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Open vs. Closed Rhinoplasty

This audio podcast has been transcribed using an automated service.  Please forgive any typographic errors or other transcription flaws.

This podcast is going to be talking about the two major ways of performing a rhinoplasty that is very basic and fundamental. One is called the endonasal or closed approach and the other approach is called the external or open technique for rhinoplasty. There are very strong proponents of both sides. I am an advocate of the open approach or the external approach. The difference essentially is that there’s a small incision along the columella and a columella is the area that it’s on the bottom of the nose between the two nostrils and this is the content. The contention here for the endonasal people is like you don’t want a scar for a rhinoplasty and you really should do it close. So, I want to talk about what the proponents, the pros, the cons of both are. And essentially I’m going to talk about why I do and choose the open approach and almost every single case in my rhinoplasty.

I probably can’t say every single case, but it is almost every single case. So let’s first start with why the people that do closed approaches preferred to do a closed approach. So the first pro is that there is no incision. So that is what they would say is you don’t want a scar, you don’t want an incision there. So they liked the close technique. The second thing is they believe that it leads to a much faster recovery because there’s no opening of the entire nose. And there would say, for easy cases, they don’t really need to do an open technique, where are difficult cases, they may, certain surgeons go to do the open approach. So they do a graduated approach from close to open and some people always do closed. The reason why I almost always do open though would be the following reasons.

So first of all, let’s talk about the scar. The incision that I make is what’s called an inverted V, so it’s very hard to see as it heals after the first one to two months. I have these close up videos on YouTube to show how almost impossible as a see the incision, even close range unless I pointed out to you and you have to look for it and then try to figure out that there is an incision there. The reason why the incisions heal so well. My hands is first. I don’t make a straight line. A straight line causes a puckering. It is visible to the naked eye. The second reason is I close the incision really, really flawlessly and perfectly. The other thing is I use Sinacola Vicryl suture, which is a suture that stays there for a couple of weeks, but it’s so small and white that it’s barely perceptible and that allows the incision to heal better but also mitigates or removes the discomfort required when I’m taking the stitches out cause I do not need to remove them.

I have found that my incisions heal incredibly well. Like you’re very, almost difficult to see them. The second thing that people argue against the open approaches I mentioned is that the open approach leads to a prolonged recovery. I will tell you that I used to do more closed procedures and I do much, many more open procedures now and I don’t see a very different, a recovery period. Most of my patients go through about a week of recovery time. Sorry if you hear that background noise under the airport giving this podcast. So I apologize for the background noise, but the second reason that people believe that there is just there’s a long recovery and I really don’t see that. I don’t see a protracted recovery time at all. I find very, very quick recoveries for my patients. So then why do an open approach are there several advantages there? 


So I will start with the first advantage which is incredible visibility or ability to see all tissues incredibly well, panoramically. This is so fundamental because I will tell you there’s so many cases when I opened the nose, even non revision cases and I can see very clearly that there are some abnormal tissues where they don’t look right and they’re asymmetric. They’re not alignment and there’s almost no way I could see that from a closed perspective. The second reason is, if there is a revision case and a lot of grafts in there that are not placed correctly, I need to go and remove those grafts and I need to open up the nose anyways to take those grafts out. The third reason is structure. I provide a lot more structural grafting that I simply, there’s no way that I can provide what I’m doing. 


A close approach. I did an entire podcast on what is called a cuddle septal extension graft, which has to be done open, in my opinion, I think is incredibly hard to get that graft position correctly in a closed environment. But what that graph does is provide predictable tip support outcomes. So that if I see the tip on the table, I know that that’s the tip that I’m going to have when I’m done. So that I don’t have the variability I had with closed approaches in the years past. I know there’s so many ways to do things and you get a great surgeon that does great closed approaches, but I feel that the open approach provides all these advantages with almost not at the negative advantages. So hopefully you like this podcast about it, and I’d be more than happy to talk to you when you come in for further descriptions of why I do what I do.