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The benefits of both the open and closed approaches were combined by use of an extended closed rhinoplasty. It is theorized that circulation would be improved, while providing greater visualization of the tip cartilages for suture techniques in those patients considered at risk for the open approach (e.g., patients who smoke, patients with multiple scars of the tip area, and patients with very thick skin who might be predicted to have a great deal of edema with subsequent fibrosis). The basic technique involves extension of the usual rim incision in the cartilage delivery technique of a closed rhinoplasty. A transfixion and intercartilaginous incision are required along with an extended rim incision, allowing more thoroughly delivered tip cartilages. Most of the usual suture techniques can then be performed: dome, intercrural, and crura-septal sutures. With the tips completely delivered, tip grafts can be sutured in place under direction vision. The one suture that is not possible at this time is the spanning suture. Thirty-two cases of extended closed rhinoplasties have been performed in patients who were not candidates for the open approach. There were no healing complications. Five patients had undesirable results, and a revision for aesthetic problems was required. The extended closed rhinoplasty offers many of the advantages of both the open and closed approaches.

Suture techniques in rhinoplasty by use of the endonasal (closed) approach