Open versus closed

Whether the surgeon opens the nose through a small incision across the columella or works entirely through the nostrils has been argued in print since 1973, was put on facing pages of Plastic and Reconstructive Surgery by Jack Gunter and Jack Sheen in 1997, and was finally pooled in 2025: across twenty studies and 1,067 patients there is no significant difference in what patients report, in breathing, in complications or in swelling. The open approach lets the surgeon see; the closed approach leaves less scar and less dissection; the result a year later belongs to the operation done, not the door used to reach it.

57papers on file 41this page is written from 10journals, 2011–2026 5open access, full text 48with a plain-language summary

Where these 57 papers were published

16Facial Plastic SurgeryFacial Plast Surg
14Aesthetic Plastic SurgeryAesthetic Plast Surg
7Plastic and Reconstructive SurgeryPlast Reconstr Surg
5JAMA Facial Plastic SurgeryJAMA Facial Plast Surg
4Aesthetic Surgery JournalAesthet Surg J
4Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
3Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
2Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
1Clinics in Plastic SurgeryClin Plast Surg
1Archives of Facial Plastic SurgeryArch Facial Plast Surg

12011 12012 62013 22014 32015 52016 42017 12018 12019 42021 122022 52023 22024 52025 52026

14 further papers on this topic came in through the history rather than the archive query: Goodman WS 1973, Goodman WS 1974, Gunter JP 1987, Weir RF 1988 and 10 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

Pooled, the two approaches come out level

Twenty studies, twelve with data poolable, 1,067 patients, 539 open and 528 closed. No significant difference in appearance scores, breathing scores, swelling, bruising, complications or operating time. The review's own caveat is that study quality was moderate: no sample-size calculations, endpoint assessment often unblinded. This is the whole comparative evidence base for a fifty-year argument, and it says the argument does not decide the result.

Rests on: Abi Zeid Daou et al., systematic review and meta-analysis.

The scar the debate was about is measurable, and small

In 529 Asian patients, a population where scarring is a real concern, 6.0% had a problematic columellar scar at six months or more: 1.7% wide and depressed, 1.3% notched, 1.7% hyperpigmented, 0.4% with columellar skin necrosis. Suture choice does not change it: a randomised trial of 41 patients and a meta-analysis of six studies and 435 patients both found no difference between absorbable and non-absorbable closure, rated by patients and by blinded clinicians. In 100 secondary open rhinoplasties the previous columellar incision was deliberately ignored and a new one placed wherever the plan wanted it, with no necrosis, no infection and scar quality between imperceptible and barely perceptible.

Rests on: Kim and Jang, 529 Asian patients · Jonas et al., randomised suture trial · Kenny et al., suture meta-analysis · Unger et al., ignoring the prior incision.

The open approach won because it made the operation teachable, not because it healed better

Opening the nose was described by Réthi in the 1930s and used by Šercer in Zagreb, and Goodman published it in North America in 1973 and 1974. What changed American practice was Gunter and Rohrich's 1987 paper applying it to secondary rhinoplasty, where seeing the deformity matters most, over 100 cases with no transcolumellar incision problems, followed by Gunter's 1989 graphic record, which made intraoperative manoeuvres drawable, comparable and therefore teachable. Structure-based rhinoplasty as codified by Toriumi and by Tebbetts is built on that visibility. The full chain is on the history of rhinoplasty and on Jack Gunter's page.

Rests on: Goodman, external approach 1973 · Goodman and Charbonneau, 1974 · Gunter and Rohrich, 1987 · Gunter, the graphic record · Toriumi, structural approach · Tebbetts, shaping the tip without structural disruption.

The 1997 exchange named the real trade, and it still holds

Sheen and Gunter were printed back to back: "Closed versus open rhinoplasty — and the debate goes on" and "The merits of the open approach in rhinoplasty". Sheen's case was that dissection costs support and that the operated nose contracts around what the surgeon disturbs; Gunter's was that you cannot correct reliably what you cannot see. Both are visible in the current literature — the endonasal argument now runs on preserving the soft-tissue envelope and the ligaments, and the open argument on exposure for structural work. Nobody has run the trial that would settle it, and after the 2025 meta-analysis nobody is likely to.

Rests on: Sheen, 1997 · Gunter, 1997 · Rad et al., principles of endonasal rhinoplasty · Ben Ner et al., soft-tissue envelope preservation in the open approach.

Closed surgery now does the things it was said not to be able to do

Structural endonasal rhinoplasty places spreader grafts, alar battens, rim grafts, columellar struts and caudal extension grafts through the nostrils. Endonasal septal extension grafting moved obstruction scores by nearly 50 points in 34 patients and held tip projection and rotation at a year in 60. Preservation techniques (push-down, let-down, low-strip septoplasty) are performed closed as standard by several published groups. And the hardest case of all has been reported closed: 700 revision patients reconstructed with costal cartilage through an endonasal approach, obstruction and appearance scores from 44.2 to 17.8, revision rate 14.2%.

