It seems that virtually any modern day patient can be a very well informed rhinoplasty patient within a matter of hours. Despite this, there is still a shortage of information with regard to rhinoplasty and the various approaches rhinoplasty surgeons use to improve a patient’s cosmesis. Little distinction and attention is given to fact that there are two main ways in which surgery can be performed, and this very lack of information can easily lead a future rhinoplasty patient into having a more traumatic and unnecessary surgery if she doesn’t do enough homework.

Dr. Raj Kanodia in Beverly Hills, California has been performing closed rhinoplasty, in his practice for the past 31 years, and worries that soon, it is going to become extinct. “Closed rhinoplasty”, commonly referred to as “finesse” rhinoplasty, is a unique surgery whereby corrections and enhancements of the nose are made internally through the nostrils, avoid the need to inflict a scar at the bottom of the nose. Enhancing and beautifying the nose without visible scarring is the premise upon which Dr. Kanodia practices rhinoplasty surgery. Closed rhinoplasty surgery is also ideal for the majority of patients having cosmetic nasal surgery for the first time since there is much decreased post operative swelling, bruising, and pain. Most patients recover very quickly, which is important, because statistically speaking these patients are young, energetic, and very social. This enables them to perform activities of daily living usually on post operative day two, and return to social events by day seven. Upon removal of the cast, most patients don’t show evidence of having had surgery and this accommodates the needs for busy patients who need to return to work, school, and can’t take extended time away from their responsibilities. Scarless surgery coupled with decreased healing times, are a few of the many advantages of having closed nasal surgery.

In general, most rhinoplasty surgeons offer open approaches to their patients. Very few surgeons perform only “closed rhinoplasty” but the overall benefits of scarless surgery overshadow the risks of any other approach and Dr. Kanodia wishes more women knew this before having surgery. The learning curve for closed rhinoplasty is invariably higher than it is for the open technique and fewer surgeons are being taught how to do it. Which is unfortunate since the majority of patients having surgery are ideal candidates for closed surgery but don’t realize that this is even an option. Most requests made by patients can be addressed using the closed technique but since a growing number of American plastic surgeons haven’t been trained to perform it, most patients aren’t offered the choice. The declining number of practicing surgeons and the trend towards more “academic” medicine is making the closed approach a less well known procedure. Still, the number of patients having closed surgery persists in Dr. Kanodia’s practice, he performs up to 300 surgeries per year, more than triple the amount averaged by most plastic surgeons. But this doesn’t mean that there isn’t a huge discrepancy between the women actually having closed surgery and the women who should be having closed surgery. If a surgeon plans to unnecessarily inflict a scar on the face, the patient should be told that she has a less invasive alternative. Dr. Kanodia understands that most educated patients, given the option, would unequivocally choose the closed approach one hundred percent of the time. If given the opportunity, most women would not accept scarring, prolonged swelling, and bruising if they were told other options were available.

Nonetheless, over the past two decades, a paradigm shift has occurred, such that rhinoplasty surgery is now more commonly performed using the “open” technique. This approach allows for a more comprehensive view of the nose and is ideal for the purposes of training in teaching hospitals. It originated from the need, by surgeons, to expose the entire nasal structure during difficult revision rhinoplasty where abundant exposure was necessary to complete surgery. Severely difficult noses that were traumatized, deformed, or obstructed weren’t amenable to closed techniques and an incision on the outside of the skin was created to facilitate surgery. Soon thereafter, the approach became more popular in the 1980’s, and more surgeons opted to use this technique on simple, straight forward cosmetic cases as well. Now, numerous patients suffer from having had open surgery needlessly and Dr. Kanodia regrets this. He suggests that open rhinoplasty compels surgeons to perform grafting and structural changes beyond what are cosmetically necessary. These changes often alter the character of the patient’s face and leave a permanent scar. The motivation to create the “perfect” nose skews a surgeon’s judgement, whereby alterations are made that don’t suit the patient’s face.

Physicians in training and students still benefit enormously from viewing open rhinoplasty surgery and it is an essential part of rhinoplasty training. The major drawback to open rhinoplasty surgery is the external incision that is made just under the tip of the nose. The rhinoplasty surgeon uses this incision to gain access to the framework of the nose and alterations are made accordingly. But external incisions on the nasal skin, in his opinion, inherently defeat the purpose of performing aesthetic surgery. A patient shouldn’t have to sacrifice aesthetics for the elective use of an incision that causes noticeable scarring. But Dr. Kanodia realizes that patients, even the most informed ones, don’t understand the ramifications of open surgery. These days, external incisions have gained acceptance within mainstream cosmetic surgery and patients don’t know that superior alternatives exists. There are many plastic surgeons that have never even witnessed closed rhinoplasty surgery, and Dr. Kanodia wonders if they wouldn’t perform it if given the proper training.

The positive aspects of closed rhinoplasty far outweigh the risks when compared to the open approach, yet eighty percent of American plastic surgeons choose not to perform it. This translates into more women unknowingly and unnecessarily having invasive plastic surgery. If more information was made available to patients contemplating surgery, the reality is that most would choose to have closed rhinoplasty, but would their surgeon be able to accommodate them?