Our Approach to Rhinoplasty
You may wonder why we performed all of our rhinoplasties closed when so many surgeons use the open approach instead.
Because it is much better for patients. Think of it as a “short scar” rhinoplasty.
Imagine that you know nothing about either operation, but that the open method has been the traditional rhinoplasty technique, instead of the other way around. The scars are visible and not always good, recovery is significant, the tip must be supported by artificial means (struts or sutures), and many of the changes are created by non-anatomic methods, and the less experienced surgeon does not have precise control over the result.
Imagine now that another method comes along, in which the scars are hidden, the solutions are anatomical, there are no struts or permanent internal sutures, and the recovery for the patient is much quicker. Most surgeons would move to that technique, just as they have moved to the short scar facelift, the endoscopic brow lift, and transconjunctival blepharoplasty.
Though open rhinoplasty has been the surgeons’ response to difficult rhinoplasty techniques, it is not necessarily the best way to achieve them for patients. We always selected closed rhinoplasty as the procedure of choice.
The Problem with Open Rhinoplasty
Open rhinoplasty has become very popular, and surgeons frequently sell it as the best approach. Open rhinoplasty supposedly has the great advantage of giving the surgeon better vision and access. While that is true, the open approach has not decreased the likelihood of an unfavorable result, and the deformities caused by an inexpertly done open rhinoplasty are often much more severe than those caused by the closed approach.
Unfortunately, open rhinoplasty is “sold” as an operation almost without complications; and to my knowledge, not a single paper has been written about the complications of open rhinoplasty. However, open rhinoplasty has many potential complications and I see them every day.
Open rhinoplasty does not solve all problems, and severely limits the surgeon’s ability to fine-tune the result and to accurately see the nasal shape. Furthermore, some deformities are difficult or impossible to correct by the open approach because the structure needed would put too much tension on the skin closure. However, I found these same rhinoplasty problems could be corrected by the closed approach.
Remember this about the open approach: virtually every unsatisfactory rhinoplasty result that I saw when I was in practice was caused by a failure to understand the interconnection of nasal parts, the inability to perceive balance and proportion, or by an inadequate understanding of the effect of rhinoplasty on the airway-not because the surgeon couldn’t see well. While some surgeons can get very good results with the open approach, many cannot. Beware of believing that open rhinoplasty is the answer: it does not solve many rhinoplasty problems.
The Benefits of Closed Rhinoplasty
Because the dissection in closed rhinoplasty is limited, swelling is less, recovery is faster, and there are no visible scars. In addition, because the normal support mechanisms in the nose have never been disrupted by the open rhinoplasty dissection, corrections can be made by more anatomical means (removing what is in excess and adding where there is a deficiency), so that the result appears more quickly and is frequently more natural than what can be obtained by the open approach.
Perhaps most important, because the skin is never pulled away from its normal position, it is possible to “fine tune” the result, so that the surgeon has more control over the outcome, and also so that the patient’s particular aesthetic goals can be achieved more often.
Why We Know So Much about the Way the Nose Works, and Why We Performed Airway Research
Although other surgeons have performed airflow studies, no one has investigated the improvement in both septal and valvular surgery, using the most modern surgical techniques, in large numbers of patients. Seeing that need, I began measuring airflow in my patients in 1991; we had more than 600 patients in the study, and many were followed for many years. I published the results in Plastic and Reconstructive Surgery and in my textbook chapters, and I included them in my 2-volume rhinoplasty text that was published in 2009 – Rhinoplasty: Craft and Magic.