Rests on: Shah and Nnabue, structural endonasal rhinoplasty · Goldfarb et al., endonasal septal extension grafting · Harel et al., 60 endonasal cases at a year · Göde and Berber, 700 closed rib revisions · Friedman et al., the endonasal push-down/let-down.

The measurable differences are early, and gone by a year

Comparing open rhinoplasty without ligament repair, open with repair, and closed with ligament preservation, 40 patients each, supratip depth, tip swelling, the Goode score and the nasolabial angle all differed in the early period and none differed at twelve months. Electrophysiological testing of the nasal muscles after open and closed surgery found reduced activity in both and no significant difference between them. What the approach changes is the first months; what the technique changes is the result.

Rests on: Boynuyogun et al., three groups of 40 · Kirgezen et al., electromyography after both approaches.

By question

The specific decisions inside the choice, and what the evidence says about each.

What the open approach buys

Direct, undistorted view of the framework; suture techniques under vision; accurate diagnosis in a nose somebody else has operated on. It costs a columellar scar, wider dissection, more early swelling, and, in the closed camp's argument, loss of ligamentous support that then has to be rebuilt. Twelve steps of closure technique have been published to make the scar disappear: 104 patients, no poor scars, 83.6% rated good.

Key papers: Gunter and Rohrich · Soto-Galindo et al., twelve steps to optimise the scar.

What the closed approach buys

No external scar, less dissection, less swelling, preserved ligaments and skin envelope, shorter operating time. And a longer learning curve, because the surgeon is working by feel and through a keyhole. Video-assisted endoscopic septorhinoplasty is the published answer to that: the endoscope gives the trainee the view the open approach gives, without the incision.

Key papers: Rad et al. · Radulesco et al., video-assisted septorhinoplasty · Radulesco et al., reply on the learning curve.

The hybrid, which is where most of the field now sits

The TRICK-TIP technique lifts the whole mobile nose as a three-layer flap through a low stairstep columellar incision without dissecting the tip skin, open exposure, closed tip. The cephalic lateral crus–scroll–Pitanguy flap preserves the soft-tissue envelope inside an open operation. Mestizo and Asian series report closed preservation with structural tip support. The categories are converging faster than the argument.

Key papers: Villegas-Alzate, TRICK-TIP in 120 patients · Ben Ner et al. · Valdivia et al., closed preservation in 417 mestizo primaries · Çakır and Coşkun, two decades combining both.

The revision nose

Open dominates revision practice because the anatomy is distorted and needs to be seen. But the endonasal case is specifically made for revision too, preserving the scarred skin envelope and the remaining ligamentous support, and the largest closed revision series on file is 700 patients with rib. In-office endonasal minor revision handles the small asymmetries without returning to theatre.

Key papers: Shomorony and Friedman, endonasal secondary techniques · Göde and Berber · Auger and Shah, in-office endonasal minor revision · Unger et al..

The tip, where the approaches disagree most

The open camp's argument is that suture shaping and grafting need vision. The closed answer is the complete release approach: deliver the lateral crus, reposition the dome, place alar strut grafts, advance the lateral crus laterally. Everything the open approach does, through the nostrils, in 100 consecutive primaries. And a 100-case open series done deliberately without any columellar strut showed that planned tip position can be hit without adding structure, if the native supports are preserved or rebuilt.

Key papers: Gassner et al., endonasal complete release · Bitik et al., open primaries without a strut · Carron et al., extended columellar strut-tip graft in endonasal rhinoplasty.

The middle vault, either way

Spreader grafts can be placed endonasally, including inside preservation operations, and spreader graft against spreader flap makes no measurable difference to the valve angle in open surgery. This is the clearest example of the general pattern: the same manoeuvre, done through either door, with the same result.

Key papers: Go et al., endonasal spreader grafts in preservation · Koplay et al., graft against flap on valve angle.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

