Revision rhinoplasty can be an extremely challenging encounter for both the surgeon and patient. The consultation should begin with a conscientious history and physical examination. It is essential that from the outset, the surgeon demonstrate a serious interest in the patient’s concerns.
Patients that present for revision rhinoplasty can generally be categorized into two groups. Those that recently underwent rhinoplasty with an unfavorable outcome and those which underwent surgery in the distant past. Those in the former group are extremely unhappy and in general are more difficult to satisfy. They are likely to have had a negative experience with the previous surgeon and are therefore frequently skeptical of the medical profession. In contrast, those in the latter group tend to be concerned with smaller changes and are easily pleased by their revision rhinoplasty result.
A general health intake form is used in our practice to screen patients firsthand. During the interview, the patient’s specific concerns should be sought out. It is important to seek out not only aesthetic, but also functional issues as well. The history should include the timing of the primary rhinoplasty as well as other subsequent revisions, if any. This is important to clarify the timing of wound maturation. We usually do not perform revision rhinoplasty before one year.
A careful aesthetic analysis is carried out. We use a stepwise approach based on the frontal, lateral, oblique and base views. It is extremely important to palpate the nasal osseocartilaginous skeleton throughout the examination. The thickness of the skin-soft tissue envelope (S-STE) should be determined. In patients with thick S-STE, it may be difficult to establish ideal tip definition.
First, the bony pyramid is examined and palpated for asymmetries, irregularities, and width. The nasal dorsum should follow a gentle curving line from the medial brow to the tip. The width of the nasal sidewall should be approximately 75 % of the alar base. Next, the middle vault is examined. It is important to note any asymmetries, width, deviations, saddling. Collapse of the upper lateral cartilages should also be noted. The latter may present with, an inverted V deformity. It is paramount to examine the dorsal septum in the middle vault area. Deviations in the middle vault can be due to upper lateral cartilage depressions, dorsal septal deviations, or both in conjunction.
The tip is then examined. The rotation, projection and its relation to the dorsum is evaluated. Next the tip is inspected for domal asymmetries, fullness, and depressions. The shape of the nasal tip should be noted. Palpation of the cartilaginous framework is essential to diagnose the deformity. Tip strength should be determined in order to successfully plan the reconstruction of the medial and lateral tip components. The nasal-labial angle is next examined. Its contributions from the nasal spine and posterior septal angle should be palpated.
From the lateral view, the level and height of the radix are examined. Ideally, its level should be between the cilliary margin and the supratarsal crease. The length of the nose should then be evaluated. Persistent dorsal humps should be palpated to help identify their constitution. The oblique view is essential in determining whether the hump is a midline or a lateral wall defect. The oblique view is also essential in defining a subtle middle collapse or saddle defect. The supratip area may also reveal a fullness, often termed a pollybeak. Careful palpation will allow the surgeon to determine the etiology. It may be a soft tissue or a cartilaginous deformity. The alar-columellar relationship should be examined. When there is increased columellar show, it must be determined whether it is due to alar retraction, a hanging columella, or a combination of both ?
A careful intranasal analysis is paramount to attaining a correct diagnosis before any rhinoplasty surgery. Inspection of the nasal septum for deviations and contributions, if any, to dorsal deviations. The caudal septum should be examined for deviations and any excess. The presence of perforations should be noted and explained to the patient. Although they may be complications of previous surgeries, the social history should be reviewed with the patient with attention to drug consumption. The septum should be palpated with a cotton tip applicator to help determine whether cartilage is present. Turbinate hypertrophy should be noted. The nasal mucosa and vestibule are examined for scaring or webbing.
Next, a careful analysis is performed of the external and internal valves. We prefer to use a cerumen curette to individually lateralize the each external and internal valve. The patient is asked to grade the improvement on a scale from 0 to 10. We feel that this helps us to identify where the obstruction lies. In addition, the patient is asked to inspire so that we may examine any dynamic collapse.
Although frequently overlooked, the position of the nasal tip can also contribute to nasal obstruction. Ptotic tips should be manually elevated to determine if any improvement to the obstruction occurs.
Only after a complete aesthetic and intranasal examination can the surgeon clearly make the diagnosis and delineate the surgical plan. It is imperative that the surgeon clearly express his thoughts regarding the revision surgery so that they are in line with the patient’s expectations.
