By far, the most challenging aspect of rhinoplasty surgery is in the nasal tip. As the nasal tip is probably the greatest variable in appearance amongst individuals and one of the most defining parts of the nose, precision in nasal tip changes during rhinoplasty is of critical importance. Therefore, good access to provide adequate visualization and workability of the nasal tip cartilages is key.
Rhinoplasty, by its history, has been traditionally done through a closed or endonasal delivery technique. By this approach, the nasal tip cartilages are delivered without using a skin incision at the columella. In the ‘right’ nose, I personally prefer this technique as it is simple, produces consistent results, and has a low rate of the need for revisional surgery. It also offers the bonus of less prolonged swelling of the nasal tip after rhinoplasty. Good patients are those that have fairly thin nasal skin, strong stiffer cartilages, and have never had rhinoplasty surgery before. The only problem with the closed approach to rhinoplasty is that it requires more finesse in delivering and suturing the cartilages than an open approach.
Open structure rhinoplasty, where the entire nasal tip is widely exposed, is done by making a incision across the columella (skin between the nostrils) and lifting the skin off of the nasal tip. With such exposure, manipulation of the nasal tip cartilages is much easier and symmetry between the sides better appreciated. For this reason, open rhinoplasty is the most common way rhinoplasty surgery is done today and, in most surgeon’s hands, produces more reliable results. It certainly is the way to go in revisional rhinoplasty (of the tip area) and in primary rhinoplasty where the patient has thick skin, nasal tip asymmetries, or weak cartilages. The fear over a columellar scar is largely unfounded as they heal nearly imperceptably. The biggest problem with gloving the nasal skin through an open approach is that some patients will have some prolonged swelling of the nasal tip, particularly those with really thick skin.
The debate between open vs. closed rhinoplasty isn’t really a debate anymore. It is more about what type of nose does a patient have and the plastic surgeon’s experience with each rhinoplasty technique.
Dr. Barry Eppley
Indianapolis, Indiana