Outcomes of Open Versus Closed Rhinoplasty, a Systematic Review and Meta-analysis

Abstract

Background:

Despite advancements in techniques, the choice between open and closed rhinoplasty remains contentious. This decision is influenced by patient-specific factors, deformity complexity, and surgeon expertise, with outcomes often tied to functional and aesthetic results.

Methods:

A systematic literature search was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Databases searched included Medline, PubMed, Embase, and Cochrane. Abstracts and full-text articles were screened, and reference lists from relevant articles were reviewed to identify additional studies. Two investigators independently performed the review. Studies comparing open and closed rhinoplasty techniques, encompassing randomized controlled trials, prospective studies, and retrospective studies, were included. The target population comprised adults (≥18 y) undergoing rhinoplasty. Key parameters analyzed were changes in Rhinoplasty Outcome Evaluation (ROE) score, Nasal Obstruction Symptom Evaluation (NOSE) score, edema, ecchymosis, complications, and operative time.

Results:

Twenty studies were included, with 12 providing data for meta-analysis (1067 patients: 539 open rhinoplasty and 528 closed rhinoplasty). Study quality was moderate, with limitations such as the absence of sample size calculations and biased endpoint assessments. No significant differences were identified between the approaches in ROE scores (standardized mean difference = −0.16), NOSE scores (standardized mean difference = 0.21), edema, ecchymosis, operative time, satisfaction, or complication rates. Heterogeneity was observed in the ROE (I² = 99%) and NOSE (I² = 86%) analyses, reflecting technique and patient variability.

Conclusions:

Open and closed rhinoplasty techniques show similar efficacy. The choice should be tailored to patient needs and surgeon expertise. Continued innovation and standardized research are essential to optimize outcomes.

Takeaways

Question: Does open or closed rhinoplasty result in superior functional and aesthetic outcomes?

Findings: This systematic review and meta-analysis found no significant differences between open and closed rhinoplasty in Rhinoplasty Outcome Evaluation scores, Nasal Obstruction Symptom Evaluation scores, edema, ecchymosis, operative time, satisfaction, or complication rates.

Meaning: Open and closed rhinoplasty yield comparable functional and aesthetic outcomes, suggesting that the surgical approach should be based on surgeon preference and case-specific considerations.

INTRODUCTION

Rhinoplasty is widely regarded as one of the most technically demanding procedures in plastic surgery.¹ Functional rhinoplasty addresses issues such as nasal valve collapse, deviated septum, or airway obstruction, aiming to improve breathing. Aesthetic rhinoplasty, on the other hand, enhances facial harmony by reshaping the nasal tip, correcting asymmetry, or reducing dorsal humps. Increasingly, patients seek a combination of these goals for comprehensive outcomes.^2,3

Evaluating rhinoplasty outcomes can be challenging due to the subjective nature of aesthetic improvements. Standardized tools such as the Nasal Obstruction Symptom Evaluation (NOSE) scale and the Rhinoplasty Outcome Evaluation (ROE) questionnaire provide objective measures for both functional and aesthetic results.^4,5 These tools are critical for comparing outcomes among surgical techniques.

Two primary approaches to rhinoplasty (open and closed) are widely used. The open technique allows direct visualization of nasal structures, offering greater control in complex cases. However, this approach may result in increased scarring and longer recovery times.^1,6 In contrast, the closed technique avoids external incisions, leading to less visible scarring and shorter recovery periods, but its limited access can be challenging.

Despite surgical advancements, the debate over the superiority of open versus closed rhinoplasty remains unresolved. The choice often hinges on patient-specific factors and the surgeon’s expertise. Some studies suggest that patient satisfaction and postoperative quality of life are influenced by functional and aesthetic outcomes rather than the surgical approach alone.^7,8 This systematic review and meta-analysis aimed to provide a comprehensive comparison of open and closed rhinoplasty techniques, focusing on their respective outcomes and implications for patient care.

