Open versus closed rhinoplasty
Open rhinoplasty adds one small incision across the columella, the strip of skin between the nostrils, so the skin can be lifted off and the whole framework seen. Closed rhinoplasty does the same operations through incisions inside the nose, working partly by feel. It was the defining argument of late twentieth-century rhinoplasty, and in 2025 it was pooled across twenty studies and 1,067 patients: no significant difference in appearance, breathing, complications or swelling.
What the choice actually changes
Four things that are different, and one that is not.
It changes what the surgeon can see, not what the patient gets
Twelve studies with poolable data, 539 open and 528 closed patients: no significant difference in appearance scores, breathing scores, swelling, bruising, complications or operating time. The approach is a decision about the surgeon's access. The result belongs to what was done inside.
Rests on: Abi Zeid Daou et al., systematic review and meta-analysis · and open versus closed in the literature.
The scar exists, and it is small
In 529 Asian patients, a group where scarring is a real concern, 6.0% had a problematic columellar scar at six months or more: 1.7% wide or depressed, 1.3% notched, 1.7% hyperpigmented, 0.4% with skin necrosis. A randomised trial and a meta-analysis both found the type of suture makes no difference to how it looks. Where a nose has been opened before, the old scar can be ignored and a new incision placed wherever the plan needs it, without necrosis or breakdown.
Rests on: Kim and Jang, 529 patients · Jonas et al., randomised suture trial · Kenny et al., suture meta-analysis.
The early months differ; the year does not
Comparing three groups of 40 (open without ligament repair, open with repair, closed with ligament preservation), the supratip depth, tip swelling, projection and rotation all differed early and none differed at twelve months. Open dissection produces more early swelling because more tissue is lifted; that resolves. Muscle function measured electrically fell after both approaches, with no significant difference between them.
Rests on: Boynuyogun et al., three groups of 40 · Kirgezen et al., nasal muscle function after both.
The real difference is which problems each approach makes easy
Open is chosen where the anatomy must be diagnosed under vision: a revision, a crooked nose, a cleft nose, major grafting with rib, or teaching. Closed is chosen where the tip work is limited, where the surgeon wants to disturb as little support as possible, and where the patient wants no external incision. Both camps now do the other camp's operations: structural endonasal rhinoplasty places spreader grafts, struts and extension grafts through the nostrils, and open surgeons publish techniques to preserve the ligaments they used to divide.
Rests on: Gunter and Rohrich, the external approach in secondary cases · Shah and Nnabue, structural endonasal rhinoplasty · Ben Ner et al., preserving the envelope in the open approach.
How the argument was settled, and by whom
The chain from 1934 to the meta-analysis, in dates that can be checked. The full history is on the history of rhinoplasty.
Before it was American
Réthi described opening the nose through a columellar incision in 1934; Šercer used the approach in Zagreb and his pupil Ivo Padovan presented his own series in the early 1970s; Wilfred Goodman of Toronto published it in 1973 and 1974. For four decades it was a facial plastic surgery technique that plastic surgery largely did not use.
Rests on: Goodman, external approach to rhinoplasty · Goodman and Charbonneau, 1974.
1987, when it crossed over
Gunter and Rohrich published the external approach for secondary rhinoplasty in Plastic and Reconstructive Surgery: over 100 cases, no problems with the stairstep transcolumellar incision, and the argument that seeing the framework gives an accurate intraoperative diagnosis. Applied first to revision, where visibility matters most.
Rests on: Gunter and Rohrich, 1987 · Jack Gunter.
1997, printed back to back
Plastic and Reconstructive Surgery ran Sheen's "Closed versus open rhinoplasty — and the debate goes on" opposite Gunter's "The merits of the open approach in rhinoplasty". Sheen's case: dissection costs support, and the nose contracts around whatever the surgeon disturbs. Gunter's: you cannot reliably correct what you cannot see. Neither paper carries an abstract in PubMed, and neither carries data — they are position pieces, and they framed the next thirty years.
