I’ve been thinking about why for difficult tips I favour the open approach. There are three main reasons for me. One is that it enables a very precise assessment of the shape of the tip cartilages and their relationship to each other. This is not a substitute for very careful analysis of the shape of the nose and the contour of the skin but I feel we can not truely understand what makes the nose the shape it is until we see the underlying cartilages. In closed approach bringing the cartilages down into the nostrils distorts them and makes it very difficult to really understand their true shape and relationships. It’s also true to say that after using a surgical technique sometimes during surgery the shape of the nose changes in a way we weren’t expecting and the open approach enables us to see and understand this directly and so correct it. Secondarily during surgery it enables accurate precise performance particularly fixing grafts into place. And thirdly I do believe that to get good definition and good shape into a nasal tip we often need to build a really strong structure in the cartilages that supports the overlying skin very well and introduces some tension into the tissues just as a really good framework on a tent keeps the material of the tent in the right shape and position. I don’t think this is as possible in the closed approach.
Of course not all nasal tips need an open approach and experience leads us to understand when the open approach is best and when the closed approach is best so it’s definately not a one operation fits all.