MATERIALS AND METHODS

Literature Search Strategy

The literature search followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and used Medline, PubMed, Embase, and Cochrane databases. The search terms included rhinoplasty, open rhinoplasty, closed rhinoplasty, treatment outcomes, patient satisfaction, and postoperative complications, among others (Table 1). The databases were searched up to November 2024. Studies with available abstracts or full-text articles were screened, and the reference lists of relevant articles were reviewed to identify additional studies meeting the inclusion criteria. Two investigators (C.A.Z.D. and R.M.J.) independently performed the systematic review. In accordance with PRISMA, the process involved removing duplicates, reviewing titles and abstracts, and performing a full article review for studies meeting the inclusion criteria. (See appendix, Supplemental Digital Content 1, which displays PRISMA 2020 flow chart, https://links.lww.com/PRSGO/E260.)

Table 1.

Search Terms and Results

No.	Query	Results from November 6, 2024
1	rhinoplasty.mp. or exp rhinoplasty/	13,370
2	plastic surgery procedures/ or dermatologic surgical procedures/ or rhinoplasty/	79,870
3	open rhinoplasty.mp.	542
4	closed rhinoplasty.mp. or endonasal rhinoplasty.m.p.	175
5	1 or 2 or 3 or 4	81,489
6	treatment outcome.mp. or exp treatment outcome/	1,333,377
7	patient satisfaction.mp. or exp patient satisfaction/	132,368
8	postoperative complications/ or pain, postoperative/ or postoperative cognitive complications/ or postoperative hemorrhage/ or “postoperative nausea and vomiting”/ or shock, surgical/ or surgical wound dehiscence/ or surgical wound infection/	514,995
9	adverse events.mp.	230,449
10	6 or 7 or 8 or 9	1,999,766
11	5 and 10	28,857

Ovid MEDLINE: Epub ahead of print and in-process, in-data-review, and other nonindexed citations (November 5, 2024).

Inclusion and Exclusion Criteria

There were no restrictions on language or publication date; however, the full text of the studies needed to be accessible. The review included studies focusing on open versus closed rhinoplasty techniques and encompassed randomized controlled trials, prospective studies, and retrospective studies. The target population consisted of adults (18 y or older) undergoing rhinoplasty procedures.

Exclusion criteria included duplicate entries, incomplete studies, studies with unavailable data, animal experiments, narrative reviews, systematic reviews, and studies exploring unrelated treatment modalities. Additionally, studies that did not compare the 2 approaches or lacked postoperative outcome measures were excluded.

Data Extraction

Data extraction was carried out by 2 authors for all studies meeting the inclusion criteria (Table 2). The extracted information included the study author, year of publication, number of patients, and age and sex distribution. Additional details collected encompassed patient demographics, preoperative evaluations, type of surgery performed, augmentation material used (if any), follow-up duration, postoperative assessments, operating time, and reported complications. Given the impact of ethnic background on nasal anatomy and aesthetic preferences in rhinoplasty, we attempted to classify the ethnicity of the study populations included in this meta-analysis. However, many studies did not provide ethnic or racial data. In such cases, we inferred the likely predominant ethnicity based on the geographic location of the treating institution, recognizing that this approach may not accurately reflect the actual patient demographics. Five parameters were chosen as endpoints for the systematic review and meta-analysis: mean change in ROE and NOSE scores, mean change in edema and ecchymosis, and mean operative time. Secondary outcomes included data on patient satisfaction and complication rates.

Table 2.

Characteristics of the Studies and Study Populations Included in the Systematic Review

