A New Modified Closed-Open Approach As Part of a Graduated and Integrative Approach to Rhinoplasty

BACKGROUND: Open versus closed approach rhinoplasty is a frequently debated topic in aesthetic plastic surgery. Although good results can often be achieved with either technique, each one of them has its unique advantages and disadvantages. We present a new modified closed-open approach employed in selected cases that encompasses features of both.

RATIONALE: Other than the devotees of a specific approach, most surgeons would agree than the closed approach is not optimum for all noses, nor should they all be opened. Conservatism in rhinoplasty is fundamental, however it should not restrict the surgeon from performing all the necessary maneuvers to achieve the desired outcome. The goal is to obtain reliable and long-term results with as little surgery as possible. Less dissection causes less soft tissue trauma, postoperative swelling and ecchymosis, and thus shortens the recovery period.

METHODS: The surgical approach is described in detail followed by clinical examples. Indications and limitations are discussed.

TECHNIQUE: The procedure begins as a closed approach through an intracartilaginous incision that does not extend to the septum leaving the mucosa at the area of the internal valve intact. Cephalic trimming of the lateral crura and dorsal rasping and/or excision are then preformed through this access. With the overlying skin and soft tissue envelope in anatomic position incremental sculpting of the nose is done in a precise manner without having to redrape the skin over the nose each time.  In patients requiring extensive nasal tip maneuvers, the alar cartilage framework is unroofed through a traditional transcolumellar but limited marginal incision extending just past the soft triangle.  It provides adequate exposure of the alar cartilages as well as easy access to the septum. However, in contrast to the open approach, it  leaves most of the alar rim uninterrupted maintaining a broad base of venous and lymphatic drainage. The whole gamut of tip-plasty maneuvers can be done with the cartilage framework in resting position quite similar to the open approach.

CONCLUSION: The modified closed-open technique circumvents the limitations of the closed approach by providing good exposure of the tip and septum without incurring the shortcomings of the open approach. In selected cases, it provides the surgeon with the opportunity to combine the advantages of both approaches.