Closed versus Open Rhinoplasty: Advantages and Disadvantages.
Nowadays, nose reshaping holds third place in the ranking of most popular aesthetic surgeries with a total of 213,780 procedures performed in America in 2017, according to the American Society of Plastic Surgeons (ASPS) (1). Nose reshaping, also known as rhinoplasty, can reshape, reduce or augment a person’s nose to achieve facial harmony and boost self-confidence. It may be performed as a reconstructive procedure to correct a birth defect or an injury such as a broken nose. Many of my patients also opt for rhinoplasty surgery in view of functional reasons rather than solely cosmetic purposes. For instance, certain breathing problems can be effectively treated by combining nose reshaping with septoplasty or endoscopic sinus surgery. The surgery typically lasts anywhere between 2-5 hours depending on how extensive the operation is. Depending on what is being accomplished during the surgery, either an open or closed rhinoplasty is used for the reshaping of the nose.
During any nose reshaping surgery, the plastic surgeon lifts up the skin of nose, makes changes to bone and cartilage, and puts the skin back down. The art and science of customizing each rhinoplasty happen when the plastic surgeon carefully decides exactly how the bone and cartilage will be altered to achieve the patient’s goals. There are major differences between an open and closed rhinoplasty, not the least of these being where the incision is made. During the closed rhinoplasty approach, two incisions are made within the inside of the nose (inside the nostrils). It is through these incisions that all alterations will be made. An open or external rhinoplasty includes the same two incisions, but one additional incision is made on the underside of the nose along the columella (the soft tissue between the nostrils). That final connecting incision is called a trans-columellar incision, and it allows plastic surgeons to open the skin of the nose or unveil the nose (2). Depending on what the surgeon is trying to achieve, each approach has its advantages and disadvantages.
Among the advantages of closed rhinoplasty are the following: a shorter surgery time, less scarring and better circulation to the skin of the nasal tip. A closed rhinoplasty procedure takes a shorter time to be completed than an open or external rhinoplasty. It is also less invasive and leaves no scarring and less swelling after surgery, so there will be a shorter recovery time and downtime in most cases. The procedure is performed internally, and the plastic surgeon will ensure that there will be no strong visible signs of the surgery, especially across the columella (the soft tissue between the nostrils). Furthermore, because there is no need to make an incision across the columella, the circulation of the skin is not disrupted. There will be less nose swelling after a closed rhinoplasty because the natural drainage channels of the skin were untouched during the procedure. Therefore, the nose will heal faster compared to patients who undergo an open rhinoplasty. Patients who want a small change to the nose, especially to the nasal bridge rather than the tip, and at the same time want to recover quickly with the least possible downtime, are good candidates for a closed rhinoplasty. A study published in the Journal of Laryngology & Otology on the effectiveness of closed rhinoplasty approach for excision of nasal dermoid found that this method gives optimal cosmetic results in excision of small, superficial nasal dermoid cysts in well-selected cases and provides adequate exposure for total extirpation (3).
There are some disadvantages with a closed rhinoplasty that include limitations when repositioning nasal skin. A closed rhinoplasty, in many cases, does not provide the visibility or access to allow a surgeon to perform the most detailed and accurate of bone and cartilage enhancements (4). There are fewer plastic surgeons who are skillful at closed rhinoplasty than open or external rhinoplasty. Because the procedure is carried out without lifting the nasal skin, the surgeon makes all the changes via the narrow openings of the nostril. It is a “blind” procedure and everything is done by feel and through sight of the outer appearance. You should ensure that your plastic surgeon has the right skill set to do the task if you chose to undergo a closed rhinoplasty. Moreover, closed rhinoplasty is not much suitable for people who want to get a lot of change in the soft tissues if their nose. Patients who require complex changes to their nose should opt for an open rhinoplasty. Complex surgical procedures are impossible with the closed rhinoplasty approach because of the lack of exposure and access.
The main advantage of the open or external rhinoplasty over the closed approach is that it allows better visualization of the cartilages that will be addressed in the surgery. Moreover, an open rhinoplasty gives plastic surgeons the ability to manipulate and alter nasal shape with more control and precision. An open rhinoplasty allows plastic surgeons to measure, analyze the anatomy of the nose and see any asymmetry or abnormalities that were not clear from an external examination (5). With an open rhinoplasty, plastic surgeons are better able to use advanced cartilage grafting techniques and place the grafts more accurately giving a longer-term support and structure. Open rhinoplasty is recommended for patients who are looking for major changes to the shape of their nose, such as reducing or increasing projection from the face. Furthermore, open rhinoplasty is suitable for patients who want to get the dorsal hump removed or their nasal tip corrected. The open approach is especially good for those who are having a revision rhinoplasty. It is also the approach preferred by plastic surgeons when working on a very intricate or severe deformity, as it gives the plastic surgeon much more control. With the amount of work needed for a complex reconstructive surgery, open rhinoplasty gives the visibility and access necessary to do comprehensive work on each part of the nose’s structure.
The main drawbacks of open rhinoplasty are the following: it is lengthier and more invasive than the closed rhinoplasty approach (therefore, the recovery time will be a little longer) and a very small scar might be visible on the nasal columella, only when patients tilt their heads back. Nonetheless, the small scar gradually fades away with time until it is hardly visible, and the side effects after surgery depend on how extensive your rhinoplasty procedure was, your genetic predisposition to heal quickly, and lifestyle choice you make during recovery (6). Regardless of the type of rhinoplasty (open or closed), following post-operative protocols that include sleeping with the head elevated, eating nutritious and low-sodium food, applying cold compresses (small gauze pads) to the eyes, avoiding putting glasses or anything else to rest on the bridge of the nose and avoiding pulling clothes over the head, can help reduce swelling significantly and make recovery easier.
(1) “Plastic Surgery Statistics Report 2016”. American Society of Plastic Surgeons. www.plasticsurgery.org
(2) “Rhinoplasty”. American Society of Plastic Surgeons. www.plasticsurgery.org
(3) Harris, R., & Daya, H. (2010). Closed rhinoplasty approach for excision of nasal dermoids. The Journal of Laryngology & Otology, 124(5), 538-542. doi:10.1017/S002221510999243X
(4) Vartanian, John. “Basic Closed Rhinoplasty”. Medscape. www.emedicine.medscape.com
(5) Momeni, A. and Gruber RP. “Primary Open Rhinoplasty”. National Center for Biotechnology Information, US National Library of Medicine. www.ncbi.nlm.nih.gov
(6) “What should I expect during my rhinoplasty recovery?”. American Society of Plastic Surgeons. www.plasticsurgery.org