Open Rhinoplasty vs. Closed Rhinoplasty

Open rhinoplasty vs. closed rhinoplasty - there is a lot of bandying about of these terms by perspective patients. The "open rhinoplasty" describes an operative technique by which an external incision is made to gain access to the interior of the nose. This is in distinction to the "closed rhinoplasty" in which all incisions are made entirely within the nasal interior.

There are disciples, defendants and proponents of each within the nasal cosmetic plastic surgery community. It is a matter of the surgeon's preference as to which technique he is most comfortable with for a given case. The nasal cosmetic surgery super-specialist will be adept at both techniques. He or she will choose a technique that seems appropriate for the case at hand.

Generally, younger surgeons appear to prefer the open technique because that is the way they have been trained. In the last twenty years that technique gained popularity, initially as a teaching device since it is easier for a student or trainee to see the nasal contour through the open approach. The more veteran nasal cosmetic surgeons were trained using the closed technique and generally were comfortable with it. But, it is not difficult for the highly experienced and specialized nasal surgeon to master the open rhinoplasty technique.

If you have never seen a photograph or a sketch of the open rhinoplasty, understand that using a horizontal incision connecting the two nostrils just below the tip, the skin is lifted as one would lift the hood of a car. Then one gets access to see the tip cartilages and when a certain instrument is placed through that opening, one can even see up to the bridge of the nose. No question that, for the novice and inexperienced surgeon or occasional rhinoplasty surgeon, this exposure is advantageous.

The open rhinoplasty tradeoff is the external scar which, while generally heals well, in some patients doesn't. Also, there is the uncertainty of how much tightening or contracture could take place during the healing.

The closed rhinoplasty, done entirely within the nose, does take greater manual dexterity and the technical facility to perform an operation "through a keyhole". Experienced surgeons will tell you that their visualization is not impaired, and in fact, this approach of course has been used for nearly 100 years with great success.




Of ultimate importance is that the surgeon be comfortable with his or her favorite technique. If you have confidence in the surgeon, have confidence in his or her judgment. Most likely, you will also be comfortable with the results that the chosen technique delivers.

If you are concerned about the visibility of the open rhinoplasty's incision, ask to see many before and after open rhinoplasty photographs, particularly close-ups. Then, you can evaluate for yourself the visibility or lack of visibility of the external incision.

- Robert Kotler, MD, FACS

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What Are Talent, Experience and Superspecialization Worth?

Recently, I reminded myself that one of the consistent business truths of life is that there are three variables in every purchase we make. The first is cost, the second is quality and the third is service.

What reminded me of this was when I visited my shoe repair shop with an urgent repair need. The shop has done very good work, and their turn-around time - the measure of service - is always short. However, their charges are higher than average. But, I don't mind paying the extra amount because I am getting quality and service.

The converse would be any low-priced service. If the price is low, then either the quality and/or service must also be low. What comes to mind is the typical fast food operation. The service is quick, the prices are low but the quality is not fantastic. So, you only get two out of three.

So how does this parallel the subject of talent, experience and superspecialization?

The most gifted cosmetic plastic surgeons with long experience and narrow focus - the superspecialists - generally deliver high-quality results. That is why they are at the top of the totem pole among other doctors. Typically, their offices render top service because they have developed efficiencies in both their surgery and practice operation. Rarely the lowest price.

You do get what you pay for.

- Robert Kotler, MD, FACS

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Some Thoughts About Cosmetic Surgery and Medical Education

I recently returned from our annual summer visit to friends and family in the Midwest. First, we visited Green Lake, WI for a reunion of our college friends. Then, my family and I visited Chicago, where my family has lived for six generations. This year, I even played in my high school's annual golf tournament where, interestingly, some of the best performances were by some of the graduates in their 70's or 80's! I guess that says a lot for practice makes perfect.

I also had an opportunity to visit my alma mater, Northwestern University Medical School. This year, I had the great pleasure of spending time with one of my most important and beloved teachers, who is still practicing and teaching half-time at Northwestern. He took me on a tour of the new Northwestern Memorial Hospital. We sadly looked at an excavation site which was formerly the home of the Lakeside Veterans Administration Hospital where my teacher taught and did research and where I had my junior year rotation in Internal Medicine under him. I also did extra work in the Pathology Department there and held a moonlighting job. I get a lot of good warm feeling when I return to the campus, although I could hardly recognize it. But, it was the seat of my medical education and I am very appreciative of the excellent education I had.

Earlier in the day, I visited the University of Illinois Chicago Medical Center. That medical center, when I was a student and resident, was the largest in the country with more hospitals and beds concentrated within one square mile than any location. The Cook County Hospital alone had over 3,000 beds. Today it has 500.

I thought a lot about the difference in education then and today. Recently, there have been a lot of constraints placed on medical education. Much of it is financial because hospitals are strapped for cash because of diminishing and poor payments from insurance companies, and the large load of either uninsured or welfare patients for whom the state and federal governments pay very little.

A tight economy and near-bankrupt governments makes it tougher to educate the students, interns, residents and fellows. During my residency, we had unlimited opportunity to perfect our cosmetic surgery skills. We were allowed to perform cosmetic procedures on patients for as little as $100. Granted, $100 then, would translate to $500 today, but still, that is a pretty reasonable price to have a nose job or eyelid surgery and for another few hundred dollars you could have a full face and neck lift. By offering patients such reasonable fees, our surgery schedule was full. And, a full schedule meant maximum learning.

Cosmetic surgery training requires experience and excellent teaching. Without patients who are willing to have their surgery at the university, where does the young trainee hone his skills? Today, there are few situations that match the wonderful opportunity we had as residents. For that reason, I see graduates of residency programs coming out with a lot less experience and skill than those of my generation. I have talked to some of the graduates who tell me they have only done five nose jobs for example. That is nowhere near a reasonable number. In a residency program, if one would do 25-50 cosmetic nasal surgeries under supervision, that would be a minimal, but adequate number. To come out with fewer cases under one's belt is inadequate to begin practicing.

In universal terms, as the United States medical care delivery system is sure to change, I am concerned that medical education will slip far down the line in priorities.

The consequences for all of us are not good.

- Robert Kotler, MD, FACS

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• Choosing the Right Cosmetic Surgeon
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