Open versus closed approach

Two-sentence lead. Structural work once reserved for the open approach (septal extension grafts, spreader grafts, full rib reconstruction) is now reported through closed (endonasal) incisions with comparable results, and a meta-analysis of 1,067 patients found no difference between open and closed in ROE, NOSE, edema, ecchymosis, operating time, satisfaction or complications. Early differences in swelling and supratip definition between open and closed fade by 12 months; columellar scar quality does not depend on suture type (randomized, 41 patients) and problematic columellar scars run about 6%.

Key points

• Pitanguy ligament study, 3 groups of 40: open without ligament repair had deeper supratip and more tip edema early than open with repair or closed with preservation (p<0.001); Goode score and nasolabial angle differed open vs closed early (p<0.05); no differences among groups at 12 months [41998167]
• Extended closed rib revision, 700 patients (2022-2024, ≥6 months follow-up): SCHNOS total 44.2 ± 5.8 to 17.8 ± 6.2 (p<0.001); revision rate 14.2% [42580758]
• Endonasal septal extension graft, 60 patients at 1 year: nasolabial angle 93.75° ± 9.45° to 101.1° ± 5.3°; Crumley ratio 3.84 to 4.04 (P<0.001) [35554489]
• Endonasal SEG with septoplasty and turbinate reduction, 34 patients (median age 38.3; 52.9% male; mean follow-up 126.6 days): NOSE 71.5 baseline, change -49.4; SNOT-22 35.4, change -24.2; ESS 6.7, change -3.4; SCHNOS cosmetic +17.1; 0 complications [38350156]
• Endonasal hybrid (paramedian dorsal component excision + low septal strip, keystone preserved), 94 primaries (65 female, 29 male; mean age 32.30 ± 9.55): complications 6.38% (6/94), all revised — tip drooping 3, dorsal irregularity 2, deviation 1; mean follow-up 10.08 ± 2.78 months [40855022]
• Closed Asian rhinoplasty with auricular cartilage only, 63 patients: all aesthetic indices improved (P<.05); nasal volume +2.9 mL, unchanged 6 to 12 months [41411306]
• Columellar scar, absorbable vs nonabsorbable suture, 6 studies (n=435): no difference on patient- or physician-reported scar [34516890]
• 12-step closure for external rhinoplasty, 104 patients, Vancouver-Manchester scale: 0 poor scars; 83.6% good; 65.5% of good scars scored a perfect 6; 1 moderate scar scored 3 [38698638]
• TRICK-TIP (transcolumellar + intercartilaginous, tip skin undissected), 120 patients: 102 independent raters scored overall result 3.6 of 5; columellar scar visibility 1.35 of 5 (1 = absent); 0 complications [38483551]
• CLC-SP flap (cephalic lateral crus-scroll-Pitanguy) in open rhinoplasty, 22 thick-skinned patients, mean follow-up 5.4 months: 19 improved breathing, 21 satisfied aesthetically, 0 pollybeak [41338277]
• Spreader flap vs graft in open approach, CT internal valve angle at 3 months: 52 flap patients (104 valves) vs 54 graft (108 valves), mean age 27.76 ± 8.16; both increased (p<0.001); flap angle higher postoperatively (p<0.001) [37640816]
• Structural endonasal techniques reviewed: hump reduction, spreader graft, alar batten and rim grafts, columellar strut, caudal extension graft; reported less operating time, swelling, and scar contracture than open [40262776]
• Endonasal spreader grafts inside preservation rhinoplasty: 3 cases, all reported improved obstruction [36730568]
• Video-assisted endoscopic septo-rhinoplasty via hemitransfixion incision with endoscopic spreader flaps, no external scar [37365307]; discussants cite limited visibility, steeper learning curve, and suture precision in a confined field [37474821, 38480658]
• Open vs closed meta-analysis, 20 studies with 12 pooled (1,067 patients: 539 open, 528 closed): no difference in ROE (SMD -0.16), NOSE (SMD 0.21), edema, ecchymosis, operating time, satisfaction or complications; heterogeneity I2 99% (ROE) and 86% (NOSE); study quality moderate [40771258]
