Revision Rhinoplasty Information
Patients undergoing secondary or revision rhinoplasty have nasal anatomic characteristics that are different and more complex than primary rhinoplasty and require special attention to detail and specialized techniques in rhinoplasty. In secondary rhinoplasty, the tissue inside the nose has undergone changes and may not tolerate extensive dissection, thinning procedures, and multiple incisions. Some noses have very thin skin and extensive scar tissue inside. The skin in revision rhinoplasty is less pliable, less able to change or tolerate expansion or contraction. Therefore, the rhinoplasty surgeon must use specialized techniques to effect a change in the structure of the nose to overcome the scar tissue. Dr. Sam Rizk, a New York facial plastic surgeon and rhinoplasty expert, points to the techniques of suture methods and cartilage graft methods to create tension greater than that exerted by the scar tissue and skin envelope to effect a greater resistence and change in the structure of the nose. These conservative suture and grafting techniques are far superior in revision rhinoplasty than excisional techniques, usually performed in primary rhinoplasty. Although, Dr Rizk points to some exceptions to this rule, where a nasal bump has not been adequately reduced. However, more common than not, a revision or secondary rhinoplasty becomes necessary when too much has been removed from the nose in the initial operation and the nose starts to collapse and becomes scooped (saddle nose deformity) and the patient starts to exhibit symptoms of difficulty breathing through the nose."
Surgical planning is important in revision or secondary rhinoplasty. Both the endonasal and open rhinoplasty approaches have a role in revision rhinoplasty, depending on the deformity. The open approach is advocated if there is complicated and distorted anatomy or significant asymmetry or lack of tip support. The endonasal approach is often useful as well and allows precise placement of cartilage pockets to place grafts to correct areas of collapse. The endonasal approach in revision rhinoplasty is also a more minimally invasive approach to a pollybeak deformity. If a pollybeak or excessive cartilage exists in the area above the tip, this is easily correctable with an endonasal intercartilaginous incision to expose the dorsum. The advantage of the endonasal approach in revision rhinoplasty is that it is minimally invasive and result in decreased scar tissue formation and better healing.
In today's world, most secondary rhinoplasty patients have already undergone a few rhinoplasty procedures and may have a cartilage depletion or a lack of cartilage in their nose secondary to previous septoplasty. This is an important point as Dr Rizk states it is necessary to obtain cartilage from a donor site such as the ear (concha grafts), or rib cartilage from a rib bank, or use alloplastic biosynthetic nasal implants to build a collapsed nose. Dr Rizk states that surgeons who expect to achieve an excellent outcome with revision or secondary rhinoplasty must be able to obtain septal, ear, or rib cartilage for the nasal reconstruction.
It is important to also understand the psychology of the secondary rhinoplasty patient who have already been disappointed with their previous rhinoplasty procedures and have less tolerance for postoperative problems. Patients also may feel guilty that he or she did not provide enough information to the surgeon, did not ask enough questions, did not do enough research into the surgeon's qualifications, or did not communicate their desires correctly to the surgeon. This guilt may increase the patient's anxiety and anticipation of the secondary rhinoplasty procedure.
In revision rhinoplasty it is necessary to assess patient motivation. Dr. Sam Rizk points out that there are many types of patients who present for revision rhinoplasty. The continuum ranges from patients who truely have a poor result and seek any improvement but who like their previous surgeons, to patients with very good results who are desperately unhappy and furious with their previous rhinoplasty surgeons. Preoperative photography and thoroughly interviewing the revision rhinoplasty patient is important. Patient anger towards the previous surgeon is different and important to distinguish from disappointment with an unanticipated outcome. Most surgeons want to help their patients and are doing their best and I Dr Rizk always reminds patients of this fact to try to diffuse their anger. Often, this allows unhappiness with the previous surgeon to fade so that attention can be directed towards the current nose and deformity to be corrected. Dr Rizk does not operate on angry patients and he attempts to convert an angry patient's attitude towards the previous surgeon from that of resentment to one of disappointment. Angry patients must understand the margin of error inherent in human surgery and healling. Patients must understand that there is no perfection in revision rhinoplasty and any patients seeking perfection is considered by Dr Rizk not a good candidate for revision rhinoplasty. Patients with body dysmorphic disorder who continually seek cosmetic surgery are also not good candidates for revision rhinoplasty.
Alar (nostril) base revisions or alar (nostril) base surgery in revision / secondary rhinoplasty-Though mose patients and surgeons evaluate alar base width as either normal or wide, Dr Sam Rizk, a nyc rhinoplasty surgeon, states the alar bases could also be too narrow from previous surgery. Narrow bases occur less commonly in primary rhinoplasty. Medial displacement of the base can occur on the cleft side after lip repair or after alar wedge resections in revision rhinoplasty. Aesthetic measurments dictate alar base width should equal intercanthal distance. Composite grafts, using the alar lobule or the ear as a donor site, can be used to properly position the nostril or vestibular stenosis in the nose. Sometimes, both nostril stenosis and malposition of the alar base exists.