Author	Date	Age, y	% F	N	N (o)	N (c)	Secondary Versus Primary	Follow-up	Study Design	Augmentation	Ethnicity
Talmadge et al2	2018	40–42	34	50	21	29	Primary	>1 y	Retrospective cohort	SC, CC, or rib	American (NE)
Saleh et al3	2012	18–91 (M = 47.56 ± 17.27)	48.67	113	55	58	Both	35.6 mo	Retrospective chart review	SC, CC, or rib	American (MN)
Metin and Avcu6	2021	>18	71.4	370	217	153	Both	12 mo	Retrospective cohort	SC	Turkish (WA)
Gökçe Kütük and Arikan7	2019	27.4 ± 6.5	64.4	90	45	45	Both	1, 3, 6 mo	Outcomes research	NR	Turkish (WA)
Uppal et al8	2020	22–38 (M = 28.55)	89.2	65	15	50	Primary	9 mo	Retrospective review	SC or other site if needed	White/European (United Kingdom)
Baz et al9	2024	19–46 (M = 29.48 ± 6.74)	64	50	25	25	Both	6 mo	Randomized comparative	NR	MENA (Egyptian)
Hellings and Trenité10	2007	19–69	65.2	46	23	23	Secondary	2.5 y	Prospective cohort	SC, CC, or rib	White/European (Dutch)
Taş and Erden11	2021	27.51 ± 7.49	70	50	24	26	Primary	>6 mo	Prospective comparative	SC	Turkish (WA)
Kiliç et al12	2015	18–44 (M = 28.6 ± 7.93)	57.5	120	60	60	Primary	2, 7 d	Retrospective cohort	NR	Turkish (WA)
Sakallioğlu et al13	2015	20–36 (M = 28 ± 8)	44	50	25	25	Primary	1, 3, 7 d	Prospective cohort	NR	Turkish (WA)
Gruber et al14	2006	18–55	72	25	21	4	Primary	11–19 mo	Retrospective cohort	NR	American (San Francisco)
Altunal et al15	2024	18–40	79	62	32	30	Primary	>1 y	Randomized control trial	SC	Turkish (WA)
Paul et al16	2018	36.9 ± 18.4	52.6	38	8	30	Both	>4 wk	Retrospective review	SC	American (Boston)
Jaberoo et al17	2016	15–67 (M = 30.5)	52.3	65	15	50	Primary	6–37 mo	Retrospective cohort	SC or none	White/European (United Kingdom)
Okur et al18	2016	18–35	70	30	15	15	Primary	NR	Prospective cohort	NR	Turkish (WA)
Kirgezenet al19	2011	18–40	39.6	48	30	18	Primary	7 ± 1.2 mo	Prospective cohort	NR	Turkish (WA)
Ozmen et al20	2008	17–63 (M = 28.34)	63.3	180	160	20	Primary	2–38 mo	Case series	None	Turkish (WA)
Constantian21	2000	14–68	66	100	36	64	Secondary	>12 mo	Retrospective chart review	SC, CC, or rib	American (New Hampshire)
Braizat et al22	2023	29.6 ± 8.1	59.7	77	38	39	Both	>1 y	Retrospective cohort	NR	Middle Eastern (Qatar)
Park et al23	2024	42.3 ± 14.3	52.2	249	143	106	Both	NR	Retrospective review	SC, CC	American (IN)

% F, percentage of population being women; CC, conchal cartilage; M, mean; MENA, Middle Eastern/North African; N, total number of patients; N (c), number of patients undergoing closed rhinoplasty; N (o), number of patients undergoing open rhinoplasty; NR, not reported; SC, septal cartilage; WA, West Asian.

Quality Assessment

The risk of bias was evaluated using the methodological index for nonrandomized studies (MINORS) criteria, as outlined in Table 3. Two independent investigators assessed each article, assigning scores based on a maximum of 24 points. The final score for each study was calculated as the average of the total scores assigned by both investigators.

Table 3.

Quality Assessment of the Studies Included in the Meta-analysis

	Baz et al9	Metin and Avcu6	Taş and Erden11	Gökçe Kütük and Arikan7	Paul et al16	Talmadge et al2	Jaberoo et al17	Kiliç et al12	Sakallioğlu et al13	Saleh et al3	Gruber et al14	Hellings and Trenité10
Clearly stated aim	1	2	2	2	2	2	2	2	2	2	1	2
Consecutive patients included	1	2	1	1	2	2	1	2	2	2	0	0
Prospective data collection	2	2	2	2	2	2	2	2	2	2	2	2
Endpoints appropriate to the aim of the study	2	2	2	2	2	2	2	2	2	2	1	2
Unbiased assessment of endpoint	0	0	0	0	0	0	0	0	0	0	0	0
Follow-up period appropriate to the aim of the study	1	2	1	1	2	2	1	2	2	2	2	2
Loss to follow-up <5%	2	1	2	2	1	2	1	2	2	1	0	1
Prospective calculation of the study size	0	0	0	0	0	0	0	0	0	0	0	0
Adequate control	2	1	2	1	1	0	1	1	2	0	0	0
Contemporary groups	2	2	2	2	2	2	2	2	2	2	2	1
Baseline equivalence of groups	2	1	2	1	1	1	0	2	2	0	0	0
Adequate statistical analyses	1	2	2	2	1	1	1	1	2	1	0	2
Total	16	17	18	17	16	16	13	18	20	14	8	12

2, adequate; 1, inadequate; 0, not reported.

