Open vs. Closed Rhinoplasty

Considering the candidate’s expectations, surgeons may either adopt open or closed Rhinoplasty.

These days, nose reshaping has third place in the ranking of the most common plastic surgeries, with a total of 213,780 operations carried out in the U.S in 2017, according to the statistics provided by the American Society of Plastic Surgeons (ASPS). By performing this surgery, which is also known as Rhinoplasty, specialists try to reshape, reduce, or augment the nose to help the patients achieve facial harmony and increase their self-confidence. It is sometimes conducted as a reconstructive procedure to cure a birth defect or an injury. Patients may aim to have it for functional reasons, not just cosmetic purposes. For example, specialists can efficiently treat serious breathing problems by combining nose reshaping with Septoplasty or other similar procedures. The surgery usually lasts between two to five hours, depending on the severity of the operation. 

During Rhinoplasty, the plastic surgeons lift the skin of the nose, make changes to the bone and cartilage, and finally put the skin back down. Surgeons must carefully think of the extent to which the bone and cartilage should be altered to obtain the patient's favorable results. Based on the purposes of the process, surgeons use either an open or closed Rhinoplasty for reshaping the nose. There are some considerable differences between an open and closed Rhinoplasty. Undoubtedly, one of these differences is related to the place where specialists make the incision. During the closed Rhinoplasty, two incisions are made within the inside of the nose. In an open or external Rhinoplasty, beside the same incisions, one additional incision will be placed on the underside of the nose along the columella (the soft tissue between the nostrils). This final incision helps plastic surgeons to open the skin of the nose. Depending on the patients' expectations and the surgeons' goals, each approach has its own merits and demerits. In the following, both of these procedures will be explained. 


The Closed Approach (Endonasal Rhinoplasty)

In the closed rhinoplasty approach (endonasal Rhinoplasty), all of the surgical incisions are made inside the nostrils. Despite the fact that parallel incisions encircle nearly half of the nostril lining, none part of the incision can be seen externally, and a visible scar is prevented. However, because the left and right nostril incisions remain disconnected, repositioning of the nasal skin is difficult, and the entire procedure must be done through narrow surgical openings with limited visibility. Since access to the nasal framework needs vigorous stretching of the nasal skin, distortion of the nasal cartilage is inevitable. While a visible scar is avoided, considerable challenges and technical limitations are related to surgical access. Consequently, closed Rhinoplasty merely refers to the relative shortage of surgical exposure relevant to the endonasal approach.


Good Candidates for Closed Rhinoplasty

The ideal candidates for this approach will need only mild to moderate structure and adjustments of their nose. Because the nose surgeon has limited visibility in this method, the potential adjustments will be limited. Therefore, surgeons don't suggest this technique for patients seeking major nose modifications.

Candidates won't be concerned with noticeable scars following the closed approach procedure, as they're all internal incisions. Additionally, candidates will experience a shorter operational time with this approach as well as a quicker recovery period.


Advantages of Closed Rhinoplasty

Among the advantages of closed Rhinoplasty are the following: a shorter surgery time, better circulation to the skin of the nasal tip, and less scarring. A closed Rhinoplasty method takes a shorter time to be completed rather than open or external Rhinoplasty because It is less invasive and leaves less swelling and no scarring after surgery compared to the open approach. The procedure is done internally, and the plastic surgeon will ensure that there will be no remarkable visible signs of the surgery, especially across the columella (the soft tissue between the nostrils). According to a research published in the Journal of Laryngology & Otology on the effectiveness of closed Rhinoplasty approach for excision of nasal dermoid, it was found that this method gives optimal cosmetic results in excision of small, superficial nasal dermoid cysts in well-selected cases. It provides adequate exposure for total extirpation.


Disadvantages of Closed Rhinoplasty

There are some drawbacks with a closed Rhinoplasty that include limitations when repositioning nasal skin. A closed Rhinoplasty, in most cases, doesn't provide the access or visibility to allow a surgeon to perform the most and detailed enhancements on bone and cartilage. Some fewer plastic surgeons are skillful at closed Rhinoplasty than external or open Rhinoplasty. Since the procedure is done without lifting the nasal skin, the surgeon performs all the changes via the narrow openings of the nostril. It is a "blind" operation, and everything is done via the sight of the outer appearance. To make sure that the procedure will be carried out in the best way possible, it's better to undergo a nose job in Iran because Iranian plastic surgeons have the right skill set to perform the task. Furthermore, since closed Rhinoplasty is not much suitable for individuals who want to get a major change in the soft tissues of their nose, Iranian experts can inform you of the most appropriate operation based on your needs. 

Also Read: A Healthy Diet to After Rhinoplasty

The Open Approach (External Rhinoplasty)

Unlike the closed Rhinoplasty, the external or open Rhinoplasty approach employs a small bridging incision (a trans-columellar incision) to connect the left and right nostril incisions. In exchange for this 4-5 mm visible part, the nasal skin can be folded upward, and unimpeded visibility of the lower nasal skeleton could be achieved. Additionally, to direct visibility of almost the whole nasal framework, distortion of the nasal cartilage is decreased as much as possible, and individual components can be assessed in their natural, undisturbed alignment. Then, the hallmark of the open Rhinoplasty is the vastly enhanced surgical access provided by the trans-columellar incision.

