What's the difference between an open rhinoplasty and a closed rhinoplasty? Should I choose a surgeon who uses one rhinoplasty technique over the other?
Should I Have an Open or Closed Rhinoplasty?
Doctor Answers 33
Choose your surgeon by his results, not the technique
This is a question that is still a ‘hot button’ issue among surgeons who have very strong feelings one way or the other. But, the debate thankfully is not quite as big a deal today as it was once was.
When rhinoplasty first became very popular in the last century, all of the work was done through the nostrils from the inside. The surgeon tunneled under the skin over the bridge of the nose and made alterations almost blindly. This is called a closed rhinoplasty because all of the incisions are enclosed inside the nose. It’s a bit like trying to carve a delicate glass figurine (the nasal cartilage) while working under a blanket (the skin). And, it’s still done almost the very same way today.
There are variations where the surgeon makes a couple extra incisions inside your nose and ‘delivers’ the tip cartilages outside your nostril so he or she can see some of the changes being made. But, this procedure provides a slightly distorted view of the anatomy and, sometimes, it may hamper the surgeon’s ability to make precise changes.
Then some bright guy came up with idea of carrying a very small incision across the columella or skin bridge that separates the two nostrils. This allows the entire skin over the nasal cartilage and bone to be lifted up to see what’s underneath. This technique is called an open rhinoplasty or external rhinoplasty.
Like most things in life, this procedure met a lot of resistance when it was first introduced from surgeons who were used to doing it the old way and didn’t want or see the need to change. But, one of the cardinal rules in surgery is that better exposure of the tissues usually allows for a better operation.
There are a few advantages to this open rhinoplasty approach.
- It allows the surgeons to better see the anatomy in an undistorted way and, so, make a better diagnosis of the anatomical problems that need correction.
- It allows for measurements to be taken and for very precise changes to be made down to the millimeter.
- And, once the changes are made, it is easier to make the nose more stable by placing sutures very precisely either in grafts or in the existing cartilage.
For these reasons, many surgeons started to grudgingly accept the open approach. It was first advocated only for very difficult or revision cases where better visualization would help more. Then surgeons began admitting that it might be helpful for procedures where a lot of work on the nasal tip was being done. Finally, they understood that if it might help for the most difficult of cases, why wouldn’t this approach help in every case? And so, today, many great rhinoplasty surgeons perform open rhinoplasty almost routinely.
We’re fans of the open rhinoplasty approach for most of our cases because we feel, in our hands, that it allows us the most control to deliver the best and most consistent results to our patients…and that’s what really matters to them and to us. A good rhinoplasty surgeon who prefers the closed approach might tell you he can do the same thing with a closed rhinoplasty. And that may or may not be true.
We do use the closed approach for select cases where we think we can do just as well with it. The truth is that most surgeons are more comfortable sticking to the techniques in which they've been trained. Surgeons are creatures of habit like most people. But, a good surgeon will learn as many techniques as possible and apply them uniquely to each individual patient.
There are a couple common criticisms leveled against open rhinoplasty.
- The first is the visible incision across the columella. But, if care is taken, this scar is barely seen, if at all, in almost every patient.
- The second criticism is that open rhinoplasty takes longer for swelling to go down after surgery, a questionable statement that is often thrown around.
In fact, a very elegant study done on cadavers showed that the lymphatics that drain fluid out of the nose are not disrupted any more by the open approach than by the closed approach. So, swelling should not be any slower to resolve with the open approach. And, surgeons who frequently do open rhinoplasty can validate this.
What this means for you is that you don’t need to obsess over which surgeon to choose because of their preferred approach. The differences really are not that great. More important than how the surgeon gets to where he or she needs to go is what is done once they are there.
A poor rhinoplasty result is a much bigger give-away that something was done than any incision can ever be. So choose a surgeon who does a lot of rhinoplasty, takes care to listen to you, and has shown you by his results that he can do for you what you desire by whatever approach he thinks best.
Have a question? Ask a doctor
Open (external) versus closed (endonasal) rhinoplasty
Let me begin by saying that I perform both open and closed rhinoplasty so there's no bias on my part towards one approach or the other. As you have heard from other surgeons on this post, the only significant difference between the two approaches is a tiny incision on the columella, between the nostrils. This incision heals nearly invisibly if created and sutured carefully. The healing of this incision has never been an issue for any of my patients.
My personal preference is to use the open approach in primary and revision rhinoplasty if there is significant work to be done on the tip of the nose. The open approach allows me to visualize these tip (lower lateral) cartilages directly and in a undistorted way while working on them. If the patient solely desires the removal of a hump or other work on the upper portion of the nose, then a closed approach is preferable.
The take home point is that you should let your surgeon decide the approach that he/she feels is required to achieve the results you are seeking. Each surgeon's training and background is different and therefore the expertise with the open or closed approach varies. Make your decision based on your level of comfort with your surgeon, the before/after photos in the office/website, the surgeon's training/credentials, and the recommendations of other patients.
