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 36
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.
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.
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Most primary rhinoplasties can be done "closed". This is...
Most primary rhinoplasties can be done “closed”. This is when all incisions are placed inside the nose thus no visible scars are created. “Open” rhinoplasty requires an incision underneath the columella which many patients complain about. On very rare occasions, such as a difficult secondary or tertiary rhinoplasty, an open rhinoplasty may be a good option. It is very important to ask your surgeon if he or she will perform an open or closed rhinoplasty.
Open Vs. Closed Rhinoplasty
Both of these techniques have their pro's and con's.
- Open Rhinoplasty is a better technique for correcting previous surgical problems or severe deformities. On the other hand, you may end up with a permanent visible scar.
- Closed Rhinoplasty leaves no external scars and is an ideal technique for the average rhinoplasty patient.
Ultimately, it is up to you and your surgeon to make the decision as to which technique is best for you in achieving the results you desire.
Open or Closed Rhinoplasty?
It is important to understand that the terms "open" or "closed' only define the surgical approach. They are both designed to accomplish the same thing with the only difference being a small incision across the lower nasal bridge (columella). The decision about what approach to use is based on how much nasal tip work is required. If the case requires more sophisticated maneuvers and/or if the case is a revision Rhinoplasty, I will use the open approach. The reason is that the anatomy and can be more clearly defined and the procedure tailored more carefully. There is no sacrifice in result between either approach in the hands of an experienced Rhinoplasty Surgeon.
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.
Should I Have an Open or Closed Rhinoplasty
Thank you for your question If you are unhappy with the look of your nose, you think that you would be much happier after a rhinoplasty operation; if you had an accident and the shape of your nose got worsened after this accident; then you can be a good candidate for rhinoplasty operation. It is a well-known fact that individuals with feeling themselves beautiful have higher self-esteem. Therefore; if the look or functionality of your nose bothers you, you can get benefit from a rhinoplasty operation.
An open approach may facilitate both visualization and ability to effect a desired change during rhinoplasty surgery.
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.