Revision rhinoplasty to rebuild tip- Closed or Open approach?

Question

In my 1st rhino, my doctor placed a columellar strut which makes my nose tip appear way too short and too upturned and narrow. I am looking to rebuild my tip and especially want to make my nose longer again. A doctor that I am considering for my revision only does closed rhinoplasties. I am nervous that this will not allow for the best result possible due to limited visibility. Is this something I should be concerned about? Would an open approach be better for what I am looking to have done?

Andrew Miller, MD · Answer

There are experts at both open and closed rhinoplasty, so whichever technique the surgeon is more comfortable will probably suit you best. The key is to determine if the surgeon actually performs many revision rhinoplasty and to look at some photos. Then you can be comfortable that a good job will be done. It is difficult to derotate an over rotated nose.

John Layke, DO, FACS · Answer

Although I perform both closed and open rhinoplasty, there is no doubt that an open approach for many revisional changes is far superior to closed.  Due to scarring contractile forces that may be present from the first surgery, a good structural platform should be created and there is no doubt that visualizing the perfect platform directly is best.  Although there are no photos to comment on, the issues that you describe often require several stable cartilage grafts in the form of extended spreader grafts with a septal extension graft, or any one of several other options which lengthen and derotate the nose.

William Portuese, MD · Answer

The closed versus open approach is simply just the approach, not what is performed on the inside of the nose. The closed approach avoids the external incision. The experience of the surgeon matters much more than whether or not it's an open or closed approach. A columellar strut, additional cartilage grafting can all be done with either closed or open approach. For many examples of revision rhinoplasty with a closed approach, please see the link and the video below

Tae Ho Kim, MD · Answer

Rhinoplasty is known to be a very difficult operation to do consistently well.  There is no debate about this!  Over the years, there has been a lot of debate about closed vs. open approach to rhinoplasty without anyone really clarifying why you would only offer one approach.  The benefit of a closed approach is simply not making an incision along the columella and not having a scar there.  If there is no difference in what a surgeon would do between open and closed technique, why would anyone do it open?  However, if there is much more that can be done with more precision using an open approach, why would a surgeon not want to use the open technique?  In my opinion, it's important to do as much with precision as possible, and, therefore, I almost always do an open technique because I know I can do a lot more.  The columellar scar is not noticeable and is a good trade to being more precise.  Now, why do surgeons offer only a closed technique?  I think it's because performing an open approach is technically much more challenging.  If a surgeon does not have the proper experience and judgment and technique with an open approach, it can turn out badly.  I would advise you to get another opinion by a board certified plastic surgeon, who has a lot of experience with rhinoplasty and revision rhinoplasty. Good luck!

Steven Wallach, MD · Answer

I prefer to perform most of my rhinoplasties using an open approach.  Some surgeons prefer a closed approach.  Good results can be obtained with both methods.  Good luck.

Robert H. Hunsaker, MD · Answer

A well done closed or a well done open may yield similar/same results. I think the bigger question is what do you mean when you say your surgeon "ONLY" does closed. Since it may or may not be the "best" option, the fact that their IS NO OTHER OPTION may limit your opportunity for the "best" result.You know the old adage - "when you are a hammer, the whole world is a nail".

Oleh Slupchynskyj, MD, FACS (retired) · Answer

As for open or closed techniques, a closed approach is ideal for a straightforward rhinoplasty with bridge refinement, hump reduction.  An open approach works for many reasons in refining the tip and there is direct visualization of the nasal anatomy and this is critical with a revision procedure  - scar tissue from the previous procedure will not be visible in the closed approach.  I would recommend you consult with at least 2 board certified facial plastic surgeons who are experienced in facial cosmetic surgery, specifically rhinoplasty who have been trained in and are experienced in both techniques and can determine which you would best benefit from.  They should be able to present you with numerous before/after photos of their patients and offer references from patients who underwent the procedure.  I would recommend you have digital computer imaging performed during your consultation so that you can see how your nose would appear following surgery.  This also ensures that you and your surgeon are in agreement as to the desired result.  For more info on the open and closed approaches, see below link.

Revision rhinoplasty to rebuild tip- Closed or Open approach?

Answers (7)

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