Umang Mehta, MD
VIDEO (Click below) Open versus Closed Rhinoplasty: the ongoing debate
In deciding open versus clsoed rhinoplasty, there is no "one size fits all" approach. In some instances, simple corrections are easily achieved with a closed approach and an open technique would be overkill with prolonged recovery. However, in more complex cases such as revision rhinoplasty there is no substitute for an open approach where complete exposure facilitates visualization for accurate placement of grafts. However, even some experts believe that a closed approach, in this case, permits a more intact blood supply and a "tighter" pocket to minimize graft displacement. This argument has gone back and forth for the past 100 years and will no doubt continue.
You might also like...
Open and closed rhinoplasty can reshape the nose
An "Open" Rhinoplasty refers to a technique where a small incision is made at the bottom of the nose (the columella). "Closed" rhinoplasty involves all incisions inside the nose with no external scar. An experienced rhinoplasty surgeon can use either technique. The choice should be based on what is the most appropriate method to achieve the results desired.
Open Rhinoplasty vs Closed Rhinoplasty
How do you know which approach is "best" for you? While you may have a preference for one or the other, your surgeon will recommend the approach that he or she feels is most appropriate, and the surgical technique employed depends primarily on the goals established by you and your surgeon. Some surgeons perform exclusively closed rhinoplasty while others prefer open rhinoplasty. There are surgeons who perform both types of rhinoplasty depending on the patient's needs.
Closed Rhinoplasty refers to a nose job that is performed via internal incisions - i.e., there are no external scars. The surgeon makes one or more incisions along the inside of the nose and lifts the skin up from the nasal framework. Once the skin is elevated, the shape of the nose is changed.
- Potentially shorter operative time
- Less swelling of the tip
- No external scar
Open Rhinoplasty, on the other hand, uses the same incisions as a closed rhinoplasty with the addition of an incision on the undersurface of the column of tissue that separates the nostrils called the columella. While this places a small scar on the exterior of the nose, in most cases, the incision heals very well and is not noticable at conversational distances.
- Better visualization for the surgeon
- Direct exposure of the anatomic structures
- More precise intraoperative diagnosis
- Less distortion of the nasal framework from intraoperative retraction
- Ideal for complex nasal deformities
The ultimate goal is the same regardless of the technique -- to produce a natural-looking nose that functions well.
Rhinoplasty San Diego
The closed rhinoplasty is performed entirely through the nostrils, whereas the open rhinoplasty has an additional incision across the skin of the columella, which is the strip of skin dividing the nostrils. Most plastic surgeons have a bias of one over the other usually based on their training and experience. I prefer the closed rhinoplasty and feel I have excellent visualization and get great results that way. I also had extensive training in closed rhinoplasty, whereas nowadays, many surgeons only learn the open method. That aside, the most important issue is not whether you choose one method versus the other but the skill and experience of the individual surgeon you choose. You should choose the best surgeon in your estimation regardless of whether that surgeon prefers the open or closed technique.
Open vs closed rhinoplasty
An open rhinoplasty requires a small scar on the columella ( skin between the openings of the nose ). I would focus on the experience of the surgeon rather than the technique utilized. All the techniques are straightforward what varies is the experience and skill of the individual providing the surgery.
Open vs closed rhinoplasty
The simple difference that you might notice is a small scar on the columella of the nose. However, this incision usually heals with a barely perceptible scar. Furthermore, open rhinoplasty in my opinion gives more control and better visualization of the underlying nasal architecture to give a better result in most cases..
Open rhinoplasty vs. closed depends on the surgeon.
I began doing all my noses closed but over time now do nearly all of them open. I first used the open technique on cleft lip and palate noses. Later I found that often times there are asymmetries in outwardly appearing symmetrical noses that can be unmasked with a blind closed rhinoplasty. I think it takes longer for the tip swelling to subside with an open approach. I do not think the scar is an issue.
Open vs Closed rhinoplasty should not be the deciding factor
An open rhinoplasty is performed with an incision across the columella. The advantage of this technique is better visualization of the cartilage (since the skin and soft tissues are dissected off the cartilage leaving everything is exposed). This technique allows surgical changes to the underlying skeleton to be seen directly. The disadvantage is that the extra dissection leads to weakening of the intrinsic support mechanisms of the nose. This means that the nose has more of a tendency to change shape during the healing phase. To compensate for this issue, surgeons will use specific grafts to support the structure when open rhinoplasty is performed. Another disadvantage is that swelling is increased vs closed rhinoplasty, and thus the healing phase is longer.
In closed rhinoplasty, all incisions are inside of the nose. This technique does not allow direct visualization of the cartilage . The learning curve for a surgeon using closed rhinoplasty is longer than with open. This technique may not be preferred in redo rhinoplasty because it can be very important to see the condition of the cartilage. The advantage of closed Rhinoplasty is that it has a shorter healing time, and the intrinsic support of the nose is not altered as significantly. Some people argue that a closed rhinoplasty looks more natural, but that tends to be more a function of the surgeon than the technique.
Bottom line: No one technique is superior to the other.. Equally good results can be obtained with each technique. You should not choose your surgeon on whether they use open vs. closed rhinoplasty. Instead, you should choose your surgeon on whether or not he/she has good, consistent results with whatever technique they use.
Lawrence Tong MD FACS FRCSC
These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.