Data Analysis

Descriptive summary statistics, including the mean and SD for continuous parametric variables, were compiled. For continuous quantitative data, the overall standardized mean difference (SMD) along with 95% confidence intervals (CIs) was calculated. In cases of missing data, the SD was estimated from the raw data or available figures using the method described by Wan et al.²⁴ For categorical data, the risk ratio (RR) was determined using the Mantel–Haenszel approach. Results for all outcomes were presented through forest plots. Heterogeneity was deemed significant when the I² value was greater than 50% or the P value was less than 0.05. Publication bias was evaluated using the Begg funnel plot and Egger test, with a P value of less than 0.05 indicating substantial bias.

RESULTS

Search Results

The search strategy yielded 28,857 articles. After removing duplicates and filtering the articles by title and intervention, 2303 articles remained for assessment. When filtering the articles by outcomes, 20 studies compared open versus closed rhinoplasty techniques and were included in the systematic review (Table 2). Of these 20 studies, 12 included the outcomes of interest and were included in the meta-analysis. The analysis included 1067 patients undergoing rhinoplasty, of whom 539 underwent the open technique and 528 the closed/endonasal technique (Table 2).

Risk of Bias Assessment

Table 3 outlines the criteria used to evaluate the risk of bias. The overall quality of the included studies was rated as moderate, with an average score of 15.4. Key limitations identified in the studies included the absence of a prospective calculation of sample size and the lack of an unbiased assessment of study endpoints.

ROE Score

The mean change in ROE scores from pre- to postrhinoplasty was reported in 5 studies: Saleh et al,³ Metin and Avcu,⁶ Gökçe Kütük and Arikan,⁷ Baz et al,⁹ and Hellings and Trenité.¹⁰ All 5 studies found a mean decrease in ROE scores compared with the preoperative values in both closed and open rhinoplasty groups. There was a total of 365 subjects in the open cohort and 304 subjects in the closed cohort.^3,6,7,9,10 Based on the analysis performed using a random effects model with the inverse variance method to compare the SMD, there was no statistical difference between both cohorts (SMD = −0.16; 95% CI [−2.62 to −2.3]; Fig. 1).

Fig. 1.

Forest plot showing changes in ROE scores in patients undergoing open vs closed rhinoplasty. IV, intravenous.

However, a significant heterogeneity was detected (P < 0.01, I² = 99%). This heterogeneity may be attributed to differences in baseline patient characteristics, variations in surgical techniques, and differing indications for surgery (functional versus cosmetic), among other factors. Additionally, the diversity in ethnic backgrounds across studies may have contributed to this variability, given the influence of ethnicity on nasal anatomy and surgical goals.

NOSE Score

Five studies assessed changes in NOSE scores from pre- to postoperatively in open versus closed rhinoplasty. The studies by Talmadge et al,² Saleh et al,³ Metin and Avcu,⁶ Gökçe Kütük and Arikan,⁷ and Taş and Erden¹¹ were analyzed with a total of 362 subjects in the open cohort and 311 subjects in the closed cohort.

Based on the analysis performed using a random effects model with the inverse variance method to compare the SMD, there was no statistical difference between the 2 cohorts (I² = 86%; P = 0.41; SMD = 0.21; 95% CI [−0.42 to 0.84]; Fig. 2). The test for overall effect does not show a significant effect; however, significant heterogeneity was detected (P < 0.01), and this can be attributed to the different surgical techniques used, the inclusion of a septoplasty and/or turbinectomy procedure, and the baseline characteristics of the population studied.^2,3,6,7,11

Fig. 2.

Forest plot showing changes in NOSE scores in patients undergoing open vs closed rhinoplasty. IV, intravenous.

Mean Change in Edema and Ecchymosis

In 2015, both Kiliç et al¹² and Sakallioğlu et al¹³ reported on immediate changes in edema and ecchymosis (on postoperative day [POD] 2–3). They used a scale from 0 to 4 to assess upper and lower eyelid edema and ecchymosis. There was a total of 85 subjects in each group. After meta-analysis, there was no statistical difference in edema between the 2 cohorts (SMD = 0.17; 95% CI, −5.81 to −6.16; P = 0.77; I² = 87%). The same applied to POD 2–3 ecchymosis, with an SMD of 0.29 and 95% CI of −3.99 to 4.57 (I² = 75%).

