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, which is part of the normal healing process. However, if after a year you still feel that your nose looks deformed in some fashion, you might want to consider having revision rhinoplasty.
Revision rhinoplasty can address a variety of different deformities, from the excessive reduction of the nasal bridge to asymmetry in the nasal tip. Most revisions are complicated procedures that require an open approach. Furthermore, the outcome of revision rhinoplasty may be harder to predict due to the primary rhinoplasty.
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 is it? 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: Overresection of the upper lateral cartilage, the cartilage that forms 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 during the fracturing of the nasal bones (this destabilizes the upper lateral cartilage).
- How to correct it: Dr. Rizk prefers surgery to filler because fillers do not fix the deformity permanently. The volume gained through hyaluronic acid-based fillers, for instance, 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 makes a later surgery more difficult to perform. Finally, fillers can move around inside the nose. Therefore, Dr. Rizk favors surgery to fillers when correcting an inverted V deformity. The surgery often involves placement of dorsal cartilage above the nasal bridge to narrow the nose and widen the middle nasal vault.
- What is it? The columella is the strip of skin between the nostrils. A hanging columella, or “alar-columellar disproportion,” is one that is visible from the profile and hangs lower than desired, typically about 4mm or more.
- How it occurs: There are many potential causes of hanging columellae. 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 is it? 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: Typically, some type of trauma to the nose, like a blow to the face, 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 is it? External nasal valve collapse is caused by weakness or narrowness in the nasal valve, the thinnest 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.
- What is it? A nasal tip that appears too narrow, or “pinched.”
- How it occurs: Some patients are born with a pinched tip, 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 is it?: 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 on some patients, while an open approach is used on others. The cartilage may be shaved or trimmed. In thin-skinned patients, a soft tissue graft or fascia may be placed over the tip cartilage. Repairing a pointy nasal tip, or another deformity of the tip, is one of the most challenging of all rhinoplasty procedures.
Open Roof Deformity
- What is it? A space is formed when the nasal bones do not come together near the top of the nose. An open roof deformity makes the nose appear excessively wide. Typically, the nasal skin grows or droops, and vertical lines or depressions start to appear.
- How to correct it: It depends on how low or high the nasal bones are positioned. Osteotomies (fractures) may be necessary, and on-lay grafts may be used to close the gap between the nasal bones.
Cleft Lip Nose Deformity
Cleft lip nose deformity is a common birth defect that can severely impact a person’s appearance. In the United States, nearly all cleft lip nose deformities are corrected in infanthood, as failure to correct this deformity can result in developmental impairment, infection, and even death. Cleft lip nose patients commonly require additional surgery later in life to fully correct the deformity.
Cleft lip nose occurs when the upper lip does not form completely in utero, leaving a separation or "cleft" in the lip. In minor cases, the cleft may appear as a small notch or bump on the upper lip. In other cases, the split may extend up to the nose, leaving an opening in the lip and lower nose.
About half of all children born with a cleft lip will also suffer from a cleft palate, which is a separation on the roof of the mouth and the most serious manifestation of the disorder. Cleft lip causes the lip and nose to develop asymmetrically, resulting in obvious deformities that can cause feeding issues, breathing difficulty, and speech problems, all of which contribute to developmental delays in the child. As such, early surgical intervention is almost always recommended.
Most often, the surgery will be performed to correct obvious asymmetries in the upper lip and nose. The surgery must be performed by a doctor who has received specific training in correcting cleft lip nose deformity. Dr. Sam Rizk, a New York facial plastic surgeon specializing in surgery of the face and neck, is highly experienced in correcting deformities associated with the cleft lip nose defect.
Cheiloplasty, the surgery performed to correct cleft lip nose, typically produces positive results and allows the child to enjoy a normal childhood after surgery. In most cases, the child will not remember the surgery or the difficulties they experienced as a result of the condition.
Some patients require only one surgery early in life to correct cleft lip deformity; however, other patients will experience uneven growth of the lip and/or nose. This can result in obvious asymmetries later in childhood and will require surgical intervention to correct.
Surgery to correct cleft lip and cleft palate can be performed at as early as 10 weeks of age, but doctors recommend that nasal deformities not be corrected until the child has finished growing. It is usually safe to correct the nasal deformities associated with cleft lip nose through rhinoplasty when the child is about 15.
Rhinoplasty to correct cleft lip nose is extremely complex and challenging. Surgeons must take many factors into consideration and are often presented with asymmetries or deformities that they have never corrected before. In addition, there are often functional problems present, such as abnormal nasal septa, turbinates, or weak nasal valves.
