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Open Rhinoplasty VS. Closed Rhinoplasty Approaches

INTRODUCTION

Dr. Sam Rizk is a New York City surgeon and world renowned rhinoplasty expert who teaches his techniques in the USA and many countries. Dr. Sam Rizk is a subspecialist in the nose as well as revision rhinoplasty. Dr. Sam Rizk does not perform body or breast plastic surgery.  He presents on many rhinoplasty topics at the American Academy of Facial Plastic Surgeons' annual conferences and is a distinguished lecturer at the “Royal College of Physicians’” yearly cosmetic surgery conference in London and a repeat lecturer at many facial plastic surgery conferences worldwide.

Dr. Sam Rizk is director of Park Avenue Facial Surgery and Park Avenue Facial Surgery Center located on Park Avenue in Manhattan's Upper East Side. He is one of only a few double board certified facial plastic surgeons who specialize revision rhinoplasty. Patients from around the US and globe seek his plastic surgery expertise either from local states like New Jersey, Connecticut, Pennsylvania, or from many far away states like California, as well as many countries in Europe, South America, Asia and the Middle East.  He has a list of celebrities, royalties, entertainers whom he has treated but also treats many regular people in search of nasal beauty.

To Dr. Sam Rizk, his surgical procedures are a work of passion and artistry, as you will understand quickly when you meet him – it’s not just a plastic surgery. Dr. Sam Rizk believes that Rhinoplasty is one of the most influential operations which can significantly beautify a person if done with expertise and artistry.  This is why many patients fly from out of town to Dr. Rizk’s ultra modern Park Avenue Facility in New York City to undergo, secondary or revision rhinoplasty by an artist and a surgeon.  Some of his specialized techniques and innovations have been published in scientific plastic surgery journals including Archives of Facial plastic surgery, Annals of Plastic Surgery, Plastic and Reconstructive Surgery Journal as well as Otolaryngology-Head and Neck surgery Journal and Plastic Surgery Practice Journal.  Some of these include 3d high definition approaches for a more precise view of the internal structures of the nose and also new ways of sculpting cartilage grafts and implants to achieve smoother and natural contours.  Grafts and implants are a necessary component of the surgical approaches especially in ethnic and revision rhinoplasty and sculpturing is very important for Dr. Sam Rizk’s approach in order to avoid sharp edges from scalpel sculpturing typically used by surgeons.  Dr. Sam Rizk's novel approach involves rotating sanding powered micro-instruments to sculpt cartilages and implants into smooth edges.

Open (external) versus closed (endonasal) rhinoplasty

De-mystifying this discussion - Dr. Sam Rizk, a New York plastic surgeon and director of Park Avenue Facial Surgery and Attending Facial Plastic Surgeon at Manhattan Eye, Ear and Throat Hospital, describes various rhinoplasty approaches which will clarify the topic.

According to Dr. Sam Rizk, a NYC nose job surgeon, the endonasal rhinoplasty is another way of describing the closed rhinoplasty, meaning that all incisions are internal, except if a nostril reduction is being performed as well. The endonasal or closed approach does not involve the incision across the columella (middle piece of skin separating the right and left nostrils). Traditionally, the open rhinoplasty approach refers to a nose surgery where a small incision is made at the columella (the piece of skin separating the right and left nostrils).

Older trained surgeons tend to only use the endonasal or closed rhinoplasty approach.  More modern surgeons tend to use the open approach.  Dr. Sam Rizk customizes the approach to the patient and may use either the open or the closed approaches or a combination of both.

Dr. Sam Rizk utilizes not only the endonasal or closed rhinoplasty and the open rhinoplasty approaches, but has pioneered a newer combined open/closed approach where the bridge is addressed internally and the tip is approached through a partial open approach to place and suture cartilage grafts without the typical lifting of the skin of the tip up to see the bridge. This combined approach by Dr. Sam Rizk allows more precision in bridge and bump removal internally by use of high definition telescopes and more precision with graft fixation with sutures in the nasal tip for a more precise result. Dr. Sam Rizk, a New York cosmetic surgeon and USA rhinoplasty expert, customizes the approach and is versatile in using these different approaches to achieve the best result for the patient's specific condition, based on skin thickness, tip support, need for cartilage grafts, etc.

Dr. Sam Rizk does not believe the surgeon should limit the patient's choices of only open or only closed based on the surgeon's abilities or training because there are advantages to both the open and closed approaches depending on specific problems and anatomy in the nose and whether it is a primary or revision surgery.

