Open or Closed? the Pitfalls of a Cookie-Cutter Rhinoplasty.

New techniques always emerge which supplant the old. The same is true with the plastic surgical procedure called rhinoplasty, or in common parlance, nose job. A nose is basically composed of three materials: overlying skin with associated fat, bone and cartilage.


A rhinoplasty involves:

  1. changing the shape and slant of the bones through selective filing and cutting
  2. changing the shape of the cartilages through removal, adding and reshaping with sutures and
  3. in selected cases, “defatting” the skin to allow the shape of the cartilages and bone to “shine through”.  

In order to perform the rhinoplasty, the surgeon must gain access to the underlying bone and cartilage through either through a closed or open technique. The former involves making incisions confined to within the nostrils and performing the surgery through the limited exposure that these incisions thus provide.  The latter, open technique, involves making the same incisions within the nostrils but joining them across the columella (the fleshy partition that separates the left and right nostril at the base of the nose).

I am frankly surprised and amused that in 2017, some plastic surgeons still insist that the closed technique, when “performed properly”,  provides equal or even superior results than those obtained with an open one. These same surgeons cite a few old masters of closed rhinoplasty from  the 1970s and 80s to support their contention that the closed method is superior. However, the best results from these old Masters do not parallel those obtained from top rhinoplasty surgeons today. Whether you like it or not, progress is inevitable and the new masters of today produce better results than the masters of yore.

I recently attended two conferences  hosting some of the top thought leaders in rhinoplasty surgery. As expected, there was not one expert in the room who would consider closed rhinoplasty an option to achieve the delicate and precise results expected by their patients.  Indeed, even in their hands they  felt that a closed rhinoplasty generally leads to a subpar result. Imagine having to work on the engine of your car only through the left and right front wheel wells. Without opening the hood to gain full unimpeded access to the engine, your ability to effectively work is exceedingly hampered.

The results of any plastic surgery should be measured by the end visual result and not by the process to achieve it. 

Those who promote closed rhinoplasty as better invariably cite less swelling and no potentially visible scar as their main selling point,  but this is a fallacious argument. When properly performed, as a top Beverly Hills rhinoplasty expert, Dr Randal Haworth has seen minimal to no difference in postoperative swelling between the open and closed methods and the scars essentially become invisible whether you are a young model or a 70-year-old person. The proponents of closed rhinoplasty  proudly display their early smooth and symmetrical results as being superior. However, in the early postoperative period, it is the very swelling that the closed proponents claim is not there that may be masking inaccurate nasal construction below. This can be seen in the many examples of  famous noses heralded in their early postoperative period but turn out poorly constructed when their swelling dissipated. Generally avoidable deformities such as inverted V deformities, pinched tips and crooked noses become unavoidably visible no matter how much makeup contouring and good lighting is available.

Famous Noses and  Deformities via Closed Techniques:

After closed rhinoplasty with obvious ‘inverted V” deformity, pinched tip and lack of harmony between the upper and lower portion of the nose
Bella Hadid with nasal deformities after closed rhinoplasty
Note the lack of continuity between the upper bony portion of the nose and the lower cartilaginous portion. An obvious “inverted V” deformity and pinched tip do not help the situation.
Ashlee Simpson with nasal deformities after closed rhinoplasty
After a closed rhinoplasty, note crooked appearance, asymmetrical and drooping pinch tip
                         

Examples of Complex Rhinoplasties Performed through the Open Technique:

Open rhinoplasty
Significant congenital asymmetry of the nostrils. After an open rhinoplasty-note significantly improved symmetry with minimal scar that a closed rhinoplasty technique can’t achieve
Unfortunate result from a closed rhinoplasty with “inverted V” deformity and asymmetrical, bulbous tip. An open rhinoplasty was performed with significant improvement of the nose
Unfortunate result from a closed rhinoplasty with “inverted V” deformity, retracted nostrils and asymmetrical, bulbous tip. An open rhinoplasty was performed with significant improvement of the nose
Unfortunate result from a closed rhinoplasty with “inverted V” deformity, retracted nostrils and asymmetrical, bulbous tip. An open rhinoplasty was performed with significant improvement of the nose
Another example of noticeable congenital asymmetry of the nostrils. After an open rhinoplasty-note significantly improved symmetry with minimal scar that a closed rhinoplasty technique can’t achieve

When precise control over the shape and symmetry of the nose is required as well as control over the subtle light reflexes and shadows embodying the beauty of a nose, nothing beats an experienced surgeon with a precise touch, an aesthetic sensibility and an open rhinoplasty technique.

Dr.Randal Haworth

2017

Open vs Closed Rhinoplasty in Beverly Hills

In order to perform a nose job or rhinoplasty whether in Beverly Hills, Los Angeles or wherever, the plastic surgeon must be physically able to manipulate only two things under the nasal skin-cartilages and bone, Well, the debate rages on and on as to what is the best of the two methods in gaining access to the internal cartilaginous and bony structures of the nose. The two methods are the “closed” and “open” techniques.

The “closed” technique involves creating incisions confined solely to within the actual nose (usually located just within the nostrils proper) whereas the “open” utilizes the same incisions as the “closed” but also incorporates a small additional one across the columella (the fleshy partition separating the left and right nostril at the bottom of the nose).

In this age of less invasive surgery afforded by modern technology through the use of endoscopes, modern radiology, etc. one would think that the “closed” technique represents a newer evolution in rhinoplasty surgery, but surprisingly, the opposite is true. The “closed” technique is the more traditional approach while the “open” evolved and gained in popularity as both patient and surgeons expectations grew. Perhaps unrealistically, patients increasingly expect perfection and in their quest to deliver the acme of results, surgeons need as much control as possible when performing the surgery. Control involves extremely accurate symmetrical suture placement (to reshape cartilage), hemostasis (to minimize bleeding), strategic cartilage graft location and stabilization among other factors. In order to gain the most control as possible, visibility must be maximized and this is where the “open” method far surpasses the”closed”.

Proponents of the “closed” technique cite prolonged swelling and a potentially visible scar across the columella as two distinct disadvantages to the “open”. However, in proper hands these supposed shortcomings can almost always be avoided. I, as a rhinoplasty specialist, used to perform 80% of my rhinoplasties as “closed”, but now I carry out 90% as “open” and I can safely say that over 95% of my rhinoplasty patients are delighted with their new nose by the end of the second week. If the surgery is carefully undertaken, I have seen essentially no difference in swelling between the “closed” and “open” techniques. However, the one difference I have seen are the clearly superior results afforded by the “open” method.

To see many “open” rhinoplasty results, click here and here for revision rhinoplasty.

Dr Randal Haworth can be contacted at 310 273 3000 and Is a Board Certified Plastic Surgeon (American Board of Plastic Surgery)  who practices at The Haworth Institute in Beverly Hills.