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Rollin K Daniel, MD
Revolution
Editorial
Rollin K. Daniel, MD
Rhinoplasty surgery tends to evolve in generational epochs persisted. Recently, Toriumi has summarized his experi-
often associated with landmark publications and the simul- ence with open structure rhinoplasty in his monumental
taneous popularization of revolutionary surgical techniques. text Structure Rhinoplasty: Lessons Learned in 30 Years.7
In 1978, Sheen published his monumental text Aesthetic This summary of 3 decades of passionate obsession with
Rhinoplasty which confirmed his status as the greatest rhi- rhinoplasty surgery reveals the changes which occur with
noplasty surgeon since Joseph.1 Three critical concepts were time and compromise even excellent early results using
summarized. First, rhinoplasty became a truly aesthetic reduction techniques. The critical need for structure to
operation which included preoperative analysis, operative resist the forces of contracture and provide essential sup-
planning, and surgical execution. Second, the reduction-only port is undeniable. Equally, the use of multiple grafts
concept of Joseph was replaced with a balanced approach derived from rib is illustrated in numerous difficult cases
combining reduction and grafting in primary rhinoplasty. always stabilizing the base first and building outwards.
Third, the previously dismal results for secondary rhino- Numerous refinements and new techniques are illustrated
plasty were dramatically improved. Suddenly, the mark of with superb documentation and follow up.
a great rhinoplasty surgeon was no longer how quickly one Despite this tour de force, one troubling question remains—
could do a “nose job,” but rather the achievement of an why are we doing an operation that can produce such a
attractive natural nose with normal function. destructive result that a rib graft reconstruction becomes nec-
As the closed approach for rhinoplasty reached its apo- essary following a primary case performed by an experienced
gee of influence, the open approach gained sudden pop- surgeon? My conclusion is that we must fundamentally
ularity. Building on the work of Goodman,2 Anderson,3 change how we perform rhinoplasty surgery which leads to
Daniel,4,5 Gunter,6 and others, rhinoplasty surgeons quickly the next revolution—the preservation rhinoplasty. The funda-
adopted the open approach. This revolution occurred for mental goal is to replace resection with preservation, excision
three reasons. First, the open approach offered better with manipulation, and secondary rib reconstruction with
visualization for analysis, surgery, and teaching. Second, minimal revisions. The foundation of this preservation rhino-
new operations were developed including tip suturing, plasty rests on new anatomical studies, advanced tip suture
advanced septal reconstruction, and midvault reconstruc- techniques, and refinement of surgical techniques.
tion which were either impossible or technically chal-
lenging via a closed approach. Third, the open approach
shortened the learning curve for the less experienced
Dr Daniel is a Clinical Professor, Division of Plastic Surgery,
surgeon and could be applied to a wider range of ethnic University of California, Irvine School of Medicine, Irvine, CA; and is
groups with good results. Rhinoplasty surgery enjoyed a the Rhinoplasty Section Co-editor for Aesthetic Surgery Journal.
wave of popularity and became one of the most frequently
Corresponding Author:
performed aesthetic surgical procedures.
Rollin K. Daniel, MD, 1441 Avocado Drive, Suite 308, Newport
Despite the improved aesthetic and functional results, Beach, CA 92660, USA.
minor revisions and major secondary rhinoplasties E-mail: rkdanielmd2@gmail.com
Daniel229
During the last decade, major advances have occurred in risk. Since the primary reason that patients do not seek
our understanding of nasal anatomy and how it relates to rhinoplasty surgery is the fear of a bad result (“nose job”
nasal aesthetics and surgical techniques. Two of the most look), it will behoove surgeons to learn the preservation
interesting are the composition of the soft tissue envelope, rhinoplasty as it reduces this risk and will lead to simple
including the nasal ligaments and the osseocartilaginous revisions rather than major secondary procedures.
vault. The nasal ligaments have long been overlooked yet
they are critical for both functional and aesthetic reasons.8 Disclosures
For example, the vertical scroll ligament helps to stabilize
Dr Daniel receives royalties from Springer Publishing (New
the internal valve via the transversalis muscle while its York, NY).
surgical reattachment can accentuate the alar groove and
maintain function.9 Anatomical dissections have shown
convincingly that the bony hump is in reality a thin “bony
Funding