• Randomized trial of columellar closure, 61 enrolled and 41 analyzed (23 absorbable, 18 nonabsorbable): no difference on the blinded Stony Brook scale or the patient scar questionnaire [34495754]
• Columellar scar after open rhinoplasty in 529 Asian patients (234 at 6 months): problematic scar 6.0% (wide or depressed 1.7%, notching 1.3%, hyperpigmentation 1.7%, hypertrophic marginal 0.8%, necrosis 0.4%); erythema normalized by 66.7 days; costal tip grafts raised scar risk 8.0% vs 3.3% (P=.02) [26822626]
• Secondary open rhinoplasty placing a new transcolumellar incision regardless of the prior one, 100 patients (Rohrich, 2000-2010): scar 1.68 before and 1.61 after on a 4-point scale (imperceptible to poor); no skin bridge necrosis, infection or breakdown [23676971]
• Nasal muscle function after 48 open and closed rhinoplasties: electroneurography amplitudes fell in both (p<.001); EMG contraction fell in 6.6% closed vs 11.1% open (p=.280) [21385740]
• Caudal septal extension graft with a polydioxanone plate in endonasal rhinoplasty, randomized 15 vs 15 (Level 1): surgeon difficulty VAS 17 vs 46 mm (P<.001); projection change from day 30 to 365 was -0.31% with the plate vs -6.5% without (P=.04); 1 infection in each arm [26501937]
• Primary open rhinoplasty without columellar strut, 100 consecutive cases: planned projection, rotation and Goode ratio achieved with statistical accuracy; columellar contour irregularity 3% [25811564]
• Extended columellar strut-tip graft in endonasal rhinoplasty, 15 patients, mean photo follow-up 32 months (8 months to 10 years): projection gain 19% in every patient (P<.05) [23450340]
• Endonasal complete release approach for the tip (lateral crus delivered, dome repositioned, long alar struts), 100 consecutive young women: no external incision, no packing, less swelling reported [23165886]
• Diced cartilage in temporal fascia through the endonasal approach for secondary dorsal augmentation, 18 patients at 15 months or more: 3 complications, 1 revision for contour, no resorption [23855009]
• External supratip suture in thick-skinned primary rhinoplasty, 31 vs 33 controls plus 19 moderate-skin patients: better supratip aesthetics on two blinded parameters (p<0.05); no ischemic complication; Level IV [36042029]
• Concurrent excision of dorsal nasal scars with reduction rhinoplasty, 33 patients: fewer affected Cakir polygons (P<0.05), better patient and Stony Brook scores, no change in SNOT-22 [34745799]
• Tissue expander (1 by 4 cm) on the dorsum for contracted saddle noses before rib reconstruction, 4 patients: all expanded; 1 exposure through the endonasal incision without harm [30566988]
• Endonasal Cottle push-down and let-down described as preservation rhinoplasty's original form; the let-down keeps pyramid tensegrity and valve physiology [33220845, 33220844]
• FLI endonasal approach combines standard incisions to expose the whole quadrangular cartilage, caudal septum, scroll and internal valve for a modified Cottle low strip septoplasty [33626586]
• Endonasal revision keeps the skin envelope and ligaments, with less edema and no external scar, in selected patients; in-office endonasal minor revision suits isolated defects without general anesthesia [42091324, 34544174]
• Endonasal graft and upper-third technique reviews describe less dissection and less cartilage use than open, and a hybrid Asian approach that gives open-level access without a transcolumellar incision [34024040, 34500488, 30005784]
• Open approach shown by video: component dorsal reduction, midvault reconstitution, tip sutures, deprojection and alar contour grafts [28953724]

