Closed Rhinoplasty (Nose Surgery) Information

The closed approach to rhinoplasty involves accessing the nose through incisions made on the inside of the nostrils (this area is called the Vestibule). By separating the skin from the underlying tissues using specialized retractors, the surgeon is able to visualize the bridge of the nose and effect changes. The nasal tip cartilages can also be "delivered" through the nostrils and sculpted under direct vision.

Endonasal rhinoplasty requires a precise knowledge not only of the nasal anatomy but also of how that anatomy will react to sculpting and changes created by the surgeon.

The surgery is generally quicker because less suturing is required, and also because it is easier to make fine judgements on profile alignment when the nose is "closed." Healing is very slightly faster with this approach as well.

Indications

An endonasal approach is generally indicated in noses that do not require complex middle vault work (spreader grafts, implants, etc.), as well as noses that do not require extensive tip manipulation. Many surgeons feel a closed approach is preferred for primary "finesse" rhinoplasty (patients who require subtle changes to the nose). This is because healing may be a bit easier to predict in these cases when the nose is not opened.

As with open rhinoplasty, there is no absolute indication for an endonasal approach.

OPEN VERSUS CLOSED RHINOPLASTY: Dr. David's personal philosophy

I strongly believe that some noses are more suited to the open approach and some to the closed (endonasal) approach.

In my own practice, it is a minority of paitents who I inform at their consultation "You will 100% require an open approach." Usually, these are revision rhinoplasty patients. In other cases, a nose may show signs of obvious asymmetry or narrowing in the middle vault, or signs of dynamic nasal valve collapse. Such patients are also told up front "You will require an open approach." I tell patients this ahead of time mainly so that they are not surprised to see a few small sutures along their columella after surgery.

In a majority of cases I inform patients that I "reserve the right" to use an open approach for their nose. If at any time before or during their surgery I determine that an open approach will help me achieve a better result then I will use it. From my experience of hundreds of rhinoplasties I know that nasal dynamics change in the course of surgery and certain techniques may become indicated only in the course of the procedure.

As you can see from the above discussion there is no clear right or wrong answer to the question "which approach would you use for my nose?" The answer is a matter of surgeon preference and depends on the experience and style of your surgeon.

Making a confident choice in selecting the best possible surgeon is more important than which approach that surgeon takes to your nose!

Once again, the patient is advised to remember that the approach (open or closed) is a means to an end. If your surgeon is experienced and comfortable with the indications for both approaches, and gets consistently good results - then it simply doesn't matter from your perspective what approach he uses.