Feb 29

Should I have an Open or Closed Rhinoplasty?

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 saying 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 we’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. You can see by the average scar shown in the before and after result below that 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.

Rhinoplasty Base ViewRhinoplasty Base View Postop

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.

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2 Comments so far

  1. a.g. November 21st, 2008 9:54 pm

    Can you cite the study you mention re: lymphatic drainage in open vs. closed approach?
    Thank You.

  2. Admin November 24th, 2008 8:55 pm

    Sure, a.g., the citation for the study mentioned is below:

    Toriumi DM, Mueller RA, Grosch T, Bhattacharyya TK, Larrabee WF Jr. Vascular anatomy of the nose and the external rhinoplasty approach. Arch Otolaryngol Head Neck Surg. 1996 Jan;122(1):24-34.

    The study was small, but very nicely showed that flow through the nasal lymphatics is preserved by careful dissection using either the closed or open approach. The degree of tip swelling regardless of approach has mostly to do with disruption of the muscular fibrous layer of the nasal skin. So, one would expect that a rhinoplasty in which a thick-skinned tip is thinned by trimming some of the fat in this layer would take longer for swelling to go down. Ultimately, it would result in a better outcome, so the swelling is a worthwhile trade off.

    Hope that helped. Let us know if you have any more questions.

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