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What you'll notice is the incisions that are made to be able to open the
nose. The incision that you've seen me making right now is the columella
incision that bridges skin, that separates the two nostrils, is referred to
as the columelum. You can see the very precise incisions that are made on
the very precise markings that are drawn on the nose with the patient
either awake before going to sleep, or after they've been put to sleep.

This other incision that you see me making right now is that marginal
incision we talked about and it's made at the margin of the coddle boarder
of each of the lower lateral cartilages. You can see that margin actually
protruding through the nostrils there when the nostrils averted. Now with
the use of a very fine precision scissor, known as a curved iris scissors.
I'm separating the skin very carefully from the underlining cartilage.

In this area of the nose along the tip, went all the way up to the dorsum,
which is the bridge of the nose, essentially skin is laying very close to
the cartilage. There are muscles underneath there and in each patient is
various thickness in the muscle. There is soft tissue there and there's
pericondum there. Pericondum is the covering of the cartilage.

What you'll see if that my instrument on my dominant or right hand, the
hand that's actually doing the surgery is carefully hugging the cartilage
and traveling up the cartilage and with my left hand I'm actually helping
avert the cartilage, push it into view so this surgery is truly a two
handed operation.

You'll see my assistant holding the suction as well as another retractor.
This is known as, you'll see what's called the three point traction method
to be able to put proper tension on the cartilage and get the nose opened
as nicely as possible.

What you'll also notice is how easy the cartilage is able to be exposed
with the scissors and a primary Rhinoplasty. In a primary Rhinoplasty it
may take just a matter of a few minutes or even less to open the nose,
where as in a revision Rhinoplasty, this entire area is going to be full of
scar tissue, and scar tissue is tight. Its nice cement, it's like concrete
and it's going to take much longer, much more effort to be able to
carefully raise the skin and soft tissue from the underlying cartilage and
bone.

This tissue right now is virgin, it's pristine and it's very pliable and
flexible, and malleable. What's coming to view right now is the left dome
and the left lateral cruse of the left lower lateral cartilage. Now I'm
flipping to the right side. My assistant is putting traction on the
nostril. I'm taking a 15 blade and completing that marginal incision and
again with the use of the scissors, I'm hugging the cartilage and while I'm
doing this, I'm wearing 2.5 magnification loops. Essentially what I'm
wearing are microscopes on my eyes.

So while the video may show a fairly far distant image, what I'm seeing is
much much closer and in my view I can see every little tiny blood vessel
because I don't' do surgery without my magnification loops. It's always
best to be able to see things as best as possible. Even though most
surgeons including myself have 20/20 vision, wearing 2.5 magnification
loops allows you to see every tiny little blood vessel so you can avoid
them or cauterize them before they become problematic.

Now you'll see the traction is placed on both of the lower lateral
cartilages and at this point I'm switching the retractor to what's called a
converse retractor because now we're getting deeper, so now my scissor tip
on the right hand is actually dissecting the area of the supra tip, or the
area just above the tip. Again this tissue is very pristine, I just put the
head of my suction can on the right hand. I can just push the tissue apart
and get into the right plane.

I have seen plenty of plastic surgeons use cotter and I'm going to show you
right there what the Q-tip beacon pushed that tissue up and opened it up.
There's absolutely no reason to have a traumatic dissection and use cottery
in the nose. Cottery is essentially an electric devise that provides a very
high temperature to sizzle, sear and cauterize blood vessels. In this area
you get a little bit of bleeding but nothing significant enough to warrant
cauterization.

What you see now is called a cottel elevator, and now what I'm doing is
actually, I'm way up top, on the bone, but I'm underneath what's called the
periostiome or covering of the bone and this allows me to elevate the skin
off of everything pretty much, all the way up to the root of the nose, or
the radix. You can see that everything gets freed up.

I can put the cotters retractor back in to take another view, and now what
you see is everything is opened up. Two whitish colored structures that you
see, are the left and right lower lateral cartilage that make up the base,
that make up the shape of the tip and that's opening the noseā€¦.

Doctor POV: Open Rhinoplasty (Part 2)

Dr. Shervin Naderi describes the incisions used preceeding the open rhinoplasty.