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Revision Rhinoplasty: A Personal Approach and Philosophy

Chapter 20. Revision Rhinoplasty: A Personal Approach and Philosophy

Stephen W. Perkins, M.D. and Shervin Naderi, M.D.

Rhinoplasty is one of the oldest and most commonly performed facial plastic surgery procedures. It is an operation carried out by surgeons of all skill levels with different training backgrounds. As such, it is easier to group all such surgeons who perform this operation into the category of “rhinoplastic surgeons.”

No matter what the background or skill level of the rhinoplastic surgeon, most will undoubtedly agree that rhinoplasty is a relatively difficult operation to grasp early on in one’s career during residency, and that it takes years to gain mastery of the nuances of the procedure. One gains a true sense of the intricacies of the operation after studying the work of the various surgeons who have dedicated their entire careers to this operation. To hear these giants in the field admit humility and see how they have learned from and fine-tuned their noses after 30 years or more of experience is an opportunity not to be missed or taken lightly.

Even after years of training and years of fine-tuning one’s technique, at times each surgeon will encounter a “tough nose” or end up with results that are less than satisfactory to the patient and/or surgeon. Just as a less than harmonious, “virgin” nose attracts undue attention and may have adverse psychosocial impacts on a patient, an operated nose, even when greatly improved from the pre-surgical state, is placed under scrutiny by the patient likes of which were not present preoperatively. Every subtle irregularity is now highlighted and noticed.

When encountering subtle irregularities or imperfections in the immediate postoperative period, whether our own patient or a patient operated on by a colleague, the initial prudent technique is that of patient education and patience. Seldom can an operated nose be improved by haste in the healing period.

Due to a variety of reasons, a surgeon may need to operate on a nose that has been operated on previously, either by the same surgeon or another. Often, this may be the third or fourth operation, making the term “revision rhinoplasty” possibly more descriptive than the commonly used term, “secondary rhinoplasty.” A variety of reasons contribute to the need for revision rhinoplasty. These include, but are not limited to, poor surgical planning, improper technique, under-resection, or more commonly overzealous reduction rhinoplasty, very thick or very thin nasal soft tissue envelope, insufficient nasal framework, unpredictable healing, inadequate surgeon and patient pre-operative communication, unrealistic patient expectations, or traumatic injury to the previously operated nose.

Revision rhinoplasty introduces a new series of challenges for the Facial Plastic Surgeon. Variable degree of scarring, loss of nasal support mechanisms due to aggressive reduction rhinoplasty, lack of adequate septal cartilage for rebuilding, are only some of the obstacles a surgeon may face venturing back into a previously operated nose. The use of auricular cartilage or other suitable building blocks, such as rib cartilage, irradiated cartilage, GORE S.A.M. (Gore-Tex Subcutaneous Augmentation Material), AlloDerm® (or other acellular tissue) and other alternatives to autogenous septal cartilage are also more common than in primary rhinoplasty. However, even in secondary rhinoplasty, allografts should be used as an alternative rather than a substitute to the more preferential autografts.1 A graft material not commonly employed but worth consideration is autologous dermal graft especially for patients concerned about the potential of Prions and other small infectious particles possibly associated with cadaveric tissue.3

Pre-operative planning including in-office patient exam and counseling is a crucial investment of time. We cannot stress enough the importance of “imaging.” This is an opportunity for the surgeon and patient each to visually communicate respective goals for the operation. This technology also allows the surgeon to show the possible limitations of the operation with respect to each individual patient’s anatomy through the use of morphing software. The office consult also provides a forum for the discussion of possible implant choices. The recovery room is not the ideal place to inform a patient that he or she now has a foreign or cadaveric implant if this possibility had not been previously addressed with the patient. Yet each patient has to be aware that it is usually after entering the nose that the surgeon can properly evaluate what was previously done and what further needs to be done to correct the problem. The columellar incision must also be mentioned to the patient. More often than not, major revisions, especially of the lobule, will necessitate an external approach while other problems may be approached through an endonasal technique for pocket grafting, alar retraction correction or dorsal refinement.

