Can I successfully have desired improvement with closed surgery? (Photo)

There definitely exists a controversy regarding Closed Vs. Open Rhinoplasty. Some patients say that Closed Rhinoplasty is best; some say that Open Rhinoplasty is the only way to go. The truth is: both are excellent approaches, but it depends on the circumstance and the patient's own anatomy and the surgeon. I will explain.

Superior, highly detailed yet understated aesthetic rhinoplasty should always be the goal. The best surgeon for the job should have a long history of performing both closed rhinoplasty and open rhinoplasty, and in your case, this surgeon should be an expert in revision rhinoplasty.

Revision rhinoplasty is far harder than primary rhinoplasty. It's in another league in terms of the skill set required, so experience is key. Looking at your photos, I can see that you have already had an unsuccessful closed rhinoplasty. Correcting your current issues would require an open rhinoplasty. Do not be frightened of open rhinoplasty. The horror stories you see online are when patients go to surgeons who are not experienced enough to produce a good result -- meaning, the problem is with the surgeon, not the approach. For example, when I perform revision rhinoplasty using the "open" approach, it is under loop magnification, which is basically five times human vision. I sew the tiny incision closed with suture material that is finer than a human hair, and more than likely, you will not see this incision once you are fully healed. The reason I advocate for an Open Rhinoplasty in your case is because it provides for the best anatomical visualization. Being able to see your delicate anatomical structures helps to ensure the most precise result. Experienced revision-rhinoplasty surgeons will tell you that visualization and accuracy are far more precise with the open approach. Your aesthetic issues can be addressed with a revision rhinoplasty using the open approach, leaving you with a beautiful, understated, less-is-more result, always reflective of a keen eye towards natural beauty.

It looks like the cartilaginous part of your bridge deviated well off to your right. In pictures 1 and 4, the bump on the upper bridge looks bigger because the cartilage has moved to the right, away from the boney prominence there. The amount of improvement possible depends on a couple factors. If your septum is very crooked and contributing to the deviation, that's good, because it means working on the septum can help straighten the nose. You didn't post profile views or a big batch of 3/4 views, but if the nose can be shortened, that helps, too, because a shorter nose doesn't show asymmetries as much as a longer nose, so whatever part of the deviation can't be fixed can be camouflaged by shortening the nose. There may be other factors at work as well.

I don't see that your skin is particularly thin. It's rather unusual to have skin thin enough to get in the way of an operation like this.

Why do you need the operation to be closed? The only difference between closed and open is that little 7millimeter incision on the columella, and it lets the surgeon really see what's going on and have options for correction. It doesn't increase the swelling or bruising or recovery, and to my mind it significantly lowers the risk. I personally wouldn't attempt your nose using the closed technique.

In case your 3/4 and profile views do show a nose that can be shortened, or they suggest other changes, how *much* to elevate the tip, or lower the bump, or make other changes? We figure that out with morphs, well before surgery. I'd love for you to see some excellent professionally-designed morphs of what could possibly be done with your nose. Morphs could also help you identify better just what's bothering you, and help you set a goal for the rhinoplasty that's accurate for your tastes. Profile and three-quarter views would be particularly important in morphing your nose. (Side note: in my opinion, morphs should really be done by the surgeon, or he should direct an assistant as she makes the morphs. Morphs should be made with a constant eye to what actually *can* be done in surgery, for that particular nose, and the surgeon has that information and judgment best.)

Finally, remember that rhinoplasty is an exquisitely difficult operation to get right, and you should only have surgery if you are able to make yourself very confident in your surgeon's skills. The changes that your nose needs require advanced techniques, and skill that most plastic surgeons don't possess with expertise. It's much better to not have surgery than to have inexpertly-performed surgery. Read my essay on how to stay out of trouble while selecting a rhinoplasty surgeon. And it also discusses how to take photos that are best for online evaluations.

And for those who have had previous surgery, it also discusses how to tell whether your first surgeon should be performing your revision.

In our practice for over 30 years, we have only performed closed rhinoplasty. All of the incisions are placed on the inside of the nose, and no painful packing as required either. Your desired results can certainly be performed with a closed technique. It's very important to know how much cartilage is left over on the inside of the nose for placement of a spreader graft underneath the concave upper lateral cartilage on your left side, which is creating the twisted/crooked look. If there's no cartilage left over from your previous septoplasty, then ear cartilage may be required. The dorsal hump can also be filed down.