Dott. Armando Boccieri
OPEN OR CLOSED RHINOPLASTY?

Has the Berlin wall between the two finally come down?

Rinoplastica aperta o chiusa

From the top: the drawn line, incision, and suturing of the columella in open rhinoplasty

Since the very birth of nasal surgery to address a whole variety of functional and aesthetic problems, a closed approach has been adopted to the nasal septum and pyramid by means of incisions inside the nasal cavities. The lesser degree of invasiveness together with the possibility for surgeons to feel the osteocartilaginous nasal structures with their own fingers and decide upon their anatomical correction have made rhinoplasty with the closed approach one of the most fascinating and difficult operations in aesthetic surgery. The results obtained with this approach still prove satisfactory today, as in the past, as long as certain prerequisites are complied with. On the one hand, closed rhinoplasty makes it possible to obtain excellent results with quick, precise execution in cases where a hump on the nasal dorsum is combined with nasal septum deviation and turbinate hypertrophy. On the other, it entails the risk of postoperative asymmetry when used to address major defects of the nasal tip requiring sophisticated procedures of reshaping. I am also convinced that it presents further limitations in secondary rhinoplasties, whereas the greater exposure of the anatomical regions offered by the open approach can lay the foundations for complete success.
The open approach to the nasal septum and pyramid by means of a small incision of the columella has become increasingly popular with surgeons over the last twenty years for these very reasons. The possibility of defining anatomical deformities through direct inspection of the osteocartilaginous architecture and the ease with which grafts can be placed are only two of the advantages leading to its widespread adoption. Moreover, the columellar scar becomes practically invisible in a short space of time if a number of particular procedures are carried out.

To conclude, the expert nasal surgeon must be capable of using both the closed and the open approach, and of recognizing which will provide the best results for which patients.

OBSERVATIONS ON THE OPEN APPROACH

Rinoplastica aperta o chiusa

Left to right: before and after open rhinoplasty: the scar of the columellar incision is almost invisible invisibile

Rinoplastica aperta o chiusa

Left to right: before and after open rhinoplasty: the scar of the columellar incision is almost invisible invisibile

The open approach is not a different surgical technique but only a different surgical approach to the nasal septum or pyramid with respect to the classic endonasal approach. A nasal surgeon should be a master of both approaches. There are no dogmatic indications for either and the surgeon must decide on the basis of personal experience which would be better for the patient in question. The open approach offers some important advantages. First of all, it eliminates the need to imagine the osteocartilaginous nasal structure, all of which can be exposed with no tension or distortion so as to arrive at a precise diagnosis of the factors responsible for nasal deformity. The rest of the team can also contribute actively to the operating surgeon’s decisions as happens in the traditional surgery of other areas. It also makes it possible to place grafts easily even in areas that are almost inaccessible with the closed approach, which ensures lasting stability. At the same time, it should be stressed that the open approach is no more traumatic for the patient. On the contrary, bleeding can be monitored more precisely under direct visual control and no further incisions are required inside the nose.
The open approach encapsulates the modern concept of rhinoplasty, no longer designed to cut and remove structures but to rebuild and reshape while preserving the osseous and cartilaginous elements already present. What is new today is the pursuit of perfect results without radically altering and hence weakening the anatomy of the structures involved. Thanks to a difference in approach, open rhinoplasty makes possible a series of surgical procedures and concepts that can in some cases enhance the precision and predictability of the end result.