Open Rhinoplasty vs. Closed Rhinoplasty

November 03, 2022    -    Nose

I have been performing rhinoplasty for over 17 years, and can start to look in the back mirror and reflect on my own journey of learning one of the most difficult procedures in cosmetic plastic surgery. What makes it so difficult you may ask? Well, there are about a hundred different variables that one has to consider in rhinoplasty, and like in a chess game, once you make one move, then the whole board changes and you have to adjust your next move based on all previous steps.

One of the first steps that I consider when deciding how I am going to reshape a nose is what kind of approach will I use, open rhinoplasty or closed rhinoplasty? Closed rhinoplasty approach means that I will make all the incisions inside the nostrils without any visible or external scar. An open rhinoplasty approach, actually is not that much different with the exception of a small scar on the central partition between nostrils called columella. This incision is shaped in a gull-wing or a stair-step pattern to help break up a scar in order to make it less visible. So why would we want to place a scar on the outside of the nose, if I can place all of the scars inside and make them less visible? It depends on many factors, including whether this is a primary rhinoplasty or secondary revision rhinoplasty surgery, whether there are major nasal tip deformities that need more tip cartilage refinement or if extensive grafting is needed to reconstruct the infrastructure of the nose. There are some surgeons that feel very comfortable doing all the maneuvering through a closed approach and others who only perform procedures via an open approach. This may depend on surgeons training, skill level and length of practice.

My own evolution in the technique that I choose developed over many years. I learned a closed approach first and it was quite challenging for me to appreciate the intricate anatomy of the nose as a trainee because all the work is done “under the hood of the car”. When I went through my fellowship and later, as an assistant professor of surgery, I performed an open rhinoplasty approach almost exclusively, as I felt that it helped me teach rhinoplasty surgery to medical students and residents. Once I have mastered the open rhinoplasty approach technique I was able to perform either open or closed rhinoplasty with equal confidence.

Lately, I have been doing most of the cases with a closed rhinoplasty approach as I feel that a closed rhinoplasty approach preserves many important structures that may be inadvertently disrupted via open rhinoplasty technique. So while the great academic debate will go on, my personal journey has brought me back to accessing a nose closed rhinoplasty approach. In the end, the debate is really only about how you access the nose. Once access to the nasal structures has been completed, rhinoplasty surgery can be performed in a virtually identical fashion.

Advantages of closed rhinoplasty approach include no visible external scars, great option for primary rhinoplasty in an individual with thicker sebaceous tip skin, and less likely to have contraction forces that may pull the tip up. The disadvantages are that it may be technically difficult to place certain grafts.

Advantages of open rhinoplasty technique include great visibility, ability to precisely place and secure grafts. The main disadvantage of an open rhinoplasty approach is that it leaves a columellar scar and also requires more extensive grafting of the tip to compensate for torsional forces that may deform the nose as it heals.

Both techniques work well when properly executed. If you would like to learn more about which surgery is a better option for you, please request a rhinoplasty consultation.