When looking at results from POD 7 in the same 2 studies, there was still no statistical difference between open and closed rhinoplasty when assessing edema (I² = 21%; P = 0.40; SMD = 0.25; 95% CI [−2.03 to 2.53]; Fig. 3) and ecchymosis (I² = 51%; P = 0.52; SMD = 0.22; 95% CI [−2.79 to 3.24]; Fig. 4). We did not find notable variability, implying that the effect sizes across studies were uniform in both size and direction. This drop in heterogeneity might be explained by the fact that, regardless of the surgical technique used, edema and ecchymosis will eventually decrease within 7 days.^12,13

Fig. 3.

Forest plot showing differences in postoperative edema in patients undergoing open vs closed rhinoplasty, 7 days postoperatively. IV, intravenous.

Fig. 4.

Forest plot showing differences in postoperative ecchymosis in patients undergoing open vs closed rhinoplasty, 7 days postoperatively. IV, intravenous.

Mean Operative Time

Mean operative time differences were reported by Talmadge et al,² Baz et al,⁹ and Sakallioğlu et al.¹³ All 3 studies included a total of 71 subjects in the open cohort and 79 subjects in the closed cohort. Based on the analysis performed using a random effects model, there was no statistical difference between the 2 cohorts (SMD = 3.16; 95% CI [−6.54 to 12.86]; Fig. 5). Significant heterogeneity was detected, which was expected given that operative time is highly dependent on the surgeon and institution. It also varies based on the ancillary surgical procedures performed alongside rhinoplasty, as well as patient complexity and baseline characteristics.^2,9,13

Fig. 5.

Forest plot showing differences in operation time in patients undergoing open vs closed rhinoplasty. IV, intravenous.

Patient Satisfaction Rates

The studies by Metin and Avcu,⁶ Hellings and Trenité,¹⁰ Taş and Erden,¹¹ and Gruber et al¹⁴ reported satisfaction rates as a categorical variable and were included in our analysis. A total of 285 subjects in the open group and 206 subjects in the closed group were included. Based on the analysis performed using a random effects model with the Mantel–Haenszel method to compare the RR, there was no statistical difference between the 2 cohorts (Fig. 6), and the overall RR (to be dissatisfied) was 1.04 with a 95% CI of 0.63–1.74 (I² = 0%).^6,10,11,14

Fig. 6.

Forest plot showing differences in dissatisfaction scores in patients undergoing open vs closed rhinoplasty. MH, Mantel–Haenszel.

Complication Rates

Complication rates were not reported in all the articles included in the systematic review; only Altunal et al,¹⁵ Taş and Erden,¹¹ Paul et al,¹⁶ Jaberoo et al,¹⁷ and Gruber et al¹⁴ included these data. Complication rates ranged from 0% to 13.3% in the open rhinoplasty cohort (n = 100) and from 0% to 30% in the closed group (n = 142). Complications included epistaxis, narrow vault, and reoperation, among others. The pooled summarized proportion for open rhinoplasty complication rate was 0.1 (95% CI [0.05–0.19]) and 0.11 (95% CI [0.03–0.29]) for the closed technique. Based on the analysis performed to compare the RR, there was no statistical difference between the 2 cohorts; the overall RR was 0.65 when comparing open rhinoplasty with closed rhinoplasty (I² = 0%; P = 0.39; RR = 0.65; 95% CI [0.08–5.60]; Fig. 7).^11,14–17

Fig. 7.

Forest plot showing differences in complication rates in patients undergoing open vs closed rhinoplasty. MH, Mantel–Haenszel.

Publication Bias

Publication bias of the included studies was assessed using the Egger test. The results showed that there was no significant bias in the studies for changes in mean ROE scores (P = 0.15) and changes in mean NOSE scores (P = 0.24).

