in fact, by using the approach of "open" rhinoplasty, we can make any change under direct vision. In addition, this technique creates a large surgical access that makes it possible to model the shape of the nose by inserting and fixing cartilage grafts; the "open" rhinoplasty makes it more easy and accurate not only the removal of cartilage from the septum, but also more accurate and stable the placement of the grafts in the different sites [6].
Despite the numerous advantages, there are also some disadvantages in the open rhinoplasty, such as, for example, a post-operative course longer and a greater presence of edema on the region of the columella, frequently accompanied with paranasal hematomas; another poorly aesthetic result is the presence of a transverse scar in correspondence of the columella [7].
The literature of the last 15 years has highlighted that many surgeons prefer the approach of "open" rhinoplasty for the greater facility in performing complex interventions on the osteo-cartilaginous tissues of the nose and for ever greater predictability of results, although the closed technique allows to achieve a minor trauma for the soft tissues with good aesthetic Figure 1 The incision to access on the mucosa of the nostril.

Conclusions
The "semi-open" technique allows operating times comparable to the traditional techniques, in addition, it allows to have an intra-operative visual field very wide, equivalent to that which can be achieved using the open technique, but without leaving any external scar; this     innovative technique provides great predictability and minimal postoperative discomfort, with no aesthetic damage. Figure 11 The suture is performed firstly with separate stitches in the submucosa and then on the mucosa.

Figure 13
The suture is performed firstly with separate stitches in the submucosa and then on the mucosa. Figure 10 The suture is performed firstly with separate stitches in the submucosa and then on the mucosa.

Figure 12
The suture is performed firstly with separate stitches in the submucosa and then on the mucosa.