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Secrets of a Beverly Hills Cosmetic Surgeon

with Robert Kotler, MD, FACS

Dr. Kotler's blog has now been retired. We appreciate all the wisdom and support he has brought to the WebMD community throughout the years.

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Tuesday, December 7, 2010

Internal or Open Rhinoplasty?

Internal rhinoplasty is another term that is used for the standard and classic technique of performing a rhinoplasty through totally hidden internal incisions.

In the last 25 years, there has been a move towards performing a somewhat contrary procedure known as external rhinoplasty — also known as open rhinoplasty.  The difference is that these procedures include, in addition to the standard and necessary internal incisions, a horizontal external incision made across the belly of the columella which is the vertical bar of tissues that separate the left and right nostrils.

Advocates of the open rhinoplasty or external rhinoplasty praise it for the greater “exposure” or visualization of the front of the nose, particularly the tip cartilages.  That is true.  It takes a bit more manual dexterity and facility to be able to reach the same point of visibility through the internal incision or closed rhinoplasty approach.  It is never quite as satisfactory.

However, there are tradeoffs.  First, the external incision may not heal perfectly.  While we see some people for whom the healing has been optimal and the incision is barely visible, there are others who are unhappy with the appearance; they have a visible scar. Their dissatisfaction is justified.  Secondly, each additional incision in rhinoplasty adds some element of unpredictability because of the uncertainty of what we call scar contractile forces. What that means is that as nature heals, it may tighten the tissue more than the surgeon would anticipate, causing a result that is not as expected. Such variance from the ideal can be minimal. However, if it is not, there is dissatisfaction.

Frankly, since rhinoplasty was first introduced on a wide-spread scale over 50 years ago using exclusively the internal rhinoplasty technique, there have been an enormous number of satisfactory procedures performed.  Some proponents of the external or open rhinoplasty consider it now to be the standard incision — that somehow, the classic internal or closed rhinoplasty approach is obsolete.  I disagree.  Many good results can be obtained with internal incisions with less unpredictability. Plus, when done internally, there is no possibility of an unsatisfactory external scar.

I do feel that the experienced surgeon should have at his command both techniques.  I have used the open rhinoplasty, but very infrequently.  I will say that for certain noses, particularly revision rhinoplasty, also known as secondary rhinoplasty cases, the better visualization via the open rhinoplasty can be important since often there was placed at the original surgery either plastic inserts, transplanted cartilage or even bone.  The access for dissection and visualization is a bit better under such circumstances.

I do want you to understand, however, that the most important thing is that the surgeon who performs the operation delivers consistently good, natural rhinoplasty results.  You need to study the cases.  You need to look at many “before” and “after” pictures. Look carefully for any signs of the external rhinoplasty incision.  If a given doctor’s work evidences too obvious an external incision, he  may not have mastered the technique, and therefore, you should be somewhat skeptical of its use by that particular cosmetic plastic surgeon.

- Robert Kotler, MD, FACS

Posted by: Robert Kotler, MD, FACS at 9:06 am

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