Different Approaches to Rhinoplasty

Cosmetic Surgery Magazine article, posted 2005

Rhinoplasty is still one of the most commonly performed procedures in plastic and cosmetic surgery. Within the category of rhinoplasty there are two commonly performed procedures: the open (external) and closed (internal) techniques.

Open Technique

With the open technique, most incisions are made inside the nose. However one is made across the cartilage that separates the nostrils – the columella. The skin is then lifted over the nose to allow the cartilage structure of the nose to be revealed. Surgeons who prefer the open technique of rhinoplasty enthuse about the increased exposure, making it easier to see significant abnormalities or imbalances. “An advantage with the open technique is you are able to see the way the cartilage sits in its natural state, without the distortion of the pulling in the closed technique,” explained Dr. Nicholas Nikolov, a plastic surgeon from Beverly Hills, Calif.

“The main drawback is you have to make sure the scar is closed properly, so that it is lined up and you don’t get a little scar on the side. The other disadvantage is people tend to be a little more swollen, and it takes a little more surgery time,” explained Dr. Nikolov.

Surgeons who practice the open technique claim the scar under the nose is virtually unnoticeable and heals easily. “Patients are usually very scared about having an external incision, and are usually very surprised at how minimal and hardly noticeable the scar is. If it is done properly you can’t see it. It tends to heal very well and I have never had a keloid.

In my experience you probably get more consistent results with the open technique of rhinoplasty,” said Dr. Nikolov. He summed up: “It is easier to achieve a reliable result through an open technique. Also, if somebody requires a cartilage graft to augment an area, I like to do that in an open technique.”

“Rhinoplasty is still one of the most commonly performed procedures…”

Closed Technique

“The closed technique has changed,” said Dr. William Binder, a Los Angeles facial plastic surgeon. Now the closed technique of rhinoplasty consists of all incisions being made inside the nose. The cartilage is then pulled out from the nose and shaped. “When we are talking about an intra-nasal or a closed approach, there are several different approaches depending on where you make the cuts.

You can make the cut at the very bottom (below all the cartilages) or you can make the cut between the lower and the upper cartilage,” said Dr. Nikolov. “The big difference with the closed technique is that you’re using the natural cartilage, supporting the natural cartilage, to form the tip. It makes a huge difference,” explained Dr. Binder. Surgeons who prefer the closed rhinoplasty technique give reasons including: it’s a quicker procedure: no visible scars are left; and if done by an experienced surgeon, there is little need for revision surgery. “The closed technique is more predictable. It becomes more natural, because you’re using the natural cartilage of the nose,” concluded Dr. Binder.

More important than which technique is chosen is that the surgeon is experienced in that particular procedure. Both open and closed approaches can have good results in the right hands.