Open vs. Closed Rhinoplasty

There are two principal surgical approaches used to perform rhinoplasty: the open approach and the closed approach. The closed approach is often – and more appropriately – referred to as the endonasal approach.

Open Approach

The open approach refers to incisions made inside the nostrils as well as on the skin of the vertical partition between the two nostrils. The skin is then lifted (peeled off) from the tip and the bridge of the nose. The rhinoplasty is then performed. The advantage of this approach is that the skeleton (cartilages and bones) of the nose is exposed and directly visible to the surgeon. Any suturing (stitching) from one cartilage to another, for example, to reshape cartilages or bring them closer together, is performed with greater ease. Open rhinoplasty also offers an advantage when there are complicated problems to deal with in reshaping the nose, such as cases of extensive deformity, or some cases of complex revision rhinoplasty. In such cases, the surgeon may find that an open rhinoplasty approach makes it easier to perform the necessary changes.

There are some disadvantages to using the open approach. First, there is an external scar. However, when the incision is stitched appropriately, it is rarely visible over time. Second, some of the structures that serve to support and “prop up” the tip of the nose may be weakened because there is a more significant degree of cutting and manipulation of tissues. To make sure the tip does not droop, the surgeon needs to place some cartilage grafts taken from elsewhere in the nose. Third, the operation takes longer, usually 3 hours or more. Fourth, the swelling and bruising after surgery are greater and take longer to resolve. Finally, whereas peeling the skin off allows the surgeon to directly view the cartilages and tissues, the surgeon cannot predict very well the effect of any changes made to the nose until months after the surgery when the nose has healed. For example, when the surgeon reduces the size of a cartilage during an open rhinoplasty, it is difficult to immediately look at the nose and determine whether the amount removed was sufficient or if more needs to be removed, because the nose is “dismantled”.

Endonasal / Closed Approach

When the endonasal approach is used, incisions are made inside the nostrils, and the surgeon accesses the cartilages and bones by passing under the skin without peeling it off. Imagine the surgeon’s instrument like a “mouse under a rug”. The modifications and alterations are performed under the skin. The surgeon is able to see the structures inside the nose by looking through the incisions made and making the necessary modifications. He is then able to look at the nose from the outside to evaluate, on the spot, the long-term effect of the alterations performed.

Which Approach is Better?

Neither the open nor the closed approach is inherently better in the hands of an experienced surgeon. Rather, they are simply different approaches to accomplish the same task but most surgeons do favor one approach over another because of personal preference and experience. However, the differences in swelling, bruising, and recovery are important and may factor into some patients’ decision regarding which approach, and therefore which surgeon, they wish to perform the procedure.

Our Approach

Dr. Samaha is trained to use both the open and endonasal approaches. He feels that the endonasal approach is the best approach for the vast majority of rhinoplasties he performs. It offers several advantages that provide an easier experience for the patient and lead to an overall better result. First, the ability to sculpt the nose and see the result immediately on the operating table allows him to obtain more consistent and predictable esthetic results. Second, his patients benefit from a very short recovery period and very little swelling and bruising. Dr. Samaha’s use of the endonasal approach, combined with a local anesthetic with sedation, are part of an overall minimally invasive approach that yields excellent results with minimum discomfort and recovery.

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