Master Techniques in Rhinoplasty has been a primary teaching reference for rhinoplasty surgeons since its first edition. Its second edition, published in 2026, has been expanded to capture the most current techniques in the field. Chapter 20, co-authored by Dr. Deepak Dugar, formalizes a technique that has been at the center of his practice for years: the endonasal, transcartilaginous approach to Closed, Scarless Rhinoplasty.
For patients who are researching rhinoplasty, the publication offers something rarely available outside academic medicine: a detailed account of how this technique is performed, by whom, and why it remains the authors' first choice for the great majority of primary rhinoplasty cases. The purpose of this article is to make the substance of that chapter accessible to patients, in plain language, while preserving the precision the chapter itself was written with.
Citation: Kanodia R, Dugar DR. "Endonasal Rhinoplasty: Transcartilaginous Approach." In: Master Techniques in Rhinoplasty, Second Edition. Chapter 20. 2026.
What is endonasal rhinoplasty?
Endonasal rhinoplasty is a closed surgical technique in which every incision is made inside the nose. Because no incision is placed across the columella (the strip of skin between the nostrils), no external scar is created, and the surgeon never lifts the skin of the nose away from its underlying framework as is done in the open approach. The nose is reshaped through small, hidden incisions, working with the cartilage and bone in their natural position.
The transcartilaginous approach described in Chapter 20 is a specific endonasal technique in which the surgeon makes a precise incision through the lower lateral cartilage itself, exposes a measured strip of cartilage to remove, and refines the tip of the nose while preserving the lateral portion of the lower lateral cartilage. Preserving this lateral cartilage is critical: it is what prevents alar collapse, alar pinching, and the visibly operated look that more aggressive techniques can produce.
Why this technique matters for patients
The most striking statement in the chapter is also one of the simplest: in the authors' view, more than ninety percent of primary rhinoplasty cases can be performed endonasally. That figure runs against the trend of the past two decades, in which most rhinoplasty teaching has shifted toward an open approach. The reason for that shift, the chapter explains, is not that the open approach produces better results in most cases, but that the endonasal approach has a longer, more difficult learning curve, and fewer surgeons commit to mastering it.
"The authors do not believe in changing noses, and instead believe in refining noses.”
The chapter argues that the majority of noses seen in private practice already possess what the authors call a beautiful tip-nostril complex. These are noses where the tip and nostril shape are already attractive, and where the patient's actual concern lies in the bony or cartilaginous profile, the length of the nose, or the width of the upper third. In those cases, performing an open rhinoplasty risks disturbing structures that did not need to be touched in the first place.
This is the philosophical core of the technique: preserve what is already attractive, refine what is not, and do not produce a nose that announces itself
Open versus closed: what the chapter actually says
Open rhinoplasty involves an external incision across the columella to lift the nasal skin envelope and visualize the framework of the nose directly. It is the dominant approach taught in residency and used by most rhinoplasty surgeons today. Closed, or endonasal, rhinoplasty places every incision inside the nose and works without lifting the skin envelope. Both approaches can produce excellent results in skilled hands, but the chapter is unambiguous in its position that, when patient anatomy permits, the endonasal approach should be the default rather than the exception
Advantages of the transcartilaginous endonasal approach
- No external scar. Every incision is inside the nose.
- Preservation of the lower lateral cartilage shape and the natural architecture of the tip.
- Reduced disruption of nasal tip support structures.
- Lower risk of alar collapse and alar pinching, both of which are well-described complications of more aggressive techniques.
- Real-time, immediate visual assessment of dorsal profile changes during surgery.
- Faster, less swollen recovery in many cases, because the skin envelope is not elevated off the framework.
When the chapter recommends an open approach
The authors are equally clear about when the endonasal technique should not be used. Severe revisions, major reconstructive cases, and certain anatomic patterns warrant an open approach. The decision is anatomical, not philosophical, and the chapter makes the case that honest patient selection is what allows the endonasal technique to produce reliable results.
Inside the technique
Patients reading this article should understand that the chapter itself is written for surgeons and is technical in nature. What follows is a plain language summary of the operative sequence, intended to convey the level of precision the technique demands rather than to substitute for a consultation.
Patient selection and preoperative evaluation
Every patient is evaluated in person. The chapter is explicit that, while virtual consultations have a useful role, electronic photographs cannot replace a physical examination and palpation of the lower lateral cartilage. Anatomy is felt as well as seen.
Anesthesia and preparation
The inside of the nose is cleaned with betadine-soaked swabs. A measured mixture of ropivacaine and lidocaine with epinephrine is injected along the soft tissues and septal mucosa to vasoconstrict the area and reduce intraoperative bleeding. Oxymetazoline-soaked cotton pledgets are placed to further decongest the turbinates. The chapter notes that excessive injection volume is a common mistake among less experienced surgeons because it can obscure the natural form of the nose.
Addressing the septum
A modified hemitransfixion incision is made five millimeters posterior to the membranous septum. This posterior placement preserves nasal tip support and conceals any scar from the lateral view. If cartilage grafting is anticipated, septal cartilage can be harvested along the floor. Septal deviations are corrected at this stage if present.
