One of the most common questions I get asked is "will my rhinoplasty be done 'open' or 'closed'?" There seems to be much needless controversy about this topic on the internet chat rooms. Granted, for years even amongst rhinoplasty surgeons, the debate was heated and controversial but in recent years the controversy has given way to a practical decision making algorithm and approach.
There are two main methods of nose surgery or Rhinoplasty. The "open" technique more appropriately referred to as the "external rhinoplasty" versus the "closed" technique more appropriately referred to as the "endonasal rhinoplasty. " To make matters slightly more complex for patients (and some surgeons) the "closed" or "endonasal" method is further subdivided to a "delivery" and a "non-delivery" method. Therefore truly there are 3 ways of performing a rhinoplasty.
The fact is that some surgeons do all of their rhinoplasties through an open approach and there are others that solely choose a closed approach. That is how they learned it and that is how they perform "the nose job. "
More commonly these days, we see surgeons who have not learned the closed technique and so they perform all of their rhinoplasties with an open approach. The open or external rhinoplasty is arguably easier to learn and easier to teach and so the pendulum has swung to this side of the debate currently in favor of the external or open rhinoplasty. Not because this is the better operation but rather because this is how most surgeons today have learned to perform the nose job.
So what is the difference between these different techniques? What are the advantages and disadvantages? And what kind of surgeon should you look for to do your Rhinoplasty?
The open technique is characterized by a "columellar incision" which is a small incision on the bridge of skin at the base of the nose that divides the two nostrils. When this incision is made in an "inverted V" fashion and then closed meticulously with fine sutures, the scar is practically invisible. The incision should not be made straight across or even in a "stair-step" pattern, which some plastic surgeons choose.
The remainder of the incisions for the open rhinoplasty are very similar to the ones in a closed rhinoplasty which are essentially all hidden inside the nose. Many patients needlessly focus on the incision and scar and many surgeons who market their closed technique use the phrase "No Scar Rhinoplasty" to advertise their approach. However, as I mentioned, the scar is almost never an aesthetic issue when done properly.
The advantages of an open technique are that the surgeon will be able to clearly visualize the tip structures and cartilages of the nose as they lay in a natural position in order to be able to diagnose causes of asymmetry or twisting. With an open technique, the rhinoplasty surgeon can also place and secure, with fine sutures, more structural grafts such as tip grafts and spreader grafts. Finally as I have mentioned above, the open technique is easier to learn and perform by less experienced surgeons. Furthermore, this is the preferred method when total tip (lobular) reconstruction is necessary in complex revision rhinoplasty cases or in patients with a history of cleft lip disorder.
The disadvantage is that the operation does take longer to perform and there will be more swelling and numbness at the tip of the nose.
The bottom line is that the open rhinoplasty is a fantastic operation for the proper nose. However, it is too invasive in a nose that needs minor changes or no tip work at all. Opening the nose in such patients creates more risk and unnecessary trauma and prolongs the healing time.
As far as the closed rhinoplasty goes, there is nothing "closed" about the operation! Some patients are shocked and awe stricken when they hear about an endonasal or closed rhinoplasty. They cannot visualize how a surgeon can perform the surgery through the nostrils! The fact is that for an experienced and skilled rhinoplasty surgeon the closed technique allows excellent visualization of everything that needs to be seen and altered.
The "delivery" modification allows the tip cartilages to be "delivered" through each nostril for clear inspection and alteration. The "non-delivery" modification allows the extremely skilled rhinoplasty surgeon to alter the nasal anatomy and create an aesthetic and beautiful nose with the least amount of trauma, minimize unnecessary dissection thereby improving healing time and minimizing scarring.
Just as there are many surgeons who perform each and every one of their nose jobs through an open technique, there are some surgeons who perform each and every one of their surgeries through a closed technique. It is much less important which technique your surgeon chooses but rather it is critical to make sure your surgeon is skilled and vastly comfortable with the operation allowing him or her to obtain great and safe results consistently. Rhinoplasty is arguably the most artistic operation ever invented by man and it requires a dedicated surgeon with a true understanding of the nose, its anatomy, and its response to surgical maneuvers. A true "rhinoplasty surgeon" dedicates the vast majority of his or her surgical practice to the operation of the nose.
Ideally, a skilled "Rhinoplasty Surgeon" will be well versed in all of the above techniques and will diagnose the aesthetic and/or functional problem with each patient's nose and then choose the most appropriate method to obtain the best results with the least trauma for each and every patient.