In cases in revision rhinoplasty where the tip has dropped, it is necessary to use a support graft. Sometimes, a columellar strut, shield graft, a plumping graft or caudal septal extension graft is needed or a combination of the above to correct the tip ptosis, lengthening of the nose and maxillary recession that occurs when tip support is lost. By lifting and supporting the nasal tip to the proper position, this also makes the person appear more youthful. To obtain cartilage for such an endeavor, it is necessary to look for a donor site either from the septum, ear, or banked rib cartilage. When overaggressive septal surgery or nasal surgery is performed, the entire nasal base can drop inferiorly and lengthen the nose. Maxillary arch retrusion can occur and can be corrected with maxillary augmentation. Loss of support to the tip of the nose requires support of the nasal base or caudal septum or nasal tip. Either rib cartilage or septum cartilage is used for tip support because a flat strong piece of cartilage is needed. Ear cartilage has insufficient strength or shape for this type of support.
Some revision rhinoplasty patients require dorsal or maxillary augmentation with either a dorsal onlay graft or a plumping graft. These scooped noses are a significant stigma to the patient and can make a male patient look very feminine in male rhinoplasty. Dr Rizk prefers to use either the patient's own (autogenous) cartilage or in thick skin patients, medpor implants, for augmentation rhinoplasty.
In patients with dorsal (bridge of nose) deformities, it is important to understand that dorsal resection affects nasal balance, nasal base size, width, middle vault width, columellar position, and nostril contour. The degree of change depends on how aggressive the surgeon is and how capable the soft tissues are of responding. By placing a dorsal graft in revision rhinoplasty that has been overresected, the dorsal graft can narrow the nose and widen the middle nasal vault, therefore, also correcting an inverted v deformity. This essentially can convert a concave dorsum into a straight one. The profile appears more normal when it is straight. Also, a higher dorsum creates an apparently smaller nasal base, despite tip grafts.
It is important to establish the goals of revision rhinoplasty and have a good line of communication with the patient. First, it is necesary to establish realistic expectations with the patient. Both patient and facial plastic surgeon must understand why the original goals were not met. If they were never achievable, better goals must be set. Second, it is necessary to defer surgery until final resolution of tissue swelling which takes an average of 1 year. Third, a well defined aesthetic concept for the correction must be established. Third, it is necessary to make a proper diagnosis. The surgeon must identify which of the anatomic variants were present and what problems have been caused by failing to treat them. Fourth, it is important to limit the dissection as much as possible to allow the nose to contract better with less scarring. Next, It is better to use autogenous cartilage in thin skin patients and reserve use of synthetic biocompatible nasal implants to thick skin patients. Also, it is important to be able to see the deformity and personally feel it is fixable for the surgeon. If a patient has unrealistic expectations or sees deformities that are not present they need not be operated on. And lastly, does the patient accept the margin of error or healing improperly inherent in any surgery, and in particular, rhinoplasty surgery.
Revision rhinoplasty aims at correcting deformities that either were not addressed or were the result of poor surgical planning or improper healing after the initial rhinoplasty. Rates of revision rhinoplasty vary from 10-20 percent. Most deformities arising from a rhinoplasty can be categorized. Each deformity has a surgical solution that is usually successful in correcting the problem. In general, revision surgery is not undertaken for at least 1 year after primary rhinoplasty, allowing for maximal healing to occur. The deformities encountered in revision rhinoplasty can be categorized into nasal dorsal deformities, midnasal deformities, and lastly deformities affecting the tip and ala-columella complex.
Nasal Dorsal Deformities - Deformities affecting the nasal dorsum after primary rhinoplasty are usually the result of inadequate or overzealous resection. Surgical errors of inadequate resection are easiest to correct. The surgeon must determine if the excess is in the cartilaginous dorsum or bony dorsum. Overresection results in deformity that requires more skill and work to correct. Surgical errors due to excessive reduction can be challanging and an experienced surgeon is required. Distorted anatomy, decreased vascularity, and scarring complicate the revision rhinoplasty. Correction of overresection invariably requires grafts to fill, elevate or contour the deficient areas.