DISCUSSION

The findings of this systematic review and meta-analysis provide a comprehensive comparison of open and closed rhinoplasty techniques, focusing on patient-reported outcomes, ecchymosis, erythema, and sensory changes. These results align with broader findings in the literature, offering a nuanced understanding of the strengths and limitations of each approach. The analysis revealed no statistically significant differences in ROE or NOSE score changes between the open and closed rhinoplasty cohorts.

Our findings align with previous studies demonstrating that rhinoplasty is significantly associated with improved ROE and NOSE scores, reflecting both functional and aesthetic benefits.²⁵ Regarding NOSE scores, our meta-analysis included studies with mixed cohorts of primary and revision rhinoplasty cases, except for Taş and Erden¹¹ and Talmadge et al,² which focused solely on primary surgery. In agreement with Gökçe Kütük and Arikan⁷ and other studies in the literature, no significant difference was observed in NOSE score improvements between primary and revision cases, emphasizing the procedure’s efficacy in addressing nasal obstruction regardless of surgical history.

In terms of ROE scores, the literature consistently shows that revision cases tend to have significantly lower postoperative scores compared with primary cases, underscoring the challenges of managing patient expectations in revision surgery. All studies included in the ROE analysis for this review incorporated both primary and revision cases, further confirming the overall positive impact of rhinoplasty on patient-reported aesthetic outcomes across techniques. Notably, rhinoplasty is associated with significant improvements in ROE scores throughout the postoperative period, yet it remains the aesthetic procedure with the lowest overall satisfaction rates.²⁶ This is particularly true for patients with high preoperative ROE scores, as discrepancies between expectations and outcomes may arise. Consequently, assessing patient expectations preoperatively is critical to achieving satisfactory results. Additionally, studies in the literature have highlighted the role of rhinoplasty as a cosmeto-functional procedure, with improved quality of life observed among younger patients and maximal benefits occurring within 6–12 months postoperatively.^7,27

The heterogeneity in our results, driven by differences in baseline characteristics, surgical methods, and adjunct procedures, mirrors challenges noted in the broader literature when standardizing rhinoplasty outcomes. Tools such as the ROE and NOSE scores remain invaluable in objectively evaluating results, despite the inherently subjective nature of aesthetic judgments.^5,28

The lack of randomized controlled trials on this topic highlights the individualized nature of rhinoplasty, where surgical decisions are based on unique patient anatomy. Most studies indicate comparable outcomes between open and closed rhinoplasty, a consistency attributed to the preoperative determination of correct surgical indications and thorough discussions with patients about the chosen method. This underscores the importance of preoperative planning and patient counseling, as these factors significantly influence satisfaction and outcomes alongside technical execution.⁶ Patient satisfaction often reflects a multifactorial interplay among preoperative expectations, surgical outcomes, and consultation quality. Future studies integrating patient-reported metrics with advanced imaging techniques may clarify subtle differences between the 2 approaches.

Postoperative complications in rhinoplasty are influenced by both the surgical technique and the precision of execution.²⁹ Open rhinoplasty offers superior visualization, which can reduce mucosal injury during osteotomies and postoperative pain, particularly when modern tools such as piezoelectric devices are used.^30,31 However, it may require longer operative times and is associated with transient sensory changes, especially at the nasal tip region.^9,15

Tip extrusion remains a key concern, particularly in cases involving structural grafts or augmentation. Although not systematically reported across studies, it is a relevant outcome when comparing approaches. Open rhinoplasty allows for accurate graft placement, lowering extrusion risk, though its extensive dissection can compromise soft tissue integrity. Conversely, closed rhinoplasty preserves native vascularity through limited dissection, although visibility is reduced.

Graft materials varied across studies, including septal, conchal, and costal cartilage. Septal cartilage is generally preferred for its low extrusion rate and ease of harvest, whereas conchal cartilage is an alternative when septal supply is insufficient.³² Rib cartilage is effective for larger structural needs but carries higher risks of warping and extrusion if improperly handled.³³

Sensory disturbances after open rhinoplasty are usually transient. Altunal et al¹⁵ reported resolution by the third postoperative month, whereas Jaberoo et al¹⁷ noted long-term numbness that was not statistically significant.¹⁷ Okur et al¹⁸ found reduced sensation with both approaches in the first postoperative week, with full recovery by 1 month.