Open (external) approach: a small incision across the columella joined to incisions inside the nostrils, lifting the skin off the framework so the whole structure is visible. [3602167]
Closed (endonasal) approach: the same operations performed entirely through incisions inside the nostrils, without the transcolumellar incision. [40262776]
Transcolumellar incision: the external part of the open approach, usually a stairstep or inverted-V across the narrowest part of the columella. [3602167, 38698638]
Delivery and non-delivery: closed techniques: delivery lifts the lower lateral cartilage out through the nostril as a flap to work on it; non-delivery works on it in place. [23165886]
Complete release approach: an endonasal method that fully dissects and delivers the lateral crus, repositions the dome and adds struts, open-style manoeuvres through a closed door. [23165886]
Structure (structural) rhinoplasty: building a framework with grafts and sutures rather than reducing one, codified by Toriumi and by Tebbetts, and the reason the open approach spread. [19331957, 15062325, 8016254]
Graphic record: Gunter's standard diagram of intraoperative manoeuvres, which made rhinoplasty comparable between surgeons and papers. [2473481]
Video-assisted (endoscopic) septorhinoplasty: endoscope-assisted closed surgery, offering the trainee an open-approach view without the incision. [37365307]
Soft-tissue envelope (SSTE): the skin, fat, muscle and ligaments over the framework. The closed argument is about disturbing it as little as possible; the open answer is to preserve or reconstruct it deliberately. [41338277, 34782138]
Pitanguy ligament: the band from the dorsum to the tip, divided in most open dissections; repairing it or preserving it changes the supratip in the early months. [41998167]
Stony Brook Scar Evaluation Scale, Vancouver-Manchester scale: the scar rating instruments used in these trials. [34495754, 38698638]
Absorbable against non-absorbable suture: the columellar closure choice; two studies say it makes no difference to the scar. [34495754, 34516890]
Hybrid rhinoplasty: deliberately combining approaches or philosophies: open exposure with tip preservation, or closed access with structural grafting. [38483551, 40550487]

The papers this rests on

The 41 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

FPSAM
Columellar Scar Following Open Rhinoplasty Using Absorbable Suture Versus Nonabsorbable Suture: A Meta-Analysis
Kenny H, Jonas RH, Oyer S

2023PMID 34516890Summary
ASJ
Evolution of the Septal Extension Graft in Endonasal Rhinoplasty: Long-term Efficacy and Reliability
Harel M, Shir-Az O, Berl A et al.

2022PMID 35554489Summary
ASJ
Asian Rhinoplasty Using Exclusively Auricular Cartilage Through a Closed Approach
Gu Q, Fu Z, Li J et al.

2026PMID 41411306Summary
APS
Clinical Implications of Pitanguy Ligament Management for Nasal Tip Contouring in Open versus Closed Rhinoplasty
Boynuyogun E, Kilic T, Yildizdal S et al.

2026PMID 41998167Summary
APS
Combination of Paramedian Dorsal Component Excision and Low Septal Strip Septoplasty: A Hybrid Rhinoplasty Technique with Endonasal Approach
Çelik V, Parspancı A, Tuluy Y

2026PMID 40855022Summary
FPS
Closed Approach Rib Revision Rhinoplasty
Göde S, Berber V

2026PMID 42580758Summary
APS
Reply to: "Invited Discussion on: Video Assisted Septo-Rhinoplasty, the Future of Endonasal Rhinoplasty-a Technical Note"
Radulesco T, Ebode D, Michel J

2025PMID 38480658Summary
FPS
Advanced Preservation Technique for the Soft Tissue Envelope in Open Approach Rhinoplasty-Cephalic Lateral Crus, Scroll, Pitanguy Flap
Ben Ner D, Busel A, D'Souza A et al.

2025PMID 41338277Summary
FPS
Structural Rhinoplasty through the Endonasal Approach
Shah A, Nnabue OE

2025PMID 40262776Summary
FPS
Twelve Steps to Optimize Scar Outcomes in External Rhinoplasty
Soto-Galindo GA, Saghir M, Apaydin F

2025PMID 38698638Summary
APS
The TRICK-TIP Rhinoplasty: Tip of the Nose Preservation Using the Combined Synergy of Open and Closed Approaches
Villegas-Alzate F

2024PMID 38483551Summary
FPSAM
Patient-Reported Outcome Measures Including Nasal Breathing Improvement After Functional Rhinoplasty Using Endonasal Septal Extension Grafting
Goldfarb JM, Taylor CM, Barrera JE

2024PMID 38350156Summary
APS
Comparison of the Effects of Spreader Graft Versus Spreader Flap on Nasal Valve Angle in Open Approach Rhinoplasty
Koplay TG, Inan I, Ozer H

2023PMID 37640816Summary
APS
Invited Discussion on: Video-Assisted Septo-Rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note
Gryskiewicz J, Alameddine KO

2023PMID 37474821Summary
APS
Video-Assisted Septo-rhinoplasty, the Future of Endonasal Rhinoplasty-A Technical Note
Radulesco T, Medawar C, Michel J

2023PMID 37365307Summary
PRS
The Use of Endonasal Spreader Grafts in Preservation Rhinoplasty
Go BC, Frost AS, Friedman O

2023PMID 36730568Summary
PRS-GO
Outcomes of Open Versus Closed Rhinoplasty, a Systematic Review and Meta-analysis
Abi Zeid Daou C, Jalkh RM, Semaan ZM et al.

2025PMID 40771258Summary
FPSAM
Patient and Observer Graded Rhinoplasty Scar Outcomes: A Randomized Controlled Trial of Fast Absorbing Versus Permanent Columellar Suture Closure
Jonas RH, Patel KG, Rist TM et al.

