What is an Open vs Closed Rhinoplasty?
You will see these terms, as well as others, used interchangeably to describe the approach a surgeon may take to operating on a nose.
For example, the open approach is often described as an external approach and the closed approach is often described as an endonasal approach and by some as a scarless Rhinoplasty.
My history with rhinoplasty includes both approaches although after 25 years of performing rhinoplasty I rarely use the open approach any longer. There are advantages and disadvantages to each and I will describe these in detail in this blog.
You can see this difference in greater detail in the illustrations in our book, Rhinoplasty
Everything You Need to Know About Fixing and Reshaping Your Nose, however, I will also describe them here for you.
What is an External or Open Rhinoplasty?
Again, this is an approach used by a surgeon to operate on the nose. The external approach is one whereby the nose is opened, something similar to opening the hood of a car, so you can see the structure of the nose. There is an incision called a marginal incision that goes along the inside of the nostril and crosses the columella which is the area of nose between the nostrils.
This incision allows the surgeon to open the nose by lifting up the skin and the underlying tissue so that they can directly view the cartilage and underlying bony structure of the nose. This often assists the surgeon in operating on the nose since reducing cartilage or framework as well adding cartilage or framework can also be done under direct vision – meaning they can view the external nose directly – and then sutured into place.
Surgeons will often use cartilage grafts to rebalance and shape the nose as well as removing cartilage. For example, if someone has a droopy tip and a bump on nose, cartilage can be removed in the area of the bump and structure and cartilage can be added with a couple of different graphs like a tip graph and a strut which is placed between the lower lateral cartilages of the nose to fix the droopy tip.
What is Closed/Endonasal or Scarless Rhinoplasty?
The closed or endonasal approach to rhinoplasty is an approach that uses incision that are placed on the inside of the nose thereby giving it the term scarless rhinoplasty. In other words, there are no external incisions that can be viewed by the surgeon or the casual observer. Through the incisions placed on the inside of the nose, I am able to create an optical cavity whereby fiber optics, good visualization and magnification allow me to see the inside of the nose including the cartilage, the bone, and the other soft tissue (often modified and changed in rhinoplasty) to leave a more satisfactory, aesthetically pleasing profile. I am also able to do the tip work in the nose more precisely with less trauma.
The Good and Not So Good Effects of Open Rhinoplasty.
Surgeons who prefer to open a nose say there the advantage of the open approach is direct vision which, in their opinion, enable them to perform the rhinoplasty more precisely. There are also disadvantages to this approach namely the amount of dissection, the amount of undermining, and what some refer to as operative trauma to the nose. Additionally, there is an incision that goes across the columella between the nostrils which disrupts the lymphatic draining of fluid from the nasal tip tissue and can result in more prolonged swelling and bruising leaving some rhinoplasty surgeons to believe there is more trauma to the nose as a result of this approach. Advocates of the open approach claim that the additional recovery, bruising, swelling and trauma are well worth it given it allows them to more precisely see and operate on the nose. Those who are advocates of the closed or endonasal approach feel that if rhinoplasty can be performed safely and as effectively through this approach why would one open a nose subjecting in to all the additional trauma.
Why I Prefer the Closed Approach Rhinoplasty.
As a rhinoplasty surgeon, I am personally an advocate of the endonasal or closed approach. I have been performing rhinoplasty for over 25 years and have performed thousands of rhinoplasties and in fact in my first 10 years of practice opened the nose on 70-80 percent of those I operated on. While I was fortunate to be trained in the endonasal/closed approach, early on I felt that the added exposure was worth the incision and additional trauma. But this changed. As I followed my patients through many years of performing this specific surgery and becoming more and more proficient at this procedure, I noticed that, in my hands, an endonasal approach is preferred in almost all cases with few exceptions.
This approach allows me to deliver a very consistent natural and customized rhinoplasty to my patients with a lot less swelling, trauma, bruising and avoiding the external incision. There are those that argue that the external incision is simply not a problem or concern. I agree having performed the open approach rhinoplasty for many years that the external incision can be performed very nicely and is virtually imperceptible when it heals. However, the amount of trauma experienced by the nose by removing all of the soft tissue cover can simply not be ignored as this does lend a degree of unpredictability to the operation with prolonged healing and scar contracture.
Using the endonasal approach, I am able to perform all of the cartilage modifications including reducing the bump of the nose, a bulbous tip, as well as precisely placing cartilage graphs in the areas where they are necessary. For example, I can perform the placement of alar baton grafts, rim grafts, radix grafts, only grafts, spreader grafts, plumping grafts, diced cartilage or cartilage gel grafts, tip grafts, composite grafts, hump removal, cartilage thinning techniques as well as a variety of suture modifications where all of these are necessary and indicated. I feel I can do the above much more precisely and less traumatically than when I open the nose which is a bigger operation with a longer recovery.
I hope this is helpful in giving you a better understanding as to the difference between the open and closed or endonasal approach. It is simply a matter of preference by the doctor and it is very difficult for me to argue against an external/open rhinoplasty as some surgeon feel they can consistently deliver better results using this method and for them this may be the best approach in their hands. However, in my skilled and experienced hands, the endonasal/closed or scarless approach is the preferred for most of my rhinoplasty patients.