Technique
Why We Prefer Closed Rhinoplasty at Our Practice near Boston, Massachusetts
Dr. Mark Constantian chooses to perform only closed rhinoplasty at his practice, located one hour north of Boston, Massachusetts. It is not uncommon for patients to have questions about this technique and our reasons for advocating it. On this page, Dr. Constantian answers commonly asked questions about the closed approach and explains why he believes it is the superior method.
- “My surgeon wants to do an open approach to my rhinoplasty. Should I accept this approach?”
- The open approach (in which an incision is made across the skin between your nostrils so that the surgeon can look directly at the inside of the nose) has become much more popular as rhinoplasty techniques have become much more complicated. Some surgeons believe that they can understand the surgical problem better and fix the structure better with an open approach. However, I only perform closed rhinoplasty at my practice near Boston, Massachusetts, for several reasons. The external scar, while usually not bad, is still often visible. The recovery and swelling from an open approach is greater than when incisions are only made on the inside of the nose.
Furthermore, after 29 years of practice, I am convinced that it is easier for me to limit the dissection, fix any cartilage grafts, and control the shape of the result better if the nasal skin is disturbed less. The fact that all the incisions are inside the nose does not mean that the surgery is “blind.” Almost every step is still done under direct vision, but the planning and technique is certainly different.
Finally, I have a much better ability to judge final shape and contour when the skin has not been cut and moved.
The key in nasal surgery, however, is not the open or closed approach; those are only access routes. The key is understanding what the patient wants and what techniques will best achieve those goals. The only way for you to make your decision is to discuss your goals with the surgeons that you see and get all of your questions answered to your satisfaction.
- “Why are you one of the few surgeons who do ‘closed’ rhinoplasty with no visible scar? Some surgeons have told me that they can see better with the open approach.”
- The two biggest advantages of the closed rhinoplasty approach are (1) the limited dissection and therefore a quicker recovery for the patient, and (2) the ability to “fine tune” the result.
Many surgeons who are advocates of the open approach say that it is particularly good for revision or secondary cases where the anatomy is distorted and the tissues scarred, and advocate the closed approach for the simple, straight primary nose.
I think that is exactly backward. The more difficult the case, the more limited the materials, the more new support is required, and the more the patient benefits from the closed approach. Perhaps the most valuable advantage of the closed rhinoplasty approach is the information that it provides the surgeon about nasal shape and balance. Unlike the open approach, in which the skin has been lifted off the lower nose to provide access to the skeleton, the surgeon never disturbs the soft tissue from their locations in performing a closed rhinoplasty. It is thus possible for me to have a much better idea of what the contour of the nasal bridge and, particularly, the nasal tip is. I can tell if the tip is augmented enough, if it is symmetrical, if it is angular or blunt, and therefore have a much greater chance of being able to produce the type of result that the patient desires. Beyond the limited dissection and the quicker recovery for the patient, the closed approach thus gives the surgeon more information about nasal shape and therefore better control of the result.
Whereas the emphasis in the open approach is the nasal skeleton, the emphasis in the closed approach is the external shape, which after all is what determines the quality of the result.
