What is the difference between closed and open rhinoplasty?

Not all Rhinoplasty (nose jobs) procedures are the same, it is important you discuss your Surgeons’ approach with them.

Historical records indicate that rhinoplasty was first done to replace the missing nose.

The nose could have been cut off in battle or, as was common at the time, as a punishment for thieving! The method was to take a piece of skin either from the inner arm or from the forehead and stitch it onto the face in order to give the appearance of a nose. Interestingly, these methods are still used today when a nose has been destroyed due to cancer, trauma, or burns.

The concept of a cosmetic rhinoplasty began with removal of the nasal hump.  Initially this was done by an “open” approach in which an incision was made on the skin of the nose directly over the hump, the hump chiselled off and then the nose closed. The idea that removal of the nasal hump could be done through the nostrils, without an incision on the skin of the nose, began with Jacques Joseph in Berlin who published on rhinoplasty in 1928.  Subsequently, instrumentation and techniques were developed to enable not just the hump to be removed, but for the nose to be shortened, the nasal septum corrected and the nasal tip refined all through the “closed” or “endo-nasal” technique.

The closed rhinoplasty technique not only enables all the required corrections to be performed through incisions entirely within the nose (therefore leaving no scars) but also gives superb control of the final result as a surgeon can feel the corrections being made (through the skin) and also visualise the corrections as they will appear in the final result.

Further refinements with the closed technique enabled the procedure to be performed with minimal bruising and without the use of nasal packs.

The concept of “open” rhinoplasty was first mentioned in 1921 and involved making an incision in the columella in order to lift the skin completely off the nose and enable better visualisation of the underlying nasal structures.  Initially, this procedure was performed only for very complex nasal reconstructions with major tip deformities (e.g. patients with a cleft lip and the associated nose deformity where the tip has slumped on one side).

It wasn’t until the 1990’s when Jack Gunter in the USA popularised the open rhinoplasty approach. The advantages were clear visualisation (from the outside) of the structures of the tip of the nose with the ability to place sutures and grafts into the tip.  The disadvantages were the visible scar on the nasal columella and a very swollen nasal tip – often with a permanent “woody” feel.

These days there are very few surgeons who are truly skilled in the art of closed rhinoplasty. For the appropriately skilled surgeon, however, there is no doubt that one can perform all the necessary alterations including removal of the nasal hump, narrowing the nose, shortening the nose, refining the nasal tip etc. through the closed approach with no external scarring, minimal bruising and rapid recovery.

In my view, therefore, open rhinoplasty is best reserved for those patients with complex nasal tip or septal deformities and for surgeons who only feel confident of achieving the required changes by using an open approach.