Open vs. Closed Rhinoplasty
To Open or Not to Open
Open rhinoplasty is the nose reshaping technique most commonly taught in today’s plastic surgery training programs. The primary reason is that this approach allows direct visualization of the nasal anatomy. This sounds good except the nasal contours created this way are different than the contours created under the nasal skin. This is especially true when the nose and septum need to be straightened.
The late Dr. Ralph Millard, regarded as the World’s Best Plastic Surgeon, and Dr. Lesavoy’s mentor, stated in A Rhinoplasty Tetralogy, “Open rhinoplasty has become popular among the younger surgeons and even some of the older surgeons who were never really at ease with the standard endorhinoplasty. There are a few surgeons for whom open rhinoplasty is actually their ‘raison d’etre.’ It is enough of a fad that general rhinoplasty books are including it in the subtitle to attract young readers much like a naked lady in a circus sideshow sign serves to bait the yokels to buy tickets.” (Millard, 1996, Page 10)
Decades later, so many nose surgeons appear to continue with their “raison d’etre,” and remain with the perceived easier open rhinoplasty as their approach to the cosmetic nose job.
What is Open Rhinoplasty?
Open Rhinoplasty is surgical nose reshaping that involves making an incision across the columella, the middle section of tissue under the tip of the nose that separates the nostrils.
Making an incision in the columella always leaves a scar which is to a various degree visible.
When is Open Rhinoplasty Indicated? For Dr. Lesavoy, on rare occasions. Open Rhinoplasty is Sometimes Indicated:
- Secondary Rhinoplasty with previous bone graft and/or cartilage grafts
- Cleft lip rhinoplasty (unilateral or bilateral when severe)
- Severe septal deviation, loss of septal cartilage
- Previous open rhinoplasty with bad scar
- Severe nasal tip asymmetry
Diagram of Closed Scarless Rhinoplasty from Rhinoplasty Tetralogy by Dr. Ralph Millard
What is Closed Rhinoplasty?
Closed rhinoplasty, also called Endorhinoplasty, is surgical nose reshaping that does not involve an incision on the outside of the nose, but on the inside of the nose. This type of rhinoplasty is sometimes referred as “scarless rhinoplasty.” The surgeon makes an internal incision just inside of the nostril to access the internal structures of the nose for the procedure.
Closed rhinoplasty is always indicated and can also be done if there is a complicated secondary cosmetic rhinoplasty including rib rhinoplasty. Closed rhinoplasty can be indicated even if there is a need for a complicated primary rhinoplasty with multiple cartilage grafts.
What is the difference in recovery between open and closed rhinoplasty?
Recovery for rhinoplasty is almost the same between open and closed except for the external incision on the outside of the nose requiring external stitches and a bit more protection during the healing process.
Closed rhinoplasty is often considered to be less invasive by plastic surgeons, such as Dr. Lesavoy, that specialize in this technique. Closed rhinoplasty specialists often see their patients heal faster, with less swelling, reduced incidence of temporary and permanent numbness, and aesthetic integrity of the columella.
Why is Closed Rhinoplasty harder to do?
Closed Rhinoplasty is not harder to perform in the hand of a surgeon trained to perform this technique. Surgeons not skilled with this technique would likely consider it to be more complicated and are known to state the possibility of increased complications with this technique. Yes, unskilled surgeons are likely to experience higher complications performing procedures in which they lack training and experience.
To Closed Rhinoplasty specialists like Dr. Lesavoy, scarless rhinoplasty is second nature to him due to his training and experience as he was trained by Dr. Ralph Millard, considered to be the world’s greatest plastic surgeon of all time. Dr. Millard would only consider an open rhinoplasty for the most complicated patients as he preferred the closed rhinoplasty to deliver the best results.
Dr. Millard considered the emergence of the Open Rhinoplasty due to the “era of instant gratification, the quick fix and shortcuts to unearned expertise. Still there is nothing wrong with making an operation easier provided the cost of the change is not exorbitant. To open the cap on the columella for more complete exposure of the tip, on the surface, seems to cost only a minor external scar but unfortunately the price of violating the nasal capsule can be far greater. I have seen unacceptable scars, notch contractures, columella trap-door bulge, asymmetrical healing, deep scarring, tip depressions and partial to almost complete loss of the columella.” (Millard, 1996, Page 11)
Unfortunately, Dr. Lesavoy has treated patients with total tip necrosis due to lack of blood supply after undergoing open rhinoplasty by other, less experienced surgeons.
Diagram from Jacques Joseph’s Nasenplastik, published in 1931. Diagram shows the closed rhinoplasty technique.
Brief History of Rhinoplasty
Evidence of rhinoplasty dates back to 3000 to 2500 BCE. However, the original rhinoplasty procedures were described as reconstructive through the ages predominantly due to warfare injuries. The rhinoplasty procedure eventually evolved to include cosmetic refinements as documented by John Orlando Roe in 1887 (USA). However, the most notable cosmetic rhinoplasty was published by Prussian Jacques Joseph. In 1928, Joseph described rhinoplasty with internal incisions.
Cosmetic nasal refinement surgery remained as closed rhinoplasty until a pair of surgeons popularized the Open Rhinoplasty in the 1970’s by Padovan and Goodman. This trend continued into the 80’s with Jack P. Gunter preferring open-rhinoplasty for secondary procedures. However, the open rhinoplasty became favored among teaching institutions resulting in endorhinoplasty being sidelined in favor of the easier approach.
As the former Chief of Plastic Surgery at UCLA, Dr. Lesavoy has remained loyal to the Closed Rhinoplasty approach to deliver the best results to patients seeking nasal refinement. Additionally, Dr. Lesavoy continues to teach the art of the endorhinoplasty to those interested in stepping away from the “raison d’etre.” As professor at UCLA, Dr. Lesavoy has taught numerous residents on the endo technique and has become an authority in septorhinoplasty and the art of Closed Rhinoplasty.
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Pamela Howard
Author
Pamela is a plastic surgery industry leader with over two decades of blogging and patient education experience.
