There has been a lot of hoopla over the past two decades over the incisions used for both primary rhinoplasty and revision rhinoplasty. There even has been name calling at medical meetings: open rhinoplasty is equated with and open mind and closed rhinoplasty attributed to a closed mind. Well this is not true and why I don’t use the term closed very often.
There is a lot of history behind the surgical approaches in rhinoplasty dates back to nasal reconstruction techniques in India in 800 BCE and in the 1600’s in Italy by Tagliacozzi. Modern intranasal or closed rhinoplasty is attributed to Drs. Jacques Joseph and John Orlando Roe in the 1890’s. In 1927 Rethi introduced the columellar, or modern open, incision. This fell out of favor until it was reintroduced by Padovan in the 1970’s. Since that time, many highly regarded nasal surgeons, such as Drs. Jack Anderson, Calvin Johnson, Dean Toriumi and Jack Gunter have advocated the open approach. Other experts, including Drs. Eugene Tardy, Frank Kamer, Jack Sheen and Thomas Rees still relied on a mostly the intranasal approach for their superior results.
So enough with the history, this is not a book chapter for doctors. Which of the two is the best way to get a superior result in rhinoplasty? There is no good answer and it really depends more on the individual surgeon. I feel that in primary (never operated) rhinoplasty I can obtain equal if not a better cosmetic result using an endonasal approach in over 90% of patients, without any incision across the bottom of the nose (this part of the nose is called the columella). It’s more important that your surgeon understands the anatomy of the nose and is an expert in rhinoplasty, than what incision they use.
Then, why would I use the open incision at all in primary rhinoplasty? The indications, medical speak for reasons, in my opinion for using the open approach are 1. A very crooked nose, 2. A short nose that needs to be made much longer, 3. A nose that requires many grafts.
For revision rhinoplasty, which comprises about a third of my nasal procedures, I use the open approach on most. My indications for this incision are 1. Unexpected changes that may have occurred during the first surgery, 2. scarring and 3. Altered anatomy from both surgical and changes during healing. These are findings that often occur in revision rhinoplasty, otherwise the patient wouldn’t be seeking revision. Going back to primary rhinoplasty, a good surgeon should be able to tell the patent’s underlying anatomy from an external exam alone, by looking at the nose, touching the nose and looking inside the nose. So, making changes should be predictable. When surgery has been performed prior, there are changes that may not be accounted for in old operative notes, scarring and often stitches that holds structures in place and defy moving (the technical term is delivering) the cartilage around as is done to modify the nasal tip in a primary case.
As for the open rhinoplasty incision, across the columella, this incision is tiny and usually barely noticeable if at all. Of course, all incisions are pink for up to 6 months, but as it heals, I feel that unless someone is looking up your nose, know what they are looking for and close enough to count nose hairs; they are unlikely to notice the incision.