The transcartilaginous incision
A two-pronged retractor and the surgeon's finger are used to evert the lower lateral cartilage into view. A measured cephalic strip of cartilage is excised with precision. The lateral portion of the lower lateral cartilage is deliberately preserved to prevent alar collapse and pinching. Vestibular skin in this area is treated with great care and preserved for closure.
Adjusting the dorsum
Through the same transcartilaginous access, the dorsum is skeletonized in a supraperichondrial and subperiosteal plane. Reduction of the cartilaginous and bony hump, lateral osteotomies, and placement of spreader grafts where indicated are all performed without external incision. The chapter notes a meaningful endonasal advantage here: dorsal profile changes can be assessed immediately and in real time with the skin envelope intact.
Closure and splinting
The transcartilaginous incisions are meticulously closed with 5-0 chromic gut sutures to prevent synechiae, alar retraction, or notching, with total preservation of the vestibular mucosa. A tailor-made Aquaplast splint is hand-cut to provide triple-layer thickness along the dorsum, which the chapter describes as critical for mitigating skin envelope swelling and preventing lateralization of the nasal bones.
“Post-rhinoplasty noses should never appear ‘surgical’ in nature. The patient and their friends and family should soon forget that rhinoplasty was ever performed.”
Why experience matters with this technique
The chapter is candid about the steep learning curve of the transcartilaginous endonasal approach. The technique requires the surgeon to interpret cartilage anatomy without direct visualization, to make symmetric and exact excisions through palpation and judgment, and to control nasal tip projection and rotation in small, precise increments. It is not a procedure a surgeon can take a weekend course in. It is the product of years of singular focus, performed correctly, repeatedly.
Dr. Dugar's contribution to the chapter reflects more than one thousand endonasal rhinoplasties performed in his own practice. He continues to perform approximately three hundred Scarless Nose® Rhinoplasty cases per year, all using the Closed, Scarless Rhinoplasty technique codified in Chapter 20. This is why the Scarless Nose® Atelier in Beverly Hills was structured around a single discipline: Closed, Scarless Rhinoplasty performed by Dr. Dugar, and nothing else.
What a patient should take from this publication
For a patient considering rhinoplasty, the publication of this chapter signals three things.
First, the closed, scarless approach is not a marketing label. It is an academically described, technically defined surgical technique with a documented operative sequence, indications, contraindications, and published outcomes. It can be evaluated, taught, and reproduced by surgeons who commit to learning it correctly.
Second, not every nose is a candidate for the endonasal approach, and not every surgeon who advertises closed rhinoplasty performs it at the level described in the chapter. Patient selection and surgeon experience are inseparable from the outcome.
Third, the philosophy embedded in the technique, that the goal of rhinoplasty is refinement and not replacement, has implications that extend well beyond the operating room. It changes how a consultation is conducted, what a surgeon agrees to do, and what a patient should expect to look like, and to remain looking like, in the decades after surgery.
Frequently Asked Questions
What is endonasal rhinoplasty?
Endonasal rhinoplasty, also called closed rhinoplasty, is a surgical technique in which every incision is made inside the nose. No external incision is made across the columella, so there is no visible scar, and the skin envelope of the nose is not lifted off its underlying framework.
What is the transcartilaginous approach?
The transcartilaginous approach is a specific endonasal technique in which the surgeon makes a precise incision through the lower lateral cartilage of the nose, excises a measured cephalic strip of cartilage, and refines the tip of the nose while preserving the lateral portion of the lower lateral cartilage to prevent alar collapse and pinching.
Where was Dr. Dugar's chapter published?
Dr. Dugar co-authored Chapter 20 of Master Techniques in Rhinoplasty, Second Edition (2026). The chapter is titled "Endonasal Rhinoplasty: Transcartilaginous Approach."
Is closed rhinoplasty better than open rhinoplasty?
Neither approach is universally better. The chapter argues that, when patient anatomy permits, the endonasal approach should be the default rather than the exception, because it preserves the natural architecture of the nose, leaves no external scar, and avoids unnecessary disruption of tip support. Severe revisions and certain reconstructive cases still warrant an open approach
Who is a candidate for endonasal, scarless rhinoplasty?
Candidates are patients with primary rhinoplasty indications whose anatomy can be safely refined without an external incision. Final determination requires an in-person consultation that includes physical examination and palpation of the lower lateral cartilage. Severe revisions and major reconstructive cases are typically referred for an open approach.
How many rhinoplasties has Dr. Dugar performed?
Dr. Dugar performs approximately 300 Scarless Nose® Rhinoplasty cases per year and has performed more than 1,000 endonasal rhinoplasties to date. The Scarless Nose® Atelier is intentionally limited to a single procedure: Closed, Scarless Rhinoplasty.
Consult with Dr. Dugar
Consultations at the Scarless Nose® Atelier are conducted personally by Dr. Dugar. In-person and virtual consultations are available; in-person evaluation, including palpation of the lower lateral cartilage, is part of the final candidacy determination.
Beverly Hills Rhinoplasty Center
414 N Camden Drive, Suite 801, Beverly Hills, California 90210
(323) 207-1536