2022PMID 34495754Summary
JAMA FPS
Columellar Incision Scars in Asian Patients Undergoing Open Rhinoplasty
Kim HC, Jang YJ

2016PMID 26822626Summary
PRS
The open approach in secondary rhinoplasty: choosing an incision regardless of prior placement
Unger JG, Roostaeian J, Cheng DH et al.

2013PMID 23676971Summary
ASJ
Electromyographic and electroneurographic changes in internal nasal muscles after endonasal and external rhinoplasty
Kirgezen T, Yigit O, Taskin U et al.

2011PMID 21385740Summary
JAMA FPS
Polydioxanone Absorbable Plate for Cartilaginous Grafting in Endonasal Rhinoplasty: A Randomized Clinical Trial
Dayan SH, Ashourian N

2016PMID 26501937Summary
PRS
Revisiting the role of columellar strut graft in primary open approach rhinoplasty
Bitik O, Uzun H, Kamburoğlu HO et al.

2015PMID 25811564Summary
JAMA FPS
Measured gain in projection with the extended columellar strut-tip graft in endonasal rhinoplasty
Carron MA, Zoumalan RA, Pastorek NJ

2013PMID 23450340Summary
JAMA FPS
Nasal tip recontouring in primary rhinoplasty: the endonasal complete release approach
Gassner HG, Mueller-Vogt U, Strutz J et al.

2013PMID 23165886Summary
ASJ
Dorsal augmentation with diced cartilage enclosed with temporal fascia in secondary endonasal rhinoplasty
Harel M, Margulis A

2013PMID 23855009Summary
APS
Fine-Tuning of the Supratip in Rhinoplasty: An External Approach
Kucukguven A, Konas E

2022PMID 36042029Summary
PRS-GO
Concurrent Excision of Dorsal Nasal Scars and Reduction Rhinoplasty: A Retrospective Cross-sectional Study
Omranifard M, Zare N, Mahabadi M

2021PMID 34745799Summary
FPS
Use of Tissue Expander for Contracted Scarred Saddle Deformity Rhinoplasty
Ostby E, Inman J, Ardeshirpour F

2019PMID 30566988Summary
FPS Clin
Preservation Rhinoplasty: The Endonasal Cottle Push-Down/Let-Down Approach
Friedman O, Ulloa FL, Kern EB

2021PMID 33220845Summary
FPS Clin
Preservation Rhinoplasty (Let-Down Technique) for Endonasal Dorsal Reduction
Montes-Bracchini JJ

2021PMID 33220844Summary
FPS
Endonasal FLI Approach for Rhinoplasty with Modified Cottle Low Strip Septoplasty
López-Ulloa F, Jasso-Ramírez E, Friedman O

2021PMID 33626586Summary
FPS Clin
Endonasal Secondary Rhinoplasty Techniques
Shomorony A, Friedman O

2026PMID 42091324Summary
FPS
In-office Endonasal Minor Revision Rhinoplasty
Auger SR, Shah AR

2022PMID 34544174Summary
FPS
Grafts in Endonasal Rhinoplasty
Lee DD, Katrib Z, Williams EF

2022PMID 34024040Summary
CPS
The Principles and Practice of Endonasal Rhinoplasty: Special Topics for Clinics in Plastic Surgery Journal
Rad AN, Bridges MA, Constantian MB

2022PMID 34782138Summary
CJO
External approach to rhinoplasty
Goodman WS

1973PMID 4791580
LARY
External approach to rhinoplasty
Goodman WS, Charbonneau PA

1974PMID 4612270
PRS
External approach for secondary rhinoplasty
Gunter JP, Rohrich RJ

1987PMID 3602167Abstract
PRS
Closed versus open rhinoplasty--and the debate goes on
Sheen JH

1997PMID 9047208
PRS
The merits of the open approach in rhinoplasty
Gunter JP

1997PMID 9047209

What is still contested

The comparative literature is 20 studies of moderate quality with no blinded endpoints and no sample-size calculations. The conclusion that the approaches are equivalent is only as strong as that. [40771258]
Almost nothing compares the approaches in the same hands on matched noses; surgeons who publish closed series are the ones who prefer closed. Preference and outcome are inseparable in this data.
Scar rates come from one large Asian series and two suture trials. There is no pooled scar rate across populations and skin types. [26822626]
The closed argument rests partly on avoiding contracture over years; the studies stop at twelve months. [41998167]
The endoscopic answer to the closed learning curve is described in technical notes, not measured against conventional closed or open surgery. [37365307, 38480658]
The 1997 exchange is the most cited moment in this argument and neither paper carries data, both are position pieces, and PubMed holds no abstract for either. [9047208, 9047209]