Pollybeak deformity (supratip fullness) - Inadequate resection of dorsal septal cartilage, excessive dorsal septal cartilage removal resulting in a dead space in the supratip region, or underprojection of the nasal tip and excessive lower lateral cartilage excision resulting in loss of tip support and underprojection leads to this deformity. If the bony dorsum is excessively reduced, this can result in rounding and fullness of the supratip area. This complication is mostly preventable by exercising proper judgement in primary rhinoplasty. Howver, some patients with good structure and poor healing can develop excessive supratip scar tissue and fullness. This tends to occur more in noses with thick skin preoperatively. Thicker skin noses take longer for the swelling to resolve. The use of intralesional steroids in the scar tissue is indicated only if the swelling or deformity is due to scar tissue. It is necessary to palpate the deformity and determine if it is soft or hard and if it is soft then it is scar tissue and is more amenable to steroid injections. Surgical treatment of pollybeak deformity is customized depending on the cause of the deformity. An inadequately resected dorsal cartilaginous septum or scar tissue can be corrected by trimming excessive tissue through an endonasal approach by putting a unilateral or bilateral intercartilaginous incision. However, tissue must be grafted if it is deficient. Cartilage grafts can be harvested from the septum if it is present or it can be harvested from the ear (concha). These grafts if added to the tip can increase projection and eliminate the pollybeak, or relative pollybeak, by raising the tip. A shield graft can also be used to increase projection and eliminate the pollybeak and this may be placed through the endonasal or open approaches.
Saddle nose deformity - Relative or true saddle or scoops in the nasal dorsum require a careful analysis to determine if it is cartilaginous , bony , or a combination in order to properly tailor the surgical revision rhinoplasty which will entail using a graft or implant. A saddle nose deformity may result also from congenital or traumatic causes, not just surgical. The surgically created saddles results from excessive resection of the bone or cartilage or both on the nasal dorsum. It is necessary to evaluate the full nose and its surrounding structures carefully, because an apparent saddle may not be a true saddle but may be a relative saddle created by an overprojected nasal tip and in this case the revision rhinoplasty must deproject the nasal tip in order to achieve nasal and facial harmony. If there is a true depression in the nose's dorsum then a graft material is required to fill the defect. Septal cartilage, if available is the best choice for elevatin adn filling the defect. If a small defect is present, then morsalizing the cartilage is a better option to make it less palpable. Conchar (ear) cartilage and temporalis fascia can also be used to fill the defect where the ear cartilage is covered by the temporalis fascia to become less palpable. Deeper saddles may require irradiated rib cartilage or a biocompatible implant such as medpor in order to correct the deformity. Whenever using implants or cartilage grafts, Dr Sam Rizk points out that the edges must be beveled and smoothed in order to not be palpable. Dr Rizk developed a method to smoothe out cartilage edges with a powered sanding tool. Alloplastic implants offer an alternative for the correction of severe saddle-nose deformities. The benefits of these implants include lack of a donor site morbidity, ease of insertion, and a good aesthetic option. Disadvantages of implants are a potential for infection, rejection, or extrusion but this risk is minimal. Properly informed patients usually accept this minimal risk associated with alloplastic implant use such as medpor or gor-tex. Medpor and gor-tex become more integrated into the nose rather than silicon or silastic implants. Silicone or silastic implants become encapsulated, have very little tissue integration, and tend to be more mobile. Proper placement of autogenous or alloplastic implants can be performed by creating precise pockets with minimal dissection. The grafts or implants should be soaked in antibiotic solution before placement. Careful contouring of grafts and implants minimizes irregularities and asymmetries. An open or closed rhinoplasty approach may be used in placing the grafts or implants.
Midnasal deformities - Perfect nasal symmetry is nonexistent and many patients exhibit facial asymmetries. Midnasal asymmetries often occur in conjunction with asymmetries or irregularities of the nasal bridge and tip. It is important to assess midnasal deformities in relation to the nasal dorsum and the nasal tip. Trauma may cause isolated midnasal deformities by subluxing the upper lateral cartilage with a possible septal displacement. A deviated septum may also cause midnasal asymmetries if not corrected. Excessive removal of the upper lateral cartilage can also cause irregularities, functional issues, breathing disorders, and a crooked looking nose. Treatment of midnasal deformities is directed at the causal problem. Bony irregularities may also contribute to midnasal asymmetries. Septal deformities causing midnasal asymmetries require correcting the nasal septum with a septoplasty. Treatment of deformities may also require a spreader or onlay graft to correct both a functional issue and cosmetic deformity. Placement of these grafts is performed with creation of precise pockets with minimal dissection through a unilateral intercartilaginous incision with the endonasal rhinoplasty or alternatively, the open rhinoplasty approach may be used. Auricular composite grafts may be used if both mucosa and cartilage have been overly resected. All of these techniques may be performed through an open rhinoplasty approach if direct visualization is desired during graft placement.
