CLOSED RHINOPLASTY

An Interview with Dr. Burak Alhan and Dr. Metin Kerem About Closed Rhinoplasty Technique

WHAT’S CLOSED RHINOPLASTY?

Closed rhinoplasty is the procedure in which all the surgical incisions remain inside the nostrils and there are no incisions on the outside.

Why do patients prefer closed rhinoplasty? / Do patients or surgeons prefer closed rhinoplasty?

Surgeons generally prefer closed rhinoplasty because, there is no scar on the outer part of the nose and we do not have to remove the stitches, and in general, many structures of the nose are preserved, so there is less swelling and bruising.

In this case, why do plastic surgeons still use open rhinoplasty technique?

We can still prefer open rhinoplasty in revision cases, where we need to see the whole nasal area clearly. But in patients who will be operated for the first time, we prefer the closed rhinoplasty technique 99% of the time.

HOW IS CLOSED RHINOPLASTY PERFORMED?

First of all, the word ‘closed’ make it seem like the procedure is performed without the surgeon seeing the nasal bone structure, however, this is completely wrong.

The incisions are made inside the nostrils, on the inner border of the nostrils. We use the ‘delivery’ technique in our clinic. In other words, we push all the nasal cartilages outward and then perform the procedure after we feel that the nose structure is almost as visible as in open rhinoplasty technique.

In fact, since the incisions in closed rhinoplasty remain higher than in open rhinoplasty incisions, it gets even easier to access to the upper parts of the nose.

So why do patients want to be operated with closed technique as well?

Because the word ‘open’ itself sounds scary, in any kind of case. Therefore, most patients want to go with ‘closed’ option, rather than an open one. Nowadays, as patients are very conscious, they do their research and study their options and they also want to go for closed technique.

So, how I do carry out the after care post closed rhinoplasty surgery?

Actually, there is not much difference between open rhinoplasty and closed rhinoplasty aftercare wise. The patient has to pay attention to the same things. First of all, all patients who have had rhinoplasty should accept the fact that every nose swells and bruises after nose surgery. Some will be less and some will swell more, but there will definitely be some swelling and bruising.

At this point, it is necessary to keep the mental state positive in the early healing period.

Other than that, the first month following the surgery, the nose is very tender and sensitive to all kinds of external impacts, so it is very important to protect the nose especially in the acute process.

Due to Covid-19, we all wear masks. We should not let the mask press the nose very hard, the mask needs to be adjusted and kept loose. So, we don’t cause any pressure to the nose.

So, let’s say that the patient came to you and told; I went to this surgeon and he told me only closed technique fits my specific case, or only open technique first my case, so what are your comments about my specific case?

For patients who are going for primary rhinoplasty, there should not be any mandatory indication to perform a specific type of technique, in primary cases, we generally prefer closed rhinoplasty, not because it fits the patient better, but we feel more comfortable using closed technique. If there are no extreme situations, most procedures are carried out with closed technique.

Some surgeons feel better using open technique, some think they are better at closed technique. In fact, most of our experiences so far have been on open rhinoplasty, but at a certain point, we also have observed the difference in quality of the surgery results and during recovery period as well.

However, there is no such thing that all patients should definitely be operated with closed technique. Every surgeon should proceed the way he/she feels most comfortable with. If a surgeon can achieve what he has in mind easier with open technique, of course it should be preferred.

HOW LONG IS CLOSED RHINOPLASTY SURGERY?

Depending on the difficulty of the case, it usually takes 2.5 to 4 hours. Of course, there are other factors that affect this duration, in some cases it may be even shorter than 2.5 hours. For example, if it is a simple operation, it may take less (for example: tipplasty surgeries). But in patients who require more detailed work, or who have severe bone deviation, or who have had previous surgery, support should be provided via cartilages imported from other parts of the body, which extends the duration of the operation.

While the shortest surgery can take 20 minutes, the longest surgery can go up to 6 hours. For example, in northern European or Caucasian races, there is not much of a deformity on the nasal bone, in these type of cases, the surgery can be completed in a shorter time just by improving the tip of the nose.

So when was the last time you made a 20-minute intervention on a Turkish patient?

We had a patient in the past weeks, but it was a minor revision. As we have slightly more arched noses in the Turkish population in general, it is not less than 2 hours on average. In 90% of our Turkish patients, the operation takes between 2-3 hours.

So who is this surgery suitable for? Is there a criteria?

First of all, our patient must be over 18, this is our first rule. Our second rule is little about the mental state of the patient. Our expectations must be realistic. We do encounter this example a lot; the patient has an ideal face in his/her mind, and he/she believes that they can achieve those results by only working on the nose. These type of patients also think, when their noses change, their whole world, their whole lifestyle or perspective will change. Unfortunately, this is unrealistic and is a no go.

