The Open Structure Method in Rhinoplasty
Calvin M. Johnson, Jr., M.D. Michael S. Godin, M.D.
From the Hedgewood Surgical Center New Orleans, Louisiana, USA.

The open structure method is designed to enable the surgeon to consistently perform a stable, reliable, and elegant rhinoplasty. The essence of the technique is to strengthen and shape the cartilage, bone, and soft tissue of the nasal skeleton precisely, under direct vision. The skin-soft tissue envelope is then repositioned to heal over the rebuilt framework. The result is a nose, which appears much the same as it did at the end of the case on the operating room table.

In contrast, closed, reductive rhinoplasty techniques have not always yielded such predictable results. Resection of bone, cartilage, and soft-tissue elements, without rebuilding support into the nose, has creative postoperative problems, especially in the tip region. Deformities such as nasal tip ptosis and collapse, lateral crural asymmetry and irregularity, alar flaring, columellar bulging, and excessive prominence of the supratip cartilaginous dorsum are commonly seen after closed rhinoplasty. Over-resection of cartilage and bone creates a disparity between the size of the nasal skeleton and the skin-soft tissue envelope. The result is a dead space, prone to scar tissue contraction, which gives the tip a blunted, amorphous appearance in thick-skinned patients, and leads to crural buckling and asymmetry in thin-skinned ones (Figure 1). Furthermore, as the nasal tip is weakened, there is a tendency to over-reduce the dorsum to make it proportional, leading to a "scooped-out", operated appearance.