We generally approach revision rhinoplasty via an external columellar incision. If the defect or deficiency is minor, such as small dorsal irregularities or alar asymmetries, the endonasal approach is used. Each individual surgeon should use the approach with which he is most comfortable and is able to achieve consistent results. Unless we are certain that the entire septal cartilage is available, we obtain consent for an auricular conchal cartilage graft. In tertiary cases where both ears have been previously grafted, costal cartilage is used. Occasionally, we have used Gore-Tex for dorsal augmentation. Its use should be limited to the dorsum to avoid extrusion-related problems.
Bony Pyramid Deformities
Excessively wide nasal bones are usually due to either incomplete osteotomies (green stick fractures) or a failure to perform osteotomies. The solution is to perform complete osteotomies. The author prefers an intranasal perforating technique without the undermining of the periosteum… The preservation of the periostium allows for a more stable bony vault in a previously osteotomized bone.
Nasal bony asymmetries can occur in several ways. Occasionally, a nasal bone may have been completely infractured, while the contralateral may have remained in a more lateral position. A lateral osteotomy in the lateralized bone usually solves the problem.
Correction of a depressed nasal bone can be accomplished in one of two ways. One technique involves performing a lateral osteotomy with subsequent outfracture of the nasal bone. A Xeroform gauze is then placed intranasaly underneath the nasal bone to hold the bone in a lateral position. For small depressions, a crushed cartilage graft may be placed in an overlay fashion above the depression.
Persistent Bony Deviations
Severely twisted noses are perhaps one of the most challenging cases in rhinoplasty. Often, noses that appear straight on the table end up with persistent deviations post-operatively. When these deviations occur in the bony pyramid, the culprit is often the ethmoid perpendicular plate. These bony deviations are best treated with bilateral lateral and medial osteotomies with the addition of either a nasal root osteotomy or an intranasal fracture of the ethmoid plate. A root osteotomy essentially mobilizes the entire nasal bony pyramid, so that it may be placed in the midline. This can be approached via a percutaneous osteotomy at the radix with a small 2 mm osteotome. This requires extreme care, as it can be a strong destabilizing maneuver. The alternative is a fracture of the ethmoid plate via an intranasal approach. This can be accomplished with a 4 mm osteotome in order to maintain the stability of the osseocartilagenous vault.
Often times, patients seek revision surgery to improve the aesthetics of the radix. The radix is an often overlooked area in rhinoplasty. When dealt with appropriately, it can often improve the nasal aesthetics tremendously.
As mentioned earlier, the ideal radix level should lie between the supratarsal crease and the ciliary margin. A low radix gives the appearance of a short nose. A radix graft can be used to elevate the radix level, and thus raise the nasal starting point. The radix height relates to the nasofrontal angle formed between the frontal and nasal bones. Ideally, this angle should be between 115 and 130 degrees. Nasofrontal angles that are shallow allow for a high radix height. This gives the illusion of a nose that blends with the frontal bar. The solution is to decrease the bony height of the nasal bones.
Middle Vault Deviations
Middle vault deviations are usually due to either deviations of the dorsal septum, collapse of the upper lateral cartilage, or a combination of both. The diagnosis relies on careful physical examination. Intranasal inspection for high septal deflections and careful palpation of the lateral nasal sidewalls will help to identify the causative factor.
Middle Vault Collapse
Middle vault collapse is a common finding in patients seeking revision rhinoplasty. In its most severe form, it can lead to internal valve collapse and severe airway obstruction. On frontal view, patients present with an inverted V , indicating a step off from the nasal bones to the upper lateral cartilages. This deformity is due to aggressive dorsal resection without re-suspension of the upper lateral cartilages. This is often the case when the upper lateral cartilages and their mucosal attachments are severed from the dorsal septum and its mucosa. The final result is inferio-medial collapse of the upper lateral cartilages. This is more likely to occur in patients with short nasal bones. The deformity is sometimes compounded by the failure to complete lateral osteotomies. This leads to a further disproportion between the upper lateral cartilages and the nasal bones.
In patients with an inverted V deformity, it is imperative to obtain a history of nasal airway obstruction as well as a physical exam to look for internal nasal valve collapse. The area where the caudal edge of the upper lateral cartilage meets the septum should form an angle of about 15 degrees. As mentioned earlier, we use a cerumen curette to elevate the valve and note improvement.
A high supratip area, in relation to the nasal tip, can have two etiologies. The most common is a high anterior septal angle. A careful examination with palpation is sufficient to make the diagnosis. Excessive soft tissue scar formation can be second cause, commonly referred to as a soft tissue pollybeak. This occurs when an overzealous reduction in a thick-skinned individual creates a dead space which is filled with soft tissue.