Located in NYC, Dr. Sam Rizk draws on his years of surgical training and experience when performing complex rhinoplasties to correct cleft lip nose deformity. If you are looking for a surgeon to treat cleft lip nose deformity, please contact us today to set up an initial consultation. Whether this is your first reconstructive surgery or you have undergone surgery before, you can be assured that our caring doctor will find the right approach to correct the problem.
A Detailed Look at Hanging Columella Rhinoplasty
From a facial profile view, many people have nostrils that are substantially higher than the tissue that separates the two sides of the nose. This condition is known as a hanging columella, or “alar-columellar disproportion”, an aesthetic deformity that many people seek to change through reconstructive nose surgery. However, fixing a hanging columella may require a different approach for each patient, depending on the etiology, or cause or origin of the deformity.
Hanging columellae often occur naturally in patients. In other cases, it may have resulted from a mistake in a previous surgery in which the alar and columella became misaligned. Revision rhinoplasty involves performing corrective nose surgery on a patient who has previously undergone reconstructive nose surgery.
This section will describe:
- Techniques for managing a hanging columella
- The anatomy of the alar-columellar relationship
- Ways to differentiate between a hanging columella and a retracted ala or a pseudo hanging columella
- How the actions taken in primary rhinoplasty can alter the normal alar-columellar relationship
Pertinent Anatomy and Etiology
In classic textbook definitions, the standard alar-columellar relationship is characterized as being able to see 2mm to 4mm of columella below the alar margin when looking at the profile view of a person’s face.
This description, however, does not adequately describe the appropriate position of the alar margin within the alar-columellar relationship. A patient may appear to have a hanging columella, when it is really the result of a retracted alar. It is imperative to understand the cause of the hanging columella, as this will dictate the appropriate corrective measures required.
Other signs of a hanging columella include excessive nostril show with a droopy tip, a short upper lip, a long lateral crus, and a strong lateral crus with no apparent notching. By contrast, the presence of alar notching, weak or deficient lateral crura, retraction of the alar margin, or an alar margin with excessive curvature may suggest alar retraction or a pseudo-hanging columella.
A hanging columella can exist naturally, or it can develop as a direct result of previous nasal surgery. The key nasal structures to consider when evaluating a hanging columella include the caudal cartilaginous septum, the membranous septum, and medial and intermediate crus.
Anatomic deformities that contribute to the hanging columella may include:
- Caudal cartilaginous septum that is excessively long
- Redundant membranous septum
- Wide, curved, convex or vertically oriented medial/intermediate crura
- Long medial crus with bowing or a C-shaped curvature
- Broad vestibular vault and medial crural ptosis
When a hanging columella develops as a result of previous surgery, the causes may include:
- Columellar strut or a caudal septal extension graft that protrudes caudally
- Suturing bifid medial crura that highlights the columella
- Shield graft that is too thick, or excessive plumping grafts
- The loss of tip projection and rotation from a previous rhinoplasty
Surgical Evaluation and Management
The most effective way to correct a hanging columella depends on the etiology, or cause, of the condition. If the hanging columella is caused by an excessive cartilaginous caudal septum or redundant membranous septum, the tissue should be removed or cut using a transfixion incision, which can be done endonasally.
However, if you seek to increase rotation, a wedge of caudal septum should be removed in the shape of a triangle, with the triangle’s base oriented dorsally. If counter-rotation is what you wish to achieve, the base should be oriented vertically toward the nasal spine. Achieving zero rotation will require removing a straight piece of cartilage. As a rule, always leave at least 1 to 1.5 cm of caudal septum to prevent the tip of the nose from collapsing.
For a membranous septum, an ellipse-shaped part of the septum should be excised, with the widest part of the ellipse where the columella protrudes most severely. The transfixion incision is then closed using septocolumellar sutures with 4.0 PDS to maintain tip projection and rotation. In rare instances, if a large nasal spine is contributing to the hanging columella it may have to be reduced.
To address medial crura that is overly bowed or wide, the medial crura is shaved at the meeting point of the medial and intermediate crura. The medial crura are then sutured together. For excessively long or curved medial crura, some surgeons employ an overlay technique followed by the placement of a columellar strut. As previously described, a lateral crural overlay technique is also effective for addressing lower lateral cartilages that are excessively long.
Finally, in cases where the hanging columella is caused by graft placement from a previous surgery, the graft (whether it be a shield graft, columellar strut, caudal septal extension graft, or plumping graft) is either excised or altered.
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. It is important that you have realistic expectations. It is also crucial that you choose a revision rhinoplasty expert such as Dr. Rizk to perform your procedure. For more information on revision rhinoplasty to correct deformities, get in touch with Dr. Rizk’s practice and make an appointment today.
Written by Dr. Sam Rizk