Introduction

If one considers the number of factors that govern the outcome of rhinoplasty, the frequency with which suboptimal results mandate a secondary procedure is not surprising. Secondary rhinoplasty may be performed to eliminate minor imperfections (revision rhinoplasty) or may include many of the maneuvers routinely used during primary rhinoplasty (secondary rhinoplasty).

Management of the secondary rhinoplasty patient is entirely different from the patient undergoing primary rhinoplasty, presenting a technical challenge and requiring even greater precision in planning and execution of the surgery. Skill is also required to manage the patient emotionally, analytically, and surgically, and to achieve aesthetic and functional objectives.^1–5 Both comprehensive knowledge of potential problems and finesse during surgery are necessary to achieve the desired aesthetic goals. The surgeon must clearly understand the patient’s concerns; define the nasal imperfections, and establish realistic goals. In this chapter the manifold differences between primary and secondary rhinoplasties are explored and discussed, including patient evaluation, surgical planning, technical details, and postoperative management.

Patient Assessment and Definition of Nasal Flaws

When secondary rhinoplasty patients are questioned about the source of their discontent, the answers are often much more explicit and precise than those given by patients seeking primary rhinoplasty. The secondary rhinoplasty patient has spent a good deal of time scrutinizing the nose and assessing its form and function. Some patients have even garnered a vast knowledge of rhinoplasty by reading medical literature and searching the Internet and arrive at the surgeon’s office armed with drawings, photographs and/or quotations from some of the experts in the field. These patients may have consulted several rhinoplasty surgeons, searching for one who will succinctly define their nasal flaws or deformities, and who instills the most confidence in them.

Listening to these patients, understanding the nature of their dissatisfaction, determining if the dissatisfaction has a realistic basis, and, particularly, noting the manner in which these concerns are expressed, may provide tangible information germane to the patient’s level of perfectionism, expectations, and whether it is likely that the patient will be pleased with the outcome of any further surgery. A patient, who states that his or her nose has been mutilated by the previous surgeon, but in whom judicious physical examination discloses only minor imperfections, is unlikely to be pleased with the outcome of any surgical treatment. Such a fastidious patient will find some reason to express discontent with the results of the future surgery as well, regardless of the outcome. Conversely, the patient whose nose appears grossly imbalanced and marred with multiple flaws yet makes mitigating remarks about the previous surgery and the surgeon has the highest probability of being satisfied with the outcome of another procedure.

Many patients seeking information about their first rhinoplasty are unaware of any breathing difficulties and often do not offer complaints of breathing problems. Careful observation often reveals that many of these patients are mouth breathers and internal examination may show significant airway compromise. The reason that these patients deny having breathing difficulty is that they have grown accustomed to obstruction and have no way of knowing how much better their breathing could be. Secondary rhinoplasty patients, on the other hand, are distinctly aware of breathing problems and commonly associate it with previous surgery. These patients have a baseline for airflow with which the change in the airway that occurred after the previous rhinoplasty can be compared. They are keenly aware if functional capacity is not what it used to be. The patient’s airway may have been adversely affected as a consequence of an alteration in internal or external valve function,^6,7 formation of scar tissue, medialization of the inferior turbinates and upper lateral cartilages, or any combination thereof.⁸

Secondary rhinoplasty patients may demonstrate more apprehension before the second surgery than was present before their initial procedure. These patients display a great deal of frustration and impatience. They often have developed a negative attitude towards surgeons, and, considering the perceived failure that they have endured, restoring their trust may prove difficult. To earn the patient’s trust, one has to display compassion and confidence, precisely describe the nasal imperfections, and succinctly and thoroughly outline the surgical plans.

One should allocate a longer time for consultation with a candidate for a secondary rhinoplasty than one allows for a primary rhinoplasty evaluation. Much of this time is spent in exploration, by the patient, to find out why the previous operation was unsuccessful. A skillful and experienced surgeon can appropriately re-direct the patient’s focus. Any unfounded statement made by the second surgeon may evoke further anger on behalf of the patient or a desire for revenge. If appropriate, potential legal actions often can be averted by explaining how difficult and complex rhinoplasties can be and how rare it is to attain a perfect outcome under most circumstances. Although it is not necessary to conceal or mitigate the previous surgeon’s misconduct, unjustified statements based solely on the patient’s emotional testimony or perception should be avoided. A one-sided story may lead the inexperienced surgeon to unjustly incriminate the previous surgeon of wrong-doing. Gestures, postures, or facial expressions, such as rolling the eyes or shaking the head, either intentional or unintentional, may signify to the patient that a wrongdoing or mishap during the previous surgery is the reason for a suboptimal result. This is unfair and unethical. Any such judgment should be deferred either until all of the facts pertaining to the previous surgery have been scrutinized, or should be avoided altogether.

Every attempt should be made to persuade the patient to return to the previous surgeon. This is a professional courtesy and often offers an economic advantage to the patient. However, the patient’s interest remains the top priority, and whenever the former surgeon’s skill is unknown or questionable, the more experienced and capable surgeon should undertake patient care.

One must determine whether a septoplasty or turbininectomy was actually performed and the operative records should be interpreted cautiously. The maneuvers described in the operative note should be substantiated by physical examination. The thoroughness of the septoplasty should also be confirmed, particularly if a suboptimal septal form or position is noted.

