Rhinoplasty External vs. Endonasal Approach
Ever since an external approach to rhinoplasty was proposed many years  ago, a debate has raged about the merits of the external versus the endonasal approach. While the debates will continue, there are now many surgeons like myself who see advantages to both approaches, depending on the patient. Before undergoing rhinoplasty, it is helpful for a patient to understand why one approach may be favored over the other.
The endonasal approach is performed with incisions that are placed inside the nose. The obvious advantage is that there are no visible incisions. There are also some who believe that there can be less swelling after surgery using this approach. Regardless, even though there is no external incision, the soft tissues still require dissection off of the skeletal structure in order to make necessary changes to its architecture. The main disadvantage of this approach is that without ‘lifting up’ the soft tissues using an external incision, there is less visibility. Although one can still make precise modifications to the cartilage and bone, this can be more difficult in less experienced hands..
 Like the endonasal approach, the external approach also involves incisions inside the nose. The major difference is that the external approach also has an incision at the columella (at the base of the nose, between the nostrils). This allows the soft tissues to be lifted off of the cartilage and bone so that the underlying structure can be directly visualized by the surgeon for precise modification. For many surgeons, this approach makes it easier for very subtle maneuvers to be performed.
The primary concern of most patients is the external scar. I reassure patients that with precise execution of the incision and meticulous closure, the scar should not be noticeable and is only faintly visible. It is extremely rare for a patient to be unhappy with the appearance of the scar. I attribute this to the great care that I take in re-approximating the skin with very small sutures so that healing and scarring are optimized. I also reinforce to patients that they should take good care of the incision post-operatively and apply sunscreen to the area of the incision. The bottom line is that the scar is not an issue to my patients,  and in patients who would be better served with an external incision, they understand its need.
So how does one decide which approach is best? Although it is impossible to decide before I evaluate a patient, there are general guidelines to which I adhere. For example, the external approach is strongly preferred in complex revision surgery. Patients who have ‘crooked noses’ or any significant asymmetry in the middle vault are also best served by the external approach, so that I can precisely re-establish symmetry to this critical area of the nose. Finally, in patients who have complex nasal airways, I will typically utilize the external approach. For patients with more straightforward needs and no functional issues, the endonasal approach can yield an excellent result. Regardless, I always select the approach that will best suit the needs and anatomy of each individual patient.
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Discussions in Rhinoplasty
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