Rhinoplasty is performed with two basic approaches: the open and the closed technique. The difference between them is how the surgeon reaches the nasal structures; the purpose of the operation and the principles of reshaping are the same in both. One of the questions patients ask most is "which is better?" The honest answer is that there is no single right technique for every nose; the choice depends on the anatomy and on what needs to be done.
The closed technique
In closed (endonasal) rhinoplasty all incisions are made inside the nostrils; there is no visible external scar. The bone and cartilage structures are reached through these incisions, and reshaping is done within a limited field of view, relying largely on touch and experience.
- Suitable for: hump removal, limited tip refinement, work on the bridge, some functional corrections.
- Possible advantages: no external scar, tip swelling may subside sooner in some patients, the operation may be shorter.
- Limitations: the field of view may be insufficient for complex tip problems, marked asymmetry and cases requiring large grafts.
The open technique
In open rhinoplasty, in addition to the internal incisions, a small incision of a few millimetres is made on the columella, the strip of skin between the nostrils. The skin is lifted and the nasal skeleton is worked on under direct vision.
- Suitable for: marked tip asymmetry, tip shaping in thick-skinned noses, the crooked nose, revision operations, cases requiring precise placement of cartilage grafts.
- Possible advantages: direct view of the structures, controlled application of suture and graft techniques, the ability to compare the two sides for symmetry during surgery.
- Limitations: a scar remains on the columella; in most patients it fades with time and is not noticed without close inspection, but in some skin types it may stay more visible. Tip swelling may last longer than with the closed technique.
Criteria that determine the choice
It is the anatomy of the nose, not the patient, that chooses the technique. During the examination I consider these questions:
- Is the problem mainly on the bridge or at the tip? Bridge problems are easier to address with the closed technique, complex tip problems with the open technique.
- Is there asymmetry? Marked asymmetry requires seeing both sides directly.
- Will grafts be needed? Tip support or valve grafts are placed with more control in the open technique.
- Has the nose been operated on before? In revisions, direct vision is usually necessary because of scar tissue.
- How thick is the skin? Tip shaping in thick skin needs more structural work.
Based on these criteria the closed technique is recommended for some patients and the open technique for others; the preference is explained with its reasoning during the examination.
Is recovery different?
In both techniques the operation is performed under general anaesthesia, a splint stays on the nose for about a week, and swelling and bruising are seen in the first days. The difference is mainly at the tip: with the open technique tip swelling may take somewhat longer to subside. Healing of the hump, bridge and airway is similar in both. The final shape takes months to settle with either method.
A common misconception
Generalisations such as "the closed technique gives a more natural result" or "the open technique lasts longer" are not correct. What determines the result is not the name of the technique but the accuracy of the plan, how much tissue is removed and how the structure is supported. The same surgeon applies both techniques with the same principles; which one is chosen varies with the patient. I describe these principles in detail on the natural rhinoplasty page.
This page is for general information; the choice of technique is made during examination. For the ultrasonic method used in bone work see Piezo Rhinoplasty, for other topics Rhinoplasty: Overview, and to arrange an appointment please use the contact page.