Open vs Closed Rhinoplasty Surgery

Rhinoplasty can be performed under a general anesthetic, sedation, or with local anesthetic. Initially, local anesthesia, which is a mixture of lidocaine and epinephrine, is injected to numb the area and temporarily reduce vascularity.

There are two possible approaches to the nose: closed approach and open approach. In closed rhinoplasty, incisions are made inside the nostrils. In open rhinoplasty, an additional inconspicuous incision is made across the columella (the bit of skin that separates the nostrils).

The surgeon first separates the skin and soft tissues of the nose from the underlying structures. The cartilage and bone is reshaped, and the incisions are sutured closed. Some surgeons use a stent or packing inside the nose, followed by tape or stent on the outside. In some cases, the surgeon may shape a small piece of the patient's own cartilage or bone, as a graft, to strengthen or change the shape of the nose.

Usually the cartilage is harvested from the septum. If there isn't enough septum cartilage, which can occur in revision rhinoplasty, cartilage can be harvested from the concha of the ear or the ribs. In the rare case where bone is required, it is harvested from the cranium, the hip, or the ribs. Sometimes a synthetic implant may be used to augment the bridge of the nose.

Rhinoplasty Surgery

Reconstructive nose surgery was first developed by Sushruta, an important Ayurvedic physician in ancient India, who is often regarded as the "father of plastic surgery." Sushruta first described nasal reconstruction in his text Sushruta Samhita circa 500 BC. He and his later students and disciples used rhinoplasty to reconstruct noses that were amputated as a punishment for crimes. The techniques of forehead flap rhinoplasty he developed are practiced almost unchanged to this day. This knowledge of plastic surgery existed in India up to the late 18th century as can be seen from the reports published in Gentleman's Magazine (October, 1794).
Patient, three days post-op. Procedures included dorsal bone reduction and re-setting and refinement of nasal tip cartilage. The typical orbital discoloration is also present due to trauma and disruption of blood vessels around the eyes. Also present is a splint.

The precursors to the modern rhinoplasty surgeons include Johann Dieffenbach (1792-1847) and Jacques Joseph (1865-1934), who used external incisions for nose reduction surgery. John Orlando Roe (1848-1915) is credited with performing the first intranasal rhinoplasty in the U.S. in 1887.

Prior to the 1970’s, all rhinoplasty surgeries were performed via the intranasal approach, which is often called closed rhinoplasty. However, in 1973, Dr. Wilfred S. Goodman published an article entitled “External Approach to Rhinoplasty”[1] which helped initiate a shift in rhinoplasty techniques to what has become known as the open rhinoplasty. The open rhinoplasty technique was further refined and popularized by Dr. Jack Anderson in his article “Open rhinoplasty: an assessment”[2]. The open approach to rhinoplasty gained in popularity during that time, but it was used mainly for first-time rhinoplasty surgery and not for revision rhinoplasty.

In 1987 Dr. Jack P. Gunter, who trained under Dr. Anderson, published an article[3] describing the merits of the open rhinoplasty approach for secondary rhinoplasty. This was a major shift in the approach to treating nasal deformities that arose from a previous rhinoplasty.