Some patients show us a photo of a world-famous top model and say I want such a nose, this is wrong, they actually want to have such a face, not just the nose. I have never seen wish picture of someone with ugly facial features but with a very beautiful nose. That is why our expectations must be realistic. We need to understand our needs well and what can be achieved.

On the one hand, another very challenging issue here is the patient saying that they do not want to change at all, but they want to change their nose… First, let’s be honest with ourselves. If we don’t want to change, why are we in a plastic surgery clinic? Of course, we do want to change, but we want this change to stay within the natural and reasonable limits. There is no harm in expressing this openly.

However, I generally ask these following questions, because there are patients who think they are ready for this surgery but they are actually not, that is why it is best to analyze patients needs prior to the surgery.

E.g;
Do you think your nose is ugly every time you look in the mirror?
Do you always try to take a photo from the your best angle?
Are you trying to appear in photos in the best way you can hide your mistakes?
If the answer to all of these questions is yes, you are probably an ideal rhinoplasty patient.

So what’s your answer to this question? ; I like the to take a selfie from this side, but I don’t like like it from the other side. Will this improve after surgery?

This is one of the questions we get asked a lot. No part of the human body is 100% symmetrical. So, it will never be 100% symmetrical after the operation as well. There will always be small millimetric differences and small asymmetries. Moreover, even if the nose is 100% symmetrical, if the base of the nose on which the nose is positioned is not symmetrical, you cannot see the nose symmetrically from both sides. Whether this is a breast augmentation surgery or liposuction, trying to achieve that perfect symmetry can lead us to disappointment. Of course, this does not mean the difference will be immensely visible, but it is important to be realistic and accept the fact that asmmetry to some extent is possible.

So, which surgeries are generally combined with rhinoplasty? Especially for patients who insist on achieving symmetry?

Patients who insist on achieving a perfect symmetry generally are not really our type of patients.

However, I strongly agree that the nose should be in harmony with other units of the face, for example, a chin implant surgery is generally combined with rhinoplasty in order to enhance the overall projection&definition of face.

There are also some patients where we perform a total facial change, of course, this does not mean the face is changed to something completely different. In these type of surgeries, we plan to make the cheeks, chin, jawline, neck, eyebrows more attractive and create a balance for overall face and to proportionize the face equally, because beauty comes with balance between all facial features. These kinds of surgeries are the ones that excite us the most, because in these cases, the nose is actually only a small part of this combination. When the change in total is performed on units adjacent to the other, it becomes incredibly striking.

Our happiest patients are those whom we perform combined procedures on, because the operation area is approached from a holistic perspective. You can have a nose surgery in thousands of different clinics, but the difference of a plastic surgery is its holistic approach…The most important thing here is not only to see the change in the nose, but also to question how can we improve the face as a whole and take action accordingly.

In this case, how long does the surgery take with these combined procedures?

It can take up to 7-8 hours, depending on what will be performed. Of course, we try to be as fast as possible, but in surgery, time concerns us less, we don’t check it very often. What concerns us most are the answers to the questions such as; whether we raise the tip of the nose a little more or if the right breast is higher than the left …

Of course, we are having a good time during this because we love what we do.

After so many procedures, when do patients return to their daily lives?

The patient spends that night in the hospital. Cold press ice is applied after surgery. We discharge our patient the next day. Then, on the third post op day of the surgery, we take silicone tampons out, which are usually used in every nose surgery. And if we made changes on the nasal bone, we also use a plaster cast which is removed on the 7th post op date. We do tapings to control the swelling for about one more week after removing the cast. After the cast is removed, the patients can return to their daily lives.

Are there any stitches to be removed?

There are no stitches that needs to be removed in closed nose surgery.

So one last question, does the tip drop after rhinoplasty?

Rhinoplasty surgery is probably one of the most evolving type of surgery in the history of plastic surgery. Earlier, in the first closed cases, the surgery was performed with the Josephine technique, the nose wings were lifted up and the tip of the nose remained relatively low because the septum was not worked on much. Of course, in the early healing period, it was not very visible as the nose looked upright as it was swelled, but after 6 months to 1 year and once all the edema dissolved, the tip of the nose looked lower than where it is supposed to be. But of course, in today’s techniques this is not even an issue.

On the other hand, the droopiness of the tip can also be caused by the loss of support. But, there is no problem if the nose is supported with certain techniques and cartilages.

To sum up, a nose that can function well and look natural is what we call success in our clinic!

So when do the stitches inside dissolve?

There are 3 different types of stitches inside. The stitches that form the cartilages of the nose, which dissolve in a long time, are out of reach. It takes about 3-4 months for these to dissolve. There are also two types of stitches that remain inside the nose on the walls of the nasal airway. Some of them dissolve in 10 days, some of them in about 1 month. Since these stitches are located very deep, patients do not notice them.

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