The problems requiring revision rhinoplasty can be categorized in relation to the anatomic site as well as the types of aesthetic and functional defects commonly seen. Common areas to address include the pyramid, lobule and airway. Most of these issues can be attributed to errors of “omission” or errors of “commission.” We define errors of “omission” as those maneuvers that needed to be done and were not in the previous surgery. On the contrary, errors of “commission” are those maneuvers that were not necessary in the previous surgery, or were done too aggressively leaving the nose usually destabilized with an over-operated appearance. In this chapter, we will present the most common reasons for revision rhinoplasty in our practice and offer some time-tested solutions to add to your “bag of tricks.”

Errors of Omission

These most commonly include inadequate tip refinement, dorsal hump reduction, or pyramid narrowing. A nose that is still overprojected or under rotated is yet another example of this error. These problems are easy to address and require completion of the maneuvers that were either done too conservatively in the previous operation or not done at all (Figure 20-1).

Here and elsewhere throughout this chapter, you will appreciate that the first step in correction of any nasal deformity, whether primary or revision, is the appropriate diagnosis of the internal structural variations leading to the external aesthetic or functional abnormality. As in any area of medicine and surgery, diagnosis is the initial, crucial step. The good rhinoplasty surgeon studies each nose, diagnoses the problem and offers a tailored solution. Much too frequently, surgeons learn a “standard” rhinoplasty operation and apply the same series of maneuvers to each nose regardless of the problem at hand and the subtle individual variations in anatomy. Without the appropriate diagnosis, the proper surgery cannot be carried out.

The Overprojected Tip

There are multiple causes of an overprojected tip and hence multiple techniques for addressing this problem. These include excess length of the caudal septum, long lower lateral cartilages, a “hanging” or under rotated tip giving the appearance of over projection, as well as previously excessive augmentative use of tip grafts. It is crucial to realize the aesthetic relationship between tip projection and rotation and how each surgical maneuver may affect one or both. Our first choice for de-projection is a complete transfixion incision disrupting nasal tip support mechanisms. The second maneuver would be appropriate resection of the caudal septum. If further de-projection is needed, the Lipsett technique is employed and we use 6.0 PDS for this purpose. This technique involves transection of the medial crus of the lower lateral cartilage somewhere between its upper and middle third followed by over lapping and suturing in order to shorten the medial crus of the lower lateral cartilage. In addition to deprojection, this maneuver also creates de-rotation. Although usually done bilaterally, the Lipsett technique can be done unilaterally to correct tip asymmetries. The original description by Lipsett did not include suture stabilization but we believe given the contracture caused by healing, suturing allows for more predictable results.8

The Under Rotated Tip

To increase tip rotation, an inverted triangular wedge of caudal septum may be resected. This will also decrease projection, as hinted above, and must be taken into account. Lateral crural flap is also a useful technique, which provides de-projection as well as rotation. This technique involves elevation of vestibular skin and mucosa at the lateral crus of the lower lateral cartilage somewhere between the middle and lateral third followed by division, overlay and suture stabilization using 5.0 Monocryl. Our technique is a modification of the one described by Kridel in 1991.9

Furthermore, it is important to understand that cephalic trim allows for rotation, which is enhanced by domal sutures. Proper placement of a columellar strut also pushes on the medial crus of the lower lateral cartilages and enhances rotation as well as providing support to the tip. More dramatic tip rotation may be achieved by releasing connections between the lower lateral cartilages (LLC) and the caudal and dorsal septum and re-suturing the LLC’s in a more rotated position.

Errors of Commission

Unfortunately, these are the more common problems encountered in our practice. It is not uncommon to find a mixture of problems, which combine errors of omission as well as errors of commission. Many of these problems are due to a combination of factors commonly involving aggressive reduction rhinoplasty with destabilization of the nose, as well as inadequate resection in certain areas making the proper diagnosis challenging. For example, a nose with saddle deformity may be due to overresection of the bony dorsum or under resection of the cartilaginous supra-tip or both.

Pyramid Abnormalities or Irregularities

The problems usually encountered in this part of the nose include dorsal ridges or visible “humps,” which commonly show up after several months, when the nasal edema has subsided, highlighting irregularities that were not addressed initially; or grafts placed intra-operatively which now show through migration or through thin skin not recognized previously. The treatment of such problems is straightforward and can be done through an endonasal approach with direct shaving of cartilage, or use of rasps in addition to crushed cartilage as camouflage “onlay.” Here, thin strips of GORE S.A.M, AlloDerm®, or other non-cellular dermal matrix, may also be used in a patient with thin skin for camouflage and thickening. Nasal fibro-fatty tissue or “soft tissue” is also an invaluable contouring tool found usually in abundance in the form of scar in a previously operated nose.

