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Reconstructive Surgery American Board of Otolaryngology - ABO

Deformities in Revision Rhinoplasty

While the majority of rhinoplasty patients are happy with the outcome of their surgeries, dissatisfaction with results is not uncommon. In rare cases, patients end up with deformities. This is more common among patients who choose to have nose surgery with someone other than a board certified facial plastic surgeon.

It is normal for the nose to be swollen in the weeks and months following rhinoplasty. Sometimes what may appear to be a deformity is actually just swelling and the normal healing process. However, if after a year you still feel that your nose looks deformed in some fashion, you may wish to consider having revision rhinoplasty.

Revision rhinoplasty can address a variety of different deformities, from excessive reduction of the nasal bridge to asymmetry in the nasal tip. It is a very complicated procedure whose results are not as predictable as the results of a primary rhinoplasty procedure (the original procedure). Most revision rhinoplasties require the open approach.

Types of Deformities Addressed in Revision Rhinoplasty

Below are explanations of some of the most common deformities addressed in revision rhinoplasty procedures.

Inverted V Deformity

  • What it is: This type of nasal deformity is characterized by an inverted V-shaped shadow in the area of the middle vault of the nose.
  • How it occurs: Over resection of the upper lateral cartilages – the cartilages forming the sides of the nose’s bridge. It often occurs when the surgeon who performed the original procedure made a mistake during the removal of a nasal bump and fracturing the nasal bones. (This destabilizes the upper lateral cartilages.
  • How to correct it: Fillers or surgery. Dr. Rizk prefers surgery because fillers do not fix the deformity permanently. The volume gained through hyaluronic acid-based fillers, for example, lasts for about six months. Fillers are also less precise than surgery and can make the nose look larger. Moreover, they can cause inflammation and scar tissue, which can make any later surgeries more difficult to perform. Finally, fillers can move around inside the nose. For all of these reasons, Dr. Rizk favors surgery to fillers when correcting an inverted V deformity. The surgery often involves placement of a dorsal cartilage above the nasal bridge to narrow the nose and widen the middle nasal vault.

Hanging Columella

  • What it is: The columella is the strip of skin between the nostrils. A hanging columella, or “alar-columellar disproportion,” is one that hangs lower than desired, so that about 4mm of nostril, or more, is visible from the profile.
  • How it occurs: There are many potential causes of hanging columellas. Some people are born with it, in which case it is often the result of either a long septum and/or the columella cartilages pushing down on the columella. Other people end up with the deformity due to a mistake made during their primary rhinoplasty procedure.
  • How to correct it: This depends on the cause of the deformity. Excess tissue may be removed after making an incision, and a portion of the septum may be removed. Other cartilage may be removed or shaved. In rare cases, the nasal spine may be reduced.

Saddle Nose Deformity

  • What it is: A saddle-like formation in the area of the septum. This type of deformity is sometimes referred to as a “scooped nose.”
  • How it occurs: Something (e.g., trauma) causes the septum to lower.
  • How to correct it: The septum can be raised or a cartilage graft can be added to the depression, to fill it in.

External Nasal Valve Collapse

  • What it is: External nasal valve collapse is a collapse of the nasal valve caused by weakness or narrowness in nasal valve, the most-narrow portion of the nasal airway.
  • How it occurs: Trauma to the nose or mistakes made during the original rhinoplasty procedure.
  • How to correct it: In some cases it is possible to treat by lifting the cheek tissue on the side of the nose that is blocked. In other cases surgery may be needed. There are several different surgical approaches that may be employed. For example, alar batten grafts may be grafted as appropriate if the collapse was caused by weakness in the nasal sidewall. The surgeon performing the revision rhinoplasty procedure will need to assess the cause prior to choosing which approach to adopt.

Pinched Tip

  • What it is: A nasal tip that appears too narrow, or “pinched.”
  • How it occurs: Some patients are born with pinched tips, but this type of deformity is often the result of overresection of the tip cartilages during the original rhinoplasty procedure.
  • How to correct it: Usually, a “tip plasty” is performed to reshape the tip with ear or other cartilage.

Pointy Nasal Tip

  • What it is: A nasal tip that appears pointy essentially means that the alar cartilages are too prominent and appear too pointy, or stick out too much.
  • How it occurs: Many patients are born with pointy nasal tips. This deformity is more common in individuals with thin skin.
  • How to correct it: It depends on the patient’s unique anatomy. The endonasal (internal incisions) approach is used in some patients, while an open approach is used in others. Cartilages may be shaved or trimmed. In thin-skinned patients, a soft tissue graft, or fascia, may be placed over the tip cartilages. Repairing a pointy nasal tip — or other deformity of the tip — is one of the most challenging of all rhinoplasty procedures.

Open Roof Deformity

  • What it is: A space formed when the nasal bones don’t come together near the top of the nose. An open roof deformity makes the nose appear excessively wide. Typically, nasal skin grows or droops into the space and vertical lines or depressions appear.
  • What it is: A space formed when the nasal bones don’t come together near the top of the nose. An open roof deformity makes the nose appear excessively wide. Typically, nasal skin grows or droops into the space and vertical lines or depressions appear.
  • How to correct it: It depends on how low or high the nasal bones are positioned. Osteotomies (fractures) may be necessary, and onlay grafts may be used to close the gap between the nasal bones.

Am I a Candidate for Revision Rhinoplasty?

Not everyone is a suitable revision rhinoplasty candidate, and not all deformities can be corrected. It depends more on what was done in the original surgery and on factors specific to your anatomy than on how many rhinoplasty procedures you have had. Important factors include the integrity of the skin, how much cartilage was removed in the original procedure, how much scar tissue there is, the extent of the deformity and whether you need grafting.

Revision rhinoplasty is a highly technical, challenging procedure. Consequently, even one revision should be taken very seriously. It is important that you have realistic expectations. It is also crucial that you choose a revision rhinoplasty specialist such as Dr. Rizk to perform your procedure.

For more information on revision rhinoplasty to correct deformities, contact the office of Dr. Rizk.

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