Rests on: Sheen, 1997 · Gunter, 1997 · Jack Sheen.
2025, the pooled answer
Twenty studies, moderate quality, 1,067 patients, no significant difference on any measured outcome. Both approaches work; the argument was about how surgeons learn and control the operation, not about what the nose looks like a year later.
Rests on: Abi Zeid Daou et al..
What to ask your surgeon
Practical questions the evidence supports asking.
Which approach do you use, and why for my nose?
The answer that matches the literature is a reason drawn from the anatomy (a revision, a crooked nose, extensive grafting, or conversely a limited tip change in an unoperated nose) rather than a general preference.
What will the scar look like?
About one patient in sixteen has a scar worth noticing at six months in the largest series, and the reported problems are a widened, notched or darker line rather than anything conspicuous. Suture type does not change it.
Rests on: Kim and Jang.
Will it change how long I take to recover?
Early swelling is greater after open dissection and equal by a year. What the approach does not change is the twelve-month timetable of a nose settling. That is on recovery.
Does it change the price?
Operating time did not differ significantly between approaches in the pooled data, so the honest answer is that the approach is not what makes one quote higher than another. See what rhinoplasty costs.
The terms, defined
The words used to describe the two approaches.
- Open (external) approach: marginal incisions inside the nostrils joined by a small incision across the columella; the skin envelope is lifted and the framework seen directly. [3602167]
- Closed (endonasal) approach: the same operations through incisions inside the nostrils only, with no external incision. [40262776]
- Transcolumellar incision: the external part of the open approach, usually a stairstep or inverted-V at the narrowest part of the columella. [3602167, 26822626]
- Delivery and non-delivery: closed techniques: delivery lifts the lower lateral cartilage out through the nostril to work on it; non-delivery works on it in place.
- Marginal incision: the incision along the lower edge of the lower lateral cartilage, used in both approaches.
- Soft-tissue envelope: the skin, fat, muscle and ligaments over the framework; how much of it is lifted is the real difference between the approaches. [41338277]
- Structural endonasal rhinoplasty: grafting and suture techniques performed closed, the answer to the claim that closed surgery cannot build. [40262776]
- Video-assisted (endoscopic) rhinoplasty: endoscope-assisted closed surgery, which gives a trainee the view the open approach gives without the incision. [37365307]
Where else this is documented
Sources outside the journals, each one free to read.
The national guideline
The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and document, whichever approach is used.
Rests on: the clinical practice guideline · the plain language summary.
The surgeons' own textbook chapters
Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on both approaches and on the argument between them. They are written for surgeons and go further into technique than a patient page should.
The reference summary
Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, sets out both approaches, their incisions and their complication lists in free full text.
The societies
- American Society of Plastic Surgeons, patient information.
- American Academy of Facial Plastic and Reconstructive Surgery, patient information.
- The Rhinoplasty Society, the surgeons' body, with its member directory. See associations.
What is not settled
- The comparative literature is twenty studies of moderate quality, without blinded endpoint assessment or sample-size calculations. "No difference" is only as strong as that. [40771258]
- Nobody has compared the approaches in the same hands on matched noses; surgeons who publish closed series are the ones who prefer closed.
- Scar rates come from one large Asian series and two suture trials; there is no pooled rate across skin types.
- The closed argument rests partly on contracture over years, and the studies stop at twelve months. [41998167]
- The 1997 exchange that framed the argument contains no data at all. [9047208, 9047209]
Written by rhinoplasty.cc from the sources linked above, 2026-09-09.
Who publishes on open versus closed approach
Ranked surgeons with papers under this topic in the archive, most first.
Rod J. Rohrich (3) · Anil Shah (2) · Edwin F. Williams (2) · Michael Lee (2) · Samuel Oyer (2) · Jacob Unger (1) · James Zins (1) · Jason Roostaeian (1) · Joe Gryskiewicz (1) · Jose Barrera (1)
The literature: Open versus closed approach, 57 papers. Video: Open versus closed, 171 videos. Every technique.