Rare instances of long-term sensory deficits have been documented, though they occur less frequently in closed procedures.¹⁸ Looking at muscle activity, Kirgezen et al,¹⁹ in their study of electromyographic and electroneurographic changes, found no significant differences in internal nasal muscle activity strength between the 2 techniques, further supporting the notion that sensorimotor outcomes are comparable with careful execution.¹⁹

Looking at postoperative ecchymosis and edema, Kiliç et al¹² and Sakallioğlu et al¹³ demonstrated significant resolution of symptoms by POD 7, regardless of the technique used. Although open rhinoplasty involves more extensive dissection, its impact on early recovery is comparable to that of closed rhinoplasty. This aligns with findings suggesting that factors such as the precision of lateral osteotomy play a more significant role in postoperative bruising and swelling than the choice of surgical approach.^12,13

The choice between open and closed rhinoplasty is not about superiority, but rather about suitability for the individual patient’s anatomy and surgical goals. Open rhinoplasty offers enhanced visualization and access, making it the preferred method for complex deformities, revision surgery, and cases requiring structural grafting. For example, Bussi and Sacchi³⁴ reported that open rhinoplasty is predominantly indicated for severely deviated noses, saddle deformities, and cleft-related asymmetries. Similarly, Münker³⁵ found that nearly two-thirds of open rhinoplasties were revision procedures.

On the other hand, closed rhinoplasty is often favored for primary cases with minimal structural alterations. Kosins³⁶ emphasized that closed preservation rhinoplasty is ideal for patients with thin skin, minor dorsal modifications, and simple tip deformities. Additionally, Gökçe Kütük and Arikan⁷ reported that patients undergoing closed rhinoplasty demonstrated more favorable improvements in self-esteem and social functioning postoperatively.

Advancements in rhinoplasty techniques, including ultrasonic instrumentation and 3-dimensional surgical planning, are beginning to narrow the functional gap between open and closed approaches, offering increased precision and control while minimizing invasiveness. Ultimately, the decision should be individualized, based on anatomical complexity, patient expectations, and surgeon expertise (Table 4).

Table 4.

Recommended Rhinoplasty Approach Based on Clinical Scenario

Clinical Scenario	Preferred Approach	Notes
Severely deviated nose (type 2 and 3)	Open	Allows better visualization and structural correction (Bussi and Sacchi34)
Crooked nose with saddle deformity	Open	Structural grafting and complex reconstruction are easier with open access
Cleft-related asymmetries	Open	Complex asymmetries often require an open approach for precision
Revision rhinoplasty (major cases)	Open	50%–66% of revisions are done open due to complexity (Bussi and Sacchi34, and Münker35)
Revision rhinoplasty (minor adjustments)	Closed	Can be suitable if minor modifications are needed and anatomy is preserved
Thin skin with minimal dorsal modification	Closed	Better scarless outcomes and faster recovery (Kosins36)
Simple tip deformity or mild overprojection	Closed	Ideal for subtle refinements
Need for major tip reconstruction or augmentation	Open	Greater exposure and grafting flexibility
S-shaped nasal bones or complex dorsum	Open or open preservation	Better control and alignment; closed may be limiting
Primary rhinoplasty with minimal deformity	Closed	Efficient and less invasive
Desire for no external scar/quicker recovery	Closed	Especially if anatomy allows and expectations are realistic
Structural dorsal rhinoplasty	Open	Structural techniques require exposure not achievable with closed approach (Kosins36)
Psychosocial concerns/self-esteem motivation	Closed (when feasible)	Some studies show better psychosocial outcomes (Gökçe Kütük and Arikan7)

Ultimately, the choice between open and closed rhinoplasty should be individualized, taking into account the patient’s anatomical complexity, aesthetic goals, and the surgeon’s experience and preferences.

The marked heterogeneity across studies underscores the need for standardized surgical protocols, patient selection criteria, and outcome reporting. Future multicenter trials with consistent methodology and long-term follow-up, along with objective assessment tools, are essential to improve reproducibility and guide clinical decision-making.

CONCLUSIONS

This comprehensive comparison underscores the importance of tailoring the surgical approach to individual patients' needs while continuing to innovate and refine rhinoplasty techniques. Both open rhinoplasty and closed rhinoplasty remain highly effective methods, with the choice dictated by a combination of patient factors and surgeon expertise.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.