Open Rhinoplasty (Nose Surgery) Information

Facial plastic surgeons have for years been debating the merits of open rhinplasty versus closed rhinoplasty. Some surgeons swear by the closed approach, insisting there is nothing they cannot do from this approach that would require an external incision. They feel that an open approach leaves an unnecessary scar. Others insist that the open approach gives more exposure needed for grafting cartilage, and rightfully note that a well performed incision can be almost impossible to detect once it has healed. The majority concensus at conferences is that there are strong indications for both approaches, and surgeons should seek proficiency with both in order to best serve their patients.

Open Rhinoplasty

Open Rhinoplasty refers to a surgical approach to the nose involving an incision across the columella (center portion between the nostrils). The open rhinoplasty incision is usually an "inverted V" or a "stair-step" design, extending horizontally across the nasal columella. This incision allows a wide exposure of the cartilage and connective tissue that comprise the nasal tip and the middle vault of the nose, hence the name "Open Approach." The incision is closed with either small absorbable sutures or nonabsorbable sutures that will be removed in about a week.

It is important for patients to understand that the approach to the nose, be it open or closed, is simply a means to an end; the "end" being a beautiful and long lasting result. The choice of whether or not to use an open approach in a particular case is a subjective decision made by the surgeon. There is no right or wrong answer in most cases, as there is tremendous overlap between what can be done through an open approach versus a closed approach in skilled hands.

Once all the healing is done, there is no way to truly distinguish between an excellent "open rhinoplasty" and an excellent "closed rhinoplasty" result.

That said, it is important for patients to have a basic understanding of the indications for this surgical technique so that they can ask informative questions, make informed decisions, and play an active role in their recovery.

Indications for Open Approach to Rhinoplasty

Indications for the Open approach to Rhinoplasty include revision rhinoplasty, the need for complex tip work, or the need for complex work in the "middle vault" of the nose. These indications are not absolute, as you will see below.

The open approach is a generally better approach to revision rhinoplasty because it allows meticulous dissection through scar tissue. For severely deformed tips, this approach also allows more room for suturing and grafting of cartilage. In some cases, however, revison rhinoplasty does not involve significant tip work and and a closed approach can actually be safer and more efficient.

In the middle vault, the open approach is a preferred approach for spreader grafts. These are cartilage grafts that are used to straighten or slightly widen the middle part of the nose and prevent or correct pinching in this area. Spreader grafts can also be inserted through a closed approach if there is minimal hump deformity.

Finally, an open approach can provide a more "sterile" environment for placement of artificial implants. These implants should not generally be placed through the nostrils if possible.

A minority of surgeons use the open approach exclusively for all their patients. Reasons for doing so may include a lack of experience with the closed approach. It is important to note that multiple grafts including columellar strut grafts and batten grafts are sometimes more easily inserted through the closed approach. While the open rhinoplasty incision generally heals beautifully in skilled hands, an unnecessary incision is always best avoided.