Techniques and terms named

open / external rhinoplasty [41998167], closed / endonasal rhinoplasty [40262776], Pitanguy ligament repair / preservation [41998167], CLC-SP flap [41338277], supra-perichondral plane [41338277], TRICK-TIP [38483551], low stairstep columellar incision [38483551], transmembranous incision / intercartilaginous incision [38483551], hemitransfixion incision [37365307], endoscopic spreader flap [37365307], Video Assisted Rhinoseptoplasty (VARS) [38480658], extended closed rhinoplasty [42580758], costal cartilage reconstruction [42580758], endonasal septal extension graft [35554489, 38350156], paramedian dorsal component excision [40855022], low septal strip septoplasty [40855022], spreader graft / spreader flap [37640816], alar batten graft [40262776], rim graft [40262776], columellar strut / caudal extension graft [40262776], endonasal spreader graft in preservation rhinoplasty [36730568], ultrasonic devices [40262776], vertical mattress + interrupted simple sutures [38698638], Vancouver-Manchester scale [38698638], absorbable / nonabsorbable suture [34516890], SCHNOS [42580758], FACE-Q [38483551], Crumley ratio [35554489], open vs closed meta-analysis [40771258], absorbable vs nonabsorbable columellar suture RCT [34495754], problematic columellar scar types [26822626], repositioned transcolumellar incision in secondary open rhinoplasty [23676971], nasal muscle electromyography [21385740], polydioxanone plate for caudal septal extension [26501937], strut-free primary open rhinoplasty [25811564], extended columellar strut-tip graft [23450340], endonasal complete release approach [23165886], endonasal diced cartilage in fascia [23855009], external supratip suture [36042029], hemostatic net principle [36042029], concurrent scar excision with reduction [34745799], dorsal tissue expander [30566988], endonasal Cottle push-down and let-down [33220845], biotensegrity of the keystone [33220844], FLI approach [33626586], endonasal secondary rhinoplasty [42091324], in-office endonasal revision [34544174], endonasal grafts and upper third [34024040, 34500488], hybrid Asian approach without transcolumellar incision [30005784], component dorsal reduction video [28953724]

Numbers to remember

• 700 closed rib revisions: SCHNOS 44.2 to 17.8; revision 14.2% [42580758]
• 120 patients in 3 groups: open vs closed differences gone at 12 months [41998167]
• 435 patients: suture type did not change columellar scar [34516890]
• 104 external closures: 0 poor scars, 83.6% good [38698638]
• 6.38% complication/revision in 94 endonasal hybrid cases [40855022]
• Endonasal SEG raised nasolabial angle to 101.1° ± 5.3°, n=60 [35554489]
• 1,067 patients: no open vs closed difference in ROE, NOSE, edema, ecchymosis, time or complications [40771258]
• Columellar scar RCT n=41: no difference absorbable vs nonabsorbable [34495754]
• Problematic columellar scar 6.0% of 234 Asian open rhinoplasties [26822626]
• Projection loss day 30 to 365: -0.31% with PDS plate vs -6.5% without, n=30 randomized [26501937]
• Columellar contour irregularity 3% in 100 strut-free open primaries [25811564]

Numbers

What is still contested or missing

• Endoscopic endonasal approach: proponents claim open-approach visibility without external scar [37365307]; discussants cite incomplete visibility and a steeper learning curve [37474821, 38480658]
• Spreader flap gave a higher CT valve angle than graft at 3 months only; no longer follow-up reported [37640816]
• Open vs closed differences were confined to the early postoperative period; long-term equivalence rests on one 120-patient series [41998167]
• Endonasal SEG functional data are a 34-patient pilot with mean follow-up 126.6 days [38350156]
• The open-closed meta-analysis carries I2 of 99% for ROE and 86% for NOSE, no sample-size calculations and biased endpoint assessment [40771258]
• The columellar suture RCT lost 20 of 61 patients to follow-up [34495754]
• Endonasal technique papers from 2021-2026 are descriptive reviews without outcome data [42091324, 34024040, 34500488, 34544174, 34704240, 34782138, 33626586, 33220845, 33220844, 30005784]
• Tissue expansion for contracted saddle noses rests on 4 patients [30566988]
• Muscle-function and PDS plate data are 48 and 30 patients respectively, the latter with 19 completing 12 months [21385740, 26501937]

Papers used

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