Open vs. Closed Rhinoplasty
There are two commonly used approaches for either primary (first-time) or revision rhinoplasty. The most common approach in the modern rhinoplasty era is what is called the open approach. This involves making small incisions along the inside of each nostril and connecting these incisions with a very tiny incision across the columella, the portion of the nose between the nostrils. This incision is generally made halfway between the upper lip and the tip of the nose. In order the make the line less visible, two common incisions are utilized. Dr. Mehta uses an upside down V-shaped incision, called the inverted-V, which involves making four 3-4 mm, connected incisions, with the middle two being in the shape of an upside-down V. The other common approach is a stairstep incision, which, as the name suggests, is a stair step-shaped incision in which one horizontal portion sits a few mm higher than the other side. Care must be taken by the surgeon to ensure that the upper incision is made far enough from the top of the nostril.
In either case, with good surgical technique, this open approach incision heals beautifully and rarely, if ever, yields a visible scar. The advantage it gives is that the skin and soft tissue can be pulled back to give the surgeon excellent access to the cartilage and bony framework of the nose during surgery. Grafts such as spreader grafts and onlay grafts can be placed more precisely and secured in place more firmly. Also, if there is work to be done on the septum, either due to a severe deviation, previous harvest, or a perforation, the access to the septum in the open approach is much greater.
In revision cases in which limited access is needed, a closed, or endonasal, approach can be used. For the most part the incisions are similar to those made during the open approach with the exception being that the incision across the columella is not made. The incisions are made along the inside of the nostrils and often further back inside the nose, to get access to the bridge of the nose. Dr. Mehta uses a closed, or endonasal rhinoplasty approach, when there is limited tip work to be done or for cases of a very minor shaving or augmentation of the nose.
The choice of open versus closed rhinoplasty depends on the surgeon’s training, experience, and personal preference. At international plastic surgery conferences, there is often heated debate over which approach is preferable for addressing various issues. In both cases, the recovery and healing process is similar and therefore, the decision should be made based on with which approach the surgeon is more comfortable. A detailed discussion of open versus closed rhinoplasty can be had during the revision rhinoplasty consultation.
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