Tip and alar-columellear deformities - Tip deformities present some of the most noticeable complications of primary rhinoplasty. Injudicious excisions of the lower lateral cartilage, caudal septum, and soft tissue in the initial rhinoplaty may result in an aesthetic deformity and a functional abnormality as well. Some common problems include a pinched nasal tip, bossa formation, or alar retraction. Pinching of the alar walls is a sign of overresection of the lateral most portion of the lower lateral cartilage. Therefore, conservative resection of cartilage can prevent this unnatural result. Collapse of the external nasal valve is common in these cases, causing a functional breathing issue as well. Forced nasal inspiration will result in collapse of the external nasal valve and a pulling in of the lateral nasal wall. Treatment consists of placing cartilage grafts into the deficient areas. Either autogenous septal or auricular cartilage grafts may be used or medpor alloplastic implants. Cartilage grafts of the proper size, shape, thickness and dimension can be harvested and are molded and sculpted with smooth edges. Thick scar tissue is sometimes encountered in this region and be elevated better by hydrodissecting it with the local anesthetic. A precise pocket is created so as to be just large enough to admit the graft. Stiffness is an important quality in the grafting for this region to hold the skin and provide support so morselizing or crushing the graft is not a good idea.
Nasal bossa are knob like - protuberances in the region of the dome. They occur most commonly when primary nasal asymmetry required major alteration of the alar cartilages at the initial surgery or from a procedure called vertical dome division where the alar cartilages were divided at the dome. Leaving sharp edges can lead to bossa formation. Bossa become hidden initially by tip swelling, bossa become evident as the swelling resolves. Overresection of the lobular tip can result in a too-narrow complete strip that may buckle over time. Bossa can be unilateral or bilateral, symmetric or asymmetric. Bossa are more of a problem and can be visualized more in thin skin patients. Surgical correction of bossa is performed through an open approach more preferable than the endonasal approach. The bossa may be shaved, until symmetry is achieved or it may be covered by a septal or auricular graft.
Columellar retraction can occur congenitally, secondary to surgery , or secondary to trauma. Any columellar retraction must be evaluated in relation to the alar-columellar and nasolabial regions. If columellar lengthening is required, a determination is made whether an auricular or composite graft or cartilage alone is needed. To make this determination, inferior retraction is placed on the columella with the thumb and index finger to assess mobility. If limited mobility is present, then a composite graft is needed. If the columella moves freely, then a graft alone will suffice. If cartilage alone is required, a precise endonasal pocket is created through an incision made at the caudal septal area as the columella is retracted inferiorly. An appropriate shaped graft is sculpted from septal or auricular cartilage and the graft is placed in the created pocket to augment the deficient caudal septum. Overcorrection is recommended as postoperative shrinkage may occur. When both vestibular skin and cartilage are deficient, a composite graft is required to lengthen the retraction. The best place to obtain a composite graft is from the posterior conchal skin which is less adherent to the cartilage but easier to manipulate. The septocolumellar dissection is performed and the composite graft is sutured into the remaining vestibular skin and caudal septum with fine catgut sutures. Columellar and caudal septal reconstruction establishes harmony to the upper lip area which is an important aesthetic unit.
Alar retraction can be a congenital deformity but most commonly it is iatraogenic, resultling from a previous rhinoplasty where excessive lobular cartilage and vestibuar skin was removed. To prevent this complication it is important to leave at least 3mm of vestibular skin. An evaluation of the alar-columellar relationship is important as a hanging columella can give the illusion of a retracted ala. If the columella is not hanging and the ala is truely retracted, then a septal or conchar cartilage graft or maybe a composite graft is needed to correct this deformity. A composite graft is reserved for deformity involving both the cartilage and vestibular skin. The concha cymba simulates best the shape of the lateral crus. Cartilage from the ear contralateral to the alar deformity approximates best the curvature of the normal ala.
To summarize the surgical plan, Dr Rizk will use grafts or implants frequently in revision rhinoplasty to correct multiple areas of deformity or collapse. donor sites may include septum, ear, rib or alloplastic biocompatible implants such as medpor. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant. The objectives include caudal support grafts to the nasal tip, multiple grafts to recreate projection and tip definition, correct internal and external nasal valve collapse with spreader and nasal batton grafts, correcting a dorsal saddle nose deformity with either a dorsal onlay graft and/or spreaders, correcting maxillary recession and the drooping nasal tip/long nose syndrome with plumping grafts or maxillary augmentation, correcting a wide nose with proper osteotomies and grafting, treating amorphous, bulbous noses with grafting combined with defatting of thick skin noses. Correcting nostril abnormalities is also the last deformity to be addressed during the revision rhinoplasty.
Revision rhinoplasty often requires a skilled facial plastic surgeon who performes revision rhinoplasty routinely. The surgery needs to be performed by a very skilled new york rhinoplasty expert such as Dr Rizk. Skill in the use of grafting is needed. Dr. Rizk has perfected the art and science of graft sculpting to achieve a smooth and natural result.
Written by Dr. Sam Rizk