Improper width or asymmetrical nasal bones are the next common dorsal abnormalities requiring attention. The flared nasal bones or wide dorsum is easy to correct with osteotomies. Medial fading osteotomies in combination with lateral osteotomies is the most common technique employed by the rhinoplasty surgeon to narrow the nasal width. A nose previously treated with osteotomies can often be re-manipulated using firm bimanual pressure.

The treatment of the overly narrow dorsum, as well as ‘open roof’ deformity dictates the use of spreader grafts, or onlay grafts (Figures 20-2; 20-3). This deformity is commonly the result of upper lateral cartilage retraction, which usually can be prevented by judicious dorsal height reduction with identification of different bony and cartilaginous components, and stepwise reduction of each offending component as well as identification of the need for spreader grafts during the primary operation. Rohrich actually has described this technique in a five-step method.2 We prefer meticulous separation of the upper lateral cartilages from the dorsal septum followed by placement of fashioned spreader grafts. Two 30-gauge needles may be used to hold the grafts in place while 5.0 Monocryl sutures are used in a mattress fashion to secure the grafts. Crushed or morsalized cartilage grafts may be also used for dorsal width augmentation and camouflage. In the event no cartilage is available, GORE S.A.M. or AlloDerm® may be substituted for this purpose. Proper osteotomies are also crucial in “closing” an open roof deformity in a nose with previous bony dorsal hump reduction where the surgeon failed to bring the nasal bones together.

Occasionally, a “double,” or intermediate, combined with a lateral osteotomy, or even an external transverse root osteotomy may be necessary to correct a deviated or “crooked” nasal pyramid. It has been shown that the puncture sites for external osteotomies are very cosmetically acceptable.5

The treatment of the deviated nose is one of the most challenging aspects of nasal surgery. Often the bony skeleton requires multiple osteotomies as mentioned above but proper correction requires evaluation of the cartilaginous framework as well. Middle vault straightening is crucial to straightening the nose. Correction of asymmetries here with reduction, augmentation or “spanning sutures” may be necessary. The proper correction of a “crooked” pyramid may also require evaluation of the septum’s contribution to the deformity with resultant septoplasty and septal cartilage “scoring.” In certain revision noses this may only be feasible through an external approach “from above.” Unilateral spreader grafts are also viable options in “straightening” the “crooked” nose, as are onlay grafts (Figures 20-2; 20-3).

The correction of the pyramid also includes evaluation of pyramid height. An overly resected dorsum will contribute to a saddle deformity, whereas an under resected cartilaginous dorsum will result in a "pollybeak" deformity (Figure 20-1). Furthermore, a combination of overresection of the bony dorsum along with an under resection of the cartilaginous dorsum and possible supra tip scar tissue will result in a "pollybeak" deformity. Each of these esthetic problems are addressed by proper evaluation and diagnosis, followed by correction of the problem and aesthetic alignment of the dorsum in relation to tip and supra-tip height. In-office steroid injections may be necessary for reduction of supra-tip scarring and hypertrophy.7

The saddle nose will require augmentation with cartilage and/or alloplastic material. Occasionally, the dorsal septum must also be augmented, especially in cases of excessive septal resection or septal necrosis. In severe cases, rib cartilage is our preferred choice, although multiple layers of auricular cartilage wrapped in AlloDerm® or Merselene mesh may also be used. Alternatively, GORE S.A.M. is an acceptable, easily available choice.

A more serious and more common pyramid abnormality, as aforementioned, is the “open roof” deformity caused by collapse or retractions of the upper lateral cartilages. This problem can be addressed with a variety of techniques including the use of spreader grafts, dorsal onlay grafts and osteotomies.

Our indication for the use of spreader grafts are: 1) unilateral asymmetry with in-fracture or inward curvature of one upper lateral cartilage, 2) Bilateral inward curvature of upper lateral cartilages with “hour glass” appearance, 3) Extremely narrow pyramid with tall mid-dorsal hump and thin skin, 4) Prevention of late contracture deformity at the upper lateral cartilage – bony junction.

