Open Rhinoplasty

Open rhinoplasty is a technique for nasal surgery where the cartilages of the nose are exposed by peeling back the nasal skin. This is achieved with a small outside incision on the “columella”, the aspect of the nose sandwiched between the two nostrils, and additional incisions placed inside the nose. The incision placed outside usually heals well and, if planned and sutured carefully, rarely causes cosmetic problems. For best camouflage, these incisions are not straight lines but usually some form of a zigzag. Open rhinoplasty found introduction into American operating rooms only in the 1990’s. This does not make it a particularly new procedure as it was practiced and taught in Europe already since the 1920’s and 30’s. Rather, it took many decades for this alternative rhinoplasty approach to go “main stream” in this country. Because it is so much easier to understand the nasal anatomy and to plan and perform the re-configuration and reshaping with rhinoplasty, most medical students, interns and residents are taught open rhinoplasty in their respective medical centers today.

Open Nasal Plastic Surgery – Easy Exposure

In performing a rhinoplasty through an open approach, the surgeon is able to look directly at the lower one third to one halve of the nose. The nasal skeleton of the lower nose and tip is made up by cartilage which is the part that the rhinoplasty surgeon is going to work on primarily. Reshaping of the upper nose is not significantly different between the two rhinoplasty approaches – the open and closed techniques. Once the cartilages are exposed, they are modified by reducing, reshaping, suturing, and supporting them. Almost always in open rhinoplasty, “grafts” are placed to ensure maintenance of the desired structure. Grafts are little pieces of cartilage, soft tissues, bone and foreign materials that are introduced to locations within the nose where they were not present originally. Some people argue that the open approach “takes the nose apart first in order to put it back together again”. Certainly, once a nose is operated on through open rhinoplasty, it cannot be just closed again. Even without doing true plastic nasal work, the shape of the nose would change due to the interruption of nasal support. As an example from the world of architecture, if one removes the outer walls of a house including beams in order to study the interiors, one cannot just put up dry walls and hope that the house will be OK. Rather, one will have to hold these walls, usually using more structural support beams than were present in the first place. Although this comparison is not entirely accurate, it does demonstrate the importance behind support grafting in open rhinoplasty.

Is Open Rhinoplasty a Superior Rhinoplasty Operation?

The short answer to this question is “No” although it may be the better operation for you and your plastic surgeon mainly because this is the preferred approach taken by the doctor. It is interesting that in the world of minimal invasive cosmetic surgery, the direction of rhinoplasty has been one to a more invasive procedure with open rhinoplasty in at least the majority of cases. This trend indicates how demanding a procedure nasal reshaping surgery really is; most experienced rhinoplasty specialists would agree that no two rhinoplasty operations are alike. Therefore, the name “nose job” is a rather poor title for such a challenging operation.

Advantages of Open Rhinoplasty

The main advantage lies in the exposure of the nasal anatomy to be altered. By removing the skin coverage of the underlying cartilages, the anatomy can be studied and altered to the liking of the plastic surgeon.

Also, grafting can be done more easily and usually is performed more extensively in open nasal operations than with endonasal ‘closed’ rhinoplasty. Unfortunately, this ease of exposure and grafting does not necessarily translate into a better outcome for every patient.

Revision rhinoplasty continues to be a common procedure sought even after open nasal reshaping plastic surgery. Some extensive secondary reconstructive rhinoplasties are best approached through the open technique. The closed rhinoplasty operation may be truly inferior for these complicated revision rhinoplasties.

Disadvantages of Open Rhinoplasty

Yes, there will be an outside incision. Although this may sound rather traumatic, if sutured precisely and if the nose heals as anticipated, this small incision rarely causes any aesthetic concern.

An open rhinoplasty is a longer operation. Usually, the additional time necessary for opening and closing the nose easily adds an additional hour or more to the overall surgery time. Open Rhinoplasties take usually 3 hours or more depending on how much work is involved.

There may be more scaring after an open nasal reshaping operation. More surgical dissection and separation of tissues are necessary for the open rhinoplasty procedure. These operated nasal tissues have to heal afterwards which means scaring. Scaring may cause thickening of tissues or it may create forces which can pull structures in unwanted directions. Therefore, added support with grafting is important. If the end result of an open rhinoplasty is satisfactory, then all this does not mean much to patient and surgeon alike. The additional scaring is more important, if revision surgery becomes necessary.
The swelling may last longer. No scientific studies have been performed to prove this notion but surgeons who perform both, open and closed rhinoplasties, certainly observed this difference. Reasons lie in the additional surgical dissection required for open rhinoplasty and the extra healing necessary afterwards. The added swelling usually has no significant implication for the patient. Some experienced rhinoplasty specialists also observed more bruising in open rhinoplasty which may be a result of the longer surgery time.

Although these advantages and disadvantages of open rhinoplasty exist, they do not make this operation better or worse if compared to the closed approach. It is truly a somewhat different operation which has the same goals. In the right hands, both rhinoplasty operations can safely lead to a pleasing outcome.

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