A note must be made however, concerning the nasal tip. At times, the dorsal height may have been adequately calculated in relation to the desired nasal tip height, only to have the nasal tip drop. Reduction of the septal angle in this case, will only worsen the problem. The solution in this case is to properly re-project the nasal tip.
Saddle deformities can be caused be a variety of factors. When associated with a previous surgery, they can be secondary to either an overaggressive dorsal reduction or a collapse of septal support from an aggressive septoplasty which failed to leave a sufficient L-shaped strut. Occasionally, an attempt to perform a caudal septoplasty for a severe caudal septal deflection, may cause a small supratip saddle deformity. Non-surgical etiologies include septal hematomas leading to abcess formation and resultant cartilage resorption, cocaine abuse, granulomatous disease, and syphilis.
The examination is critical in determining a surgical plan. In cases where the dorsum was over resected, the solution lies in dorsal augmentation. However if the saddle is secondary to loss of septal support, the surgical plan must include a nasal reconstruction with reconstitution of the L strut. The authors prefer autologous rib in these cases. The reconstruction of patients with a history of drug use should be delayed until the patient has been rehabilitated. Patients with a history of granulomatous disease should be in a quiescent state and have medical clearance.
Caudal Septal Deflections
Deviations of the caudal septum can have a strong effect on the nasal tip. In the mildest form, the deviated caudal septum can distort the columella and cause it to deflect to one side. The most severe effect, however, is the deviation of the nasal tip to one side. A deviated caudal septum is best diagnosed by palpating the caudal aspect of the septum with the index finger and the thumb. An effective caudal septoplasty will help to bring the columella and nasal tip to the midline.
Caudal Septal Excess
In patients with excessive columellar show, it is important to differentiate between alar retraction and a hanging columella. To establish the exact etiology, a line is drawn bisecting the nostril on the lateral view. The distance from the alar rim to this line ( A to L ) should be equal to the distance from the caudal edge of the columella to the line ( C to L ). Excess in the superior area ( A to L ) is due to alar retraction, whereas excess in the inferior area ( C to L ) is do to columellar excess. Columellar excess can be caused by either a weakened medial crural complex after rhinoplasty or by excess of the caudal septum and/or the nasal spine. Palpation of the medial crura and the caudal septum will detect the deformity and allow its correction.
The nasal ala can become retracted from aggressive lateral crural resection during rhinoplasty. The resection of vestibular mucosa during cephalic resection may also contribute to the retraction. Post-surgical scarring elevates the alar rim when there is a deficiency of the cartilage. In cases of mild retraction and alar rim graft can help to bring the alar rim caudaly. However, when severe retraction exsits, a composite graft will bring the alar rim inferiorly.
External Valve Collapse
The external valve is comprised of the alar rim and the fibrofatty tissue in the nasal ala. Collapse of this sturucture can occur naturally in patients with inherent weakness. However, aggressive resection of the lateral crura can lead to a weakened external valve. Examination is performed with a cerumen curette as mentioned previously. When aggressive resection was previously undertake, stregnth can be added to the nasal ala with the use of alar batten grafts. Alternatively, if the weakness to the ala is congenital, alar strut grafts can be used to strengthen the lateral cartilages.
The nasolabial angle can be influenced by various factors. The columellar limb of the angle is subject to influences from the caudal septum and the nasal spine. Excess in either or both of these two structures will tend to widen the angle. The correction lies in conservative resection of the offending structure. Deficiencies of the posterior septal angle allow for the columellar limb to retract and will create an acute nasolabial angle. For mild cases, a plumping graft may be used. However, when there is a severe deficiency of the posterior septal angle, a caudal septal extension graft can be used.
Nasal tip asymmetries can be one of the most challenging deformities in revision rhinoplasty. The authors advocate careful inspection and palpation of the nasal tip asymmetries during the examination. Using this method, the surgeon can sometimes ascertain whether tip grafts, dome division, or excessive cephalic resection are responsible for the tip deformities present. However, the diagnosis is often accurately made when the domes are exposed surgically.
Domal bossea may occur when the lower lateral cartilages are aggressively resected and the S-STE contracts around the domal area. This may also occur when the domes are divided along with aggressive cephalic resections.
The transition between the nasal tip and the nasal ala should be smooth and without significant demarcations as seen from the frontal view. The base view should demonstrate a nasal tip with a triangular shape. Alar pinching presents with a narrow nasal tip and a steep drop off between the nasal ala and the tip. This deformity can be due to aggressive resection of the lateral crura, often done to narrow the nasal tip. Alternatively, very tight dome-binding sutures can also lead to pinching by making the nasal tip too narrow and breaking the normal smooth transition between the lateral crus and the dome.