Lobule Abnormalities

Some lobular problems may be addressed through an endonasal approach with precise pocket grafting. Other more severe abnormalities necessitate an external columellar approach.

Alar Collapse and/or Retraction

Alar collapse or retractions are due to weakness of the ala secondary to lack of cartilaginous support or scaffolding in this area. In a patient presenting for revision rhinoplasty this defect may have been congenital and unrecognized by the primary surgeon or iatrogenic as a result of the previous surgery. These defects may be corrected through an endonasal technique. For alar collapse, cartilage grafts may be placed through a marginal incision in a precise pocket as an alar batten (Figure 20-4). This maneuver may also help with symptoms of nasal airway obstruction due to external valve collapse. Alar retractions of significance require composite auricular cartilage grafts obtained through an anterior approach from the cymba concha and secured in place with 5.0 Plain Gut suture. Bolsters are not necessary. The harvested composite graft is placed on the vestibular side of the ala in order to replace missing or contracted vestibular skin or mucosa, as well as to provide cartilaginous support at the point of maximal retraction. Our technique for graft harvest, while very similar to that described by Dr. Constantian,4 differs from his in that we are able to usually close the defect primarily by extending the incision at the concha cymba inferiorly along the antihelix with undermining of the concha skin enabling tension free closure.

More severe alar collapse causing a “pinched” tip appearance is usually due to either buckling of the lateral alar crus, aggressive cephalic trims, lateral division or rim strips, or total removal of the lateral crus. These problems necessitate providing support in the form of alar strut grafts. These are placed underneath the lateral crus of the lower lateral cartilages and in an open approach may be secured using absorbable sutures (Figures 20-5; 20-6). Alternatively, the graft may be the only cartilage in this area used to rebuild the lateral crus due to a total resection. The ultimate goal is to end up with a nasal base that is triangular in shape with good alar support.

Lobular Reconstruction & the ‘Short Nose’

Major lobular reconstruction is a challenging problem and requires an external columellar incision with careful study of the underlying problems. Problems to be addressed are asymmetries of tip and ala, unusual bossae, alar-columellar disproportions, rotation and projection. There are a variety of reasons for the development of bossae and each problem needs to be evaluated fully and treatment individualized.6 Areas that need to be resolved often include, loss of tip support, tip under-projection or over-rotation. Iatrogenic causes of a “short nose” include overresection of caudal septum, over shortening of upper lateral cartilages, over rotation or resection of alar cartilages, overresection of dorsum, loss of nasal septum or stunt of growth from previous surgical maneuvers in younger patients.

If the nose is not overtaken by scar tissue and if there is adequate tip cartilage in place, techniques used in primary rhinoplasty may also be used here, such as lateral crural steal or modifications of the Goldman tip technique for tip projection.10,11 These techniques involve “borrowing” cartilage from the more lateral portions of the lower lateral cartilages to augment the dome and provide enhanced projection. However, often given the findings encountered in a revision nose such as hostile scar tissue and inadequate lower lateral cartilages, the best approach is the “back to basics” approach. This involves rebuilding of the cartilaginous support scaffolding of the nose from the ground up (Figures 20-6; 20-8). The rhinoplasty surgeon must be comfortable with nasal anatomy and be able to use septal, auricular or rib cartilage, in addition to other materials to recreate the tip architecture. Once the major support mechanisms are restored, fine-tuning can be done with a variety of grafts or minor reductive shaves or augmentative onlays and grafts. Dorsal augmentation, infratip lobule grafts, single and double layer shield grafts, “cap” grafts, Peck grafts, “blocking” grafts and excision of posterior caudal septal angle, to name a few, are all techniques which must be learned well and considered in such situations. In more severe cases, the D.A.R.T. (Dynamic Adjustable Rotation Tip) technique with the use of spreader grafts or a dorsal onlay graft combined with a columellar strut in a cantilever technique may be a viable option (Figure 20-7).12 In yet more radical situations the use of GORE S.A.M. and other synthetic material may be required. We do not use calvarial bone. Occasionally, in a severely retracted nose, the limiting factor will be the pliability of the skin and soft tissue envelope. In some cases, the surgeon may discuss with the patient the possible need for total nasal reconstruction with the use of paramedian forehead flaps (Figures 20-9, 20-10).