Despite many aspects of an unattractive nose that can be modified using a closed Rhinoplasty approach (thereby preventing a trans-columellar incision), the modest risk of a visible columellar scar is more than offset by the enhanced accuracy, effectiveness, or versatility of the open Rhinoplasty approach. Open Rhinoplasty has revolutionized truly the treatment of complex nasal deformities such as twisted noses, cleft-lip Rhinoplasty, or severe post-Rhinoplasty deformities. In fact, most Rhinoplasty specialists regard open Rhinoplasty as the procedure of choice for difficult nasal anatomy of any kind, and many of the most effective techniques of contemporary Rhinoplasty may only be performed through the open approach.

For these same reasons, open Rhinoplasty is a suggested approach for primary (non-revision) Rhinoplasty since it enhances diagnostic accuracy and facilitates precision re-engineering of the misshapen nose. However, the technical needs of open Rhinoplasty are rigorous, and substantial dedication and commitment to this approach are required to gain superior results consistently. One of the most important technical issues of using the open method is the precise suture realignment of the trans-columellar incision. When made correctly, the healed trans-columellar incision is often invisible and seldom results in an unpleasant scar. Indeed, considering the significance of this approach, having Rhinoplasty in Iran is highly recommended because of experts, up-to-date facilities, and efficient services that are offered in Iran's specialized clinics.


Good Candidates for Open Rhinoplasty

The ideal candidate for open Rhinoplasty will most likely need more gentle finesse operations or more dramatic adjustments to the structure and shape of their nose. The open approach provides surgeons with full visibility so the specialists can make evaluations more meticulously to improve the final contour.

Initially, nose surgeons used open Rhinoplasty for repairing cleft lip-nose deformities in candidates, and they realized more visibility would allow them to diagnose the candidate better and provide better reconstruction.  

Although a nose surgeon could use bone or cartilage grafts to the nose with either the closed or open approach, in the majority of cases, open Rhinoplasty provides a better option. Candidates should be aware of the fact that small columellar incisions can leave an unobtrusive scar. It will be a fine incision scar that is not easily noticed and will be faded as time passes.

Besides, candidates should agree with general anesthesia and understand that their recovery may be longer considering the operating time and the kind of anesthesia.


Advantage of Open Rhinoplasty

The main advantage of the external or open Rhinoplasty over the closed approach is that it allows better visualization of the cartilages that will be eradicated during the surgery. Furthermore, an open Rhinoplasty gives plastic specialists the ability to manipulate and alter nasal shape with more precision and control. In other words, an open Rhinoplasty allows plastic surgeons to measure, analyze the anatomy of the nose and check out any asymmetry or abnormalities that were not clear from an external examination. With an open Rhinoplasty approach, plastic surgeons are better able to use advanced cartilage grafting techniques and place the grafts more accurately, giving a longer-term structure and support. Open Rhinoplasty is suggested for candidates who are looking for bigger changes to the shape of their nose, such as decreasing or increasing projection from the face.

Moreover, open Rhinoplasty is suitable for candidates who want to get the dorsal hump eradicated or their nasal tip corrected. This approach is especially suitable for those who are having a revision operation. With the amount of work required for complex reconstructive surgery, open Rhinoplasty gives the access and visibility essential to do comprehensive work on each section of the nose's structure. 


Disadvantages of Open Rhinoplasty

The main drawbacks of open Rhinoplasty are the following: it is lengthier and more invasive rather than the closed Rhinoplasty approach (therefore, the recovery time will be much longer), and a very small scar may be visible on the nasal columella, only when candidates tilt their heads back. Nevertheless, the small scar slowly fades away with time until it is hardly visible, and the side effects after surgery depend on how extensive your Rhinoplasty operation was, your genetic predisposition to heal quickly, and lifestyle choice you make during recovery.


After undergoing Rhinoplasty, following the instructions given by specialists such as sleeping with the head elevated, eating a well-balanced diet, applying cold compresses (small gauze pads) to the eyes, avoiding putting on glasses or anything else on the nose or head can reduce swelling considerably and help you have a short recovery process.


In general, candidates are highly suggested to research to find a knowledgeable surgeon who has significant experience in both open and closed approaches. Patients are typically recommended to undergo Rhinoplasty in Iran because Iranian experts are well-known and carry out such cosmetic procedures successfully every year. The majority of them are also members of American and European societies of plastic surgery or other specialties. They can assure you that the most appropriate procedure will be determined based on your expectations and overall condition. Consulting with an experienced plastic surgeon is also necessary for individuals who had previously undergone nasal surgeries or suffered from deformities that need complicated techniques. The last point to mention is that Rhinoplasty cost in Iran is so reasonable compared to other options. Thus, if you decide to have these operations in Iran's specialized clinics, you can save a considerable amount of money besides enjoying the beauty of this country's natural scenery.