The Two Main Approaches to Rhinoplasty
When researching rhinoplasty, you'll quickly come across two main surgical approaches: closed rhinoplasty and open rhinoplasty. The debate about which is better has been ongoing for decades, and if you search online, you'll find strong opinions on both sides.
As a surgeon who has performed both techniques extensively, I want to share my perspective on why I returned to closed rhinoplasty after initially switching to the open approach, and what this means for patients considering nose surgery.
What's the Actual Difference?
The fundamental difference is simple:
- Closed rhinoplasty: All incisions are made inside the nostrils. There is no external scar.
- Open rhinoplasty: A small incision is made across the columella (the strip of skin between your nostrils), allowing the surgeon to lift the nasal skin like opening a car bonnet.
Proponents of open rhinoplasty argue that being able to see the nasal structures directly makes the surgery more precise. The analogy often used is working on a car engine with the bonnet open versus closed.
But there's more to the story than visibility alone.
My Journey Between the Two Techniques
When I was training about 20-25 years ago, closed rhinoplasty was the standard. That's what I learned, and that's what I initially performed. Then, as happens in surgery, fashions changed. The literature started saying that open rhinoplasty was superior, that you could achieve better results with direct visualisation.
So I made the switch. I started performing open rhinoplasties.
And then I noticed something troubling: all my patients were getting swelling at the tip of their nose. Not just a little swelling during the immediate recovery, but persistent puffiness that took a very long time to resolve.
At first, I wondered if I was doing something wrong. So I did what any conscientious surgeon would do. I bought DVDs from the Dallas Rhinoplasty Course, one of the most prestigious rhinoplasty teaching programmes in the world. I spent an entire weekend watching five years' worth of their surgical videos.
What I discovered was illuminating. Each year, they would bring back patients from the previous year to show their results. And what I saw was that these patients, operated on by world-leading rhinoplasty surgeons, still had tip swelling at one year post-op.
It wasn't me. It was the technique.
Why Open Rhinoplasty Causes More Swelling
When you make an incision across the columella and lift the nasal skin, you're cutting through the lymphatic drainage pathways that normally allow fluid to drain from the nasal tip downwards. With these pathways disrupted, fluid accumulates in the tip, causing prolonged swelling.
This isn't a complication or a surgical error. It's an inherent consequence of the approach. Every open rhinoplasty will have more tip swelling than a comparable closed rhinoplasty.
After recognising this pattern, I went back to performing closed rhinoplasty. My results were just as good, but my patients had much less swelling and faster recovery.
The Complete Transfixion Incision
Now, when I say I perform closed rhinoplasty, I don't mean a minimal procedure. I use what's called a complete transfixion incision. This is a long incision made inside the nostril that connects both sides, allowing me to lift the nasal skin internally, move it in all directions, and access all the structures I need to modify.
Think of it this way: with open rhinoplasty, you lift the bonnet from the top to work on the engine. With my closed technique, you put the car on a ramp and work from underneath. You can still access everything you need. You're just approaching it differently.
The incisions inside the nose are quite extensive. They run from the inside of one nostril, all the way up, and across to the other side. But they're all hidden inside, and they heal remarkably well.
When Might Open Rhinoplasty Be Preferred?
There are situations where open rhinoplasty may be the better choice:
- Severe tip deformities requiring extensive cartilage grafting
- Revision rhinoplasty with significant scar tissue
- Cases requiring very precise tip work between the nostril crease and the tip itself
But for the majority of rhinoplasties, including reducing dorsal humps, refining tips, straightening crooked noses, and improving breathing, closed rhinoplasty achieves excellent results with less swelling and faster recovery.
What This Means for Your Recovery
With closed rhinoplasty, you can typically expect:
- Less bruising: Without the columellar incision, there's less trauma to the tissues
- Less tip swelling: The lymphatic drainage remains intact
- Faster resolution of swelling: Most patients see significant improvement by 6-8 weeks
- No external scar: All incisions are hidden inside the nose
You'll still have a splint on your nose for about a week, and there will be some bruising around the eyes. But the overall recovery tends to be smoother and quicker than with the open approach.
The Importance of Surgeon Training
Here's an important point: the best technique is the one your surgeon is most experienced and comfortable with. A surgeon who was trained primarily in open rhinoplasty and has performed thousands of open procedures will likely get better results with that technique than if they tried to switch to closed.
The reason I can achieve excellent results with closed rhinoplasty is that I was trained in it from the beginning. I learned how to visualise the nasal structures through feel and experience, how to make precise modifications without direct vision, and how to troubleshoot problems through internal access.
When choosing a surgeon, ask about their preferred technique and why. Their answer will tell you a lot about their training, their experience, and their approach to patient care.
The Bottom Line
There's no universally "better" technique. Both closed and open rhinoplasty can achieve excellent results in the right hands. What matters is choosing a surgeon who is experienced in their preferred approach and who can explain why that approach is right for your specific anatomy and goals.
My preference for closed rhinoplasty comes from direct experience with both techniques and a commitment to minimising my patients' recovery time while maintaining excellent aesthetic outcomes. Your nose should look natural, refined, and balanced, and you should be able to enjoy that result as quickly as possible.
Frequently Asked Questions
In closed rhinoplasty, all incisions are made inside the nostrils with no external cuts. In open rhinoplasty, a small incision is made across the columella (the skin between your nostrils) allowing the surgeon to lift the skin and see the underlying structures directly.
Yes, closed rhinoplasty typically results in less swelling, particularly at the nasal tip. Because the skin isn't lifted off the underlying structures, the lymphatic drainage pathways remain intact, leading to faster resolution of swelling.
In experienced hands, yes. A surgeon trained in extensive closed rhinoplasty techniques can achieve equivalent results to open rhinoplasty for most patients. The key is proper training and experience with the technique.
Many surgeons trained in recent decades learned open rhinoplasty as their primary technique. Open rhinoplasty provides direct visualisation of the nasal structures, which some surgeons find helpful. However, this comes with increased tip swelling and longer recovery.