The evolution of the combined use of endonasal and external columellar approaches to rhinoplasty

By individualizing rhinoplasty techniques for each patient and incorporating the lessons taught by the long-term follow-up on my rhinoplasty patients over the past 20 years, I have incorporated a blend of the endonasal and external columellar approaches to accomplish the desired aesthetic goals for my patients.By recognizing an increased need of spreader grafts for the midnasal vault, the placement of alar strut grafts to support the lateral crus, the use of alar spanning grafts and more suture grafts in the lobule, and refinement grafts in the nasal lobule, I have increased the use of the external columellar approach to approximately 50% of my rhinoplasties, which involves a significant number of secondary rhinoplasties and primary cases with specific indications. By paying attention to detail and using camouflage cartilage grafting, revision rates in my practice have fallen from approximately 7% to 4%.