Open vs. Closed Rhinoplasty
Prior to discussing the different types of rhinoplasties performed, some definitions of the terminology used may be helpful, especially since medical and surgical “lingo” can sometimes be confusing.
Demystifying the “Lingo”
A surgical technique is a maneuver or series of maneuvers the surgeon makes to accomplish a certain task. There are often many different techniques to accomplish a certain task. For example, a complex task like refining the nasal tip. This can be done by reducing the bulk of the tip cartilages, re-orienting the cartilages, or placing sutures (stitches) to bring the cartilages together to refine the tip. All of these are techniques of tip refinement and may each be used alone or in combination to perform the desired refinement.
A surgical approach is the path the surgeon takes to access the area being modified. For example, to perform techniques of tip refinement, the surgeon needs to access the tip cartilages and expose them. The incisions made and tissues dissected in getting to these cartilages constitute the approach.
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 between the two nostrils. The skin is elevated (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. Second, there is some loss of support to the tip of the nose because there is a more significant degree of cutting and manipulation of tissues. To restore support, 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, it obscures his/her ability to appreciate 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, 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 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 visualize the structures 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 effect of the alterations performed. The principal disadvantage of the endonasal approach is that many surgeons are not comfortable using it because their training in rhinoplasty surgery may have emphasized mainly the open approach.
Which Approach is Better?
It is important to remember that the advantages and disadvantages listed above do not make one approach better than another. They are simply different approaches to accomplish the same task. Most surgeons favor one approach over another because of personal preference and experience. However, experienced rhinoplasty surgeons recognize that they need to be able to perform both types of approaches depending on the patient’s anatomy and the needs of the operation.
The Bottom Line
It is not the approach (open vs. endonasal) but the surgeon that makes the difference. Some surgeons obtain excellent results with an open rhinoplasty whereas others achieve similarly great outcomes with an endonasal approach because this is the approach that works best in their hands. 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. However, remember that these are short-term considerations and do not necessarily affect the final outcome.
Any further questions concerning the differences between open and closed rhinoplasty can be addressed after you set up your consultation.