Summary

Entering a previously operated nose brings with it a long list of challenges as well as the satisfaction of completing an often mentally tasking procedure. The first requirement for success is the proper diagnosis of the aesthetic and functional problem at hand. Even minute cartilage, bony and soft tissue asymmetries will become present down the line and may bother the patient and the surgeon. Although diagnosis is the first step, each surgeon must have a variety of techniques available to address each diagnosed problem. With such a combination approach and respect for the nasal tissue, good operative results may be expected.

Each surgeon would benefit from being comfortable with the external approach, as well as the variety of endonasal approaches. Many of the techniques discussed here are commonly used in the complicated primary rhinoplasty as well. What each facial plastic surgeon must be able to rely on is the “back to basic” approach. When all else fails, do not be afraid to take the nose, the scar tissue and whatever remnant cartilage apart and build from the ground up. This is the essence of being able to properly revise a previously operated nose.

Also, make all the minor adjustments as needed as you see them at the time of the operation. Chances are if some minor detail bothered you during the case but you “let it go,” with time and resolution of edema, this annoyance will be further highlighted and may distract you and the patient from appreciating an otherwise great surgical result.

References

1. Rokade AV, Hughes K. Outcome of GORE-TEX implants in augmentation rhinoplasty. Otolaryngology – Head & Neck Surgery. 131(2): 81, 2004

2. Rohrich RJ, Muzaffar AR, Janis JE. Component Dorsal Hump Reduction: The Importance of Maintaining Dorsal Aesthetic Lines in Rhinoplasty. Plastic & Reconstructive Surgery. 114(5): 1298-1308, 2004

3. Erdogan B, Tuncel A, Adanali G, Deren O, Ayhan M. Augmentation Rhinoplasty with Dermal Graft and Review of the Literature. Plastic & Reconstructive Surgery. 111(6): 2060-2068, 2003

4. Constantian MB. Indications and Use of Composite Grafts in 100 Consecutive Secondary and Tertiary Rhinoplasty Patients: Introduction of the Axial Orientation. Plastic & Reconstructive Surgery. 110(4): 1116-1133, 2002

5. Hinton AE, Hung T, Daya H, O’Connell M. Visibility of Puncture Sites After External Osteotomy in Rhinoplastic Surgery. Archives of Facial Plastic Surgery. 2003; 5:408-411.

6. Kridel RWH, Yoon PJ, Koch J. Prevention and Correction of Nasal Tip Bossae in Rhinoplasty. Archives of Facial Plastic Surgery. 2003; 5:416-422

7. Hahasono MM, Kridel RWH, Pastorek NJ, Glasgold MJ, Koch J. Correction of the Soft Tissue Pollybeak Using Triamcinilone Injection. Archives of Facial Plastic Surgery. 2002;4:26-30

8. Lipsett E, A New Approach to Surgery of the Lower Cartilaginous Vault. Archives of Otolaryngology. 1959; 70: 42-47

9. Kridel RW, Konior RJ: Controlled Nasal Tip Rotation via the Lateral Crural Overlay Technique. Archives of Otolaryngology Head & Neck Surgery. 4/1991; 117(4): 411-415

10. Kridel RW, Konior RJ, Shumrick KA, Wright WK: Advances in Nasal Tip Surgery. The Lateral Crural Steal. Archives of Otolaryngology Head & Neck Surgery. 10/1989; 115(10): 1206-12

11. Goldman IB: The Importance of the Mesial Crura in Nasal-Tip Reconstruction. Archives of Otolaryngology Head & Neck Surgery. 1957; 65: 143-147

12. Dyer WK 2nd, Yune ME: Structural Grafting in Rhinoplasty. Facial Plastic Surgery. 10/1997; 13(4): 269-77

Figure Legends

Figure 20-1.

“Under-surgery” by another surgeon resulted in a classic “Polly-beak” deformity which was corrected mainly through completion of dorsal cartilage resection.

Figure 20-2.

Narrow asymmetric dorsum corrected using Spreader and Onlay grafts

Figure 20-3.

Nasal diagram showing Spreader graft placement

Figure 20-4.

Alar weakness corrected with Batten graft

Figure 20-5.

Nasal diagram showing graft placement

Figure 20-6.

Alar collapse corrected with Alar Strut & Batten grafts

Figure 20-7.

Nasal diagram showing graft placement