Dr. Sam Rizk will select the endonasal endoscopic or closed approach for the following conditions of the nose:

  1. If the patient requests are mainly bridge work or a bump and bridge width with little or no tip work
  2. If patient has bridge or bump work and would like some tip work as well but and the tip is symmetrical
  3. If patient requests lifting of the nasal tip in a long nose situation
  4. If the patient’s skin is not too thick and not too much tip work is required
  5. In revision surgical procedure with external nasal valve collapse mainly or a pinched tip with good tip support

Dr. Sam Rizk will select the open rhinoplasty approach or external rhinoplasty approach if the following conditions of the nose exist:

  1. The patient’s skin is very thick and the tip cartilages are weak as in ethnic rhinoplasty
  2. There is significant asymmetry of the nasal tip cartilages
  3. In revision or secondary rhinoplasty where there is poor tip support and significant asymmetries
  4. In rhinoplasty patients which require significant dorsal implants or nasal tip grafts

Grafts may be placed through the endonasal as well as the open approaches, but are only secured and sutured through the open approaches.  With the closed approach, smaller pockets are made so grafts do not have a chance to move but are not tied down with the closed approach so there is still a chance of movement of grafts with the closed approach.

Philosophy and Future Direction of rhinoplasty advances in both open and closed rhinoplasty

Dr. Sam Rizk emphasizes that it’s not only the approach that matters in achieving a natural and beautiful nose, but more importantly the philosophy of the surgeon.  According to Dr. Sam Rizk, a surgeon, older aggressive rhinoplasty techniques involving excessive removal of cartilage frequently resulted in scooped and pinched noses without tip support and compromised the patient’s breathing from loss of functional support.  Dr. Sam Rizk’s philosophy emphasizes newer tip-shaping approaches and techniques which use endonasal or open suture shaping technology to reshape cartilages and excise less cartilage.  This philosophy creates changes in the nose while respecting the major and minor tip support structures in the nose.  This philosophy has sometimes been called “cartilage preservation” where less cartilage is removed and cartilage grafts are used to support various areas of the nose to provide structural support with the suture-modification to reshape cartilage.  Grafting techniques are used in conjunction with suture-reshaping techniques to create tip and dorsal bridge definition and has advanced the face lift field.  Dr. Sam Rizk being at the forefront of rhinoplasty surgery in New York, United States, and the World, has further added a new dimension to rhinoplasty by pioneering visualizing the inside of the nose with 3d high definition telescopes to achieve a more precise operation. Dr. Sam Rizk also has also advanced the concept of cartilage sculpting, instead of using the regular surgical knife, with a rotating sanding micro-surgical tool.  All these advances allow more precision, a preserving or creating a natural profile and front view of the nose in harmony with the face, while avoiding the pinched sharped edges of older cartilage grafts.

Dr. Sam Rizk feels that cartilage grafts sculpted into a smooth graft by Dr. Rizk’s new methods and micro instruments and cartilage suturing techniques provide a reliable alternative for tip narrowing and modification.  Tip Cartilage suturing techniques can modify the convexity of cartilages, narrow the dome region or bring the domes closer together.  Suture techniques can also change the relationship of the columella and caudal septum to the nasal tip, thereby shortening the nose or lifting a drooping nasal tip. Dr. Sam Rizk, NYC board certified facial plastic surgeon, further states that nasal tip projection can also be modified by suture techniques and deprojection also can be done with suture techniques using specialized septo-columellar horizontal mattress sutures.  These modifications are made using the existing tip anatomy and do not weaken but may actually strengthen the tip support structures.  If the nasal tip is very broad, either a single or double dome tip sutures may be used.  Tip dome suturing can also be used to correct a bulbous nasal tip, correct or narrow the boxy tip, efface bifidity, medialize divergent intermediate crura, provide strength to soft weak tip cartilages, increase tip support or projection and correct some asymmetries.  The strength and pliability of the cartilages affects its ability to change with suture techniques.  If not enough definition is created by tip suture techniques, the cartilage graft techniques can then be used.  Dr. Sam Rizk also believes it is important to remove a fibrofatty tissue between the domes to allow greater approximation of the domes with the tip suturing techniques.  It is exceedingly important to recognize that Dr. Sam Rizk is trained equally with open and endonasal rhinoplasty approaches and will select the best approach for your nose to achieve the ideal natural outcome, without any surgeon bias as to which approach he feels more comfortable with.