Careful assessment of the face may disclose other facial disharmonies relevant to the rhinoplasty that may be contributing to the patient’s dissatisfaction. These abnormalities may include forehead prominence or retrusion, variations of chin deformities,^9,10 hypoplasia of the malar bones, and a dysmorphic maxilla or mandible. If these disharmonies go undetected, achieving an optimal outcome is difficult, if not impossible. These features, only if deemed detrimental to the outcome of rhinoplasty, should be brought to the patient’s attention and documented. However, insistence in correcting these flaws as a condition to proceeding with the rhinoplasty should be avoided. It is crucial to ensure that the patient has realistic goals and expectations, and is not suffering from a psychological condition that may result in patient dissatisfaction in spite of a successful technical outcome. Disproportionate concern about the nose form should be analyzed carefully since the incidence of body dysmorphic disorder is higher on this group of patients, as outlined in the primary rhinoplasty chapter. Additionally, recommendations for selection of patients, also profiled previously, should be carefully considered.

Physical Examination

The external nasal evaluation should begin with observation of the skin. If the patient has thick, sebaceous skin, the previous surgery may have failed as a result of these unfavorable conditions, and this will remain a challenge during the secondary rhinoplasty. This factor must be noted and discussed with the patient. These patients are less suitable candidates for external incisions, such as those used for alar base narrowing or for open techniques. If indicated, referral to a dermatologist may be appropriate in an effort to reduce sebaceous over-activity prior to surgery. Tretinoin or isotretinoin are often prescribed, in which case surgery should be postponed for at least 3-6 months after the cessation of the treatment to minimize the likelihood of treatmentinduced hypertrophic scarring or bleeding. Effective techniques should be incorporated into the surgical plan to achieve a better tip definition for those patients with unfavorable nose integument characteristics. During surgery, the surgeon must avoid any dead space, especially in the supratrip area; otherwise blood may collect and be subsequently replaced with fibrofatty tissue, thereby reducing tip definition.

Many patients have telangiectasis which may become more numerous or pronounced after the secondary rhinoplasty. It is important to inform the patient that additional measures may have to be implemented at a later time to improve this condition.

Suboptimal scars from the initial surgery may forecast subsequent healing problems. Some patients have thin skin, particularly over the dorsum of the nose, as a consequence of dissection in the subcutaneous plane rather than the subperiosteal plane during the initial surgery, leaving the periosteum attached to the underlying hump. In these patients, as the dorsal hump is removed, some of the valuable soft tissue is also eliminated. In patients with such thin skin, every dorsal imperfection will be discernible. Therefore, it may be necessary to augment the soft tissues using a layer of dermis or fascia graft. This type of skin thinness may also result in a purplish discoloration of the nose on patients who have undergone dorsal augmentation with alloplastic materials. This color change may become more noticeable in a cold environment. This can be eliminated by the addition of soft tissue in the subcutaneous plane of the dorsum.

A systematic examination of the external nose starting from the radix and ending at the subnasale, may disclose a variety of imperfections. An under-resected radix, which is a fairly common finding, results in an undesirable transition from the forehead to the nose and is commonly associated with an appropriately lowered dorsum but a fuller than ideal radix (Fig. 12.1). The radix may also be too deep as a result of a preexisting problem that was not corrected or perhaps of under-correction during the initial surgery. Over-reduction of the radix is extremely rare.

Fig. 12.1 Profile view of patient demonstrating under-resected radix.

Asymmetry or irregularity of the nasal bones is another common cause of concern for the secondary rhinoplasty patient (Fig. 12.2). In an optimal rhinoplasty outcome, there is a graceful transition of shadows from the eyebrows to the tip of the nose. With suboptimal results, these dorsal defining lines are distorted or a second line posterior to the existing dorsal line can be seen, usually indicating a step deformity due to the nasal bone osteotomy being too anterior (Fig. 12.3). Upper lateral cartilages may also appear asymmetric as a result of unilateral over-resection or, more commonly, caused by anterior deviation of the septum (Fig. 12.4). Over-resection at mid-vault may result in an inverted V deformity as a consequence of collapse and medial shifting of the upper lateral cartilage (Fig. 12.5). Increased awareness of this problem and, especially, the use of spreader grafts, have reduced the prevalence of this deformity, although it is still seen fairly commonly. This imperfection is often not noticeable intraoperatively, early postoperatively, or even after up to 1-2 years after surgery. Depending on the thickness of the skin, it may only become discernible several years after surgery.

Fig. 12.2 Frontal view of patient demonstrating asymmetric nasal bones after primary rhinoplasty.

Fig. 12.3 Osteotomy during initial surgery may have been too anterior, resulting in step deformity.

Fig. 12.4 Deviation of anterior septum resulting in appearance of asymmetric upper lateral cartilages.

Fig. 12.5 Patient with inverted V deformity.

Abnormalities in the tip area may range from minor imperfections, such as asymmetry of the domes, to gross deformities and complete distortion.¹¹ An under-projected tip is a common feature of noses requiring secondary surgery. Nasal-tip width abnormalities are also prevalent. The alar rims may be retracted or hanging. Disproportionate width of the alar base is a common undesirable finding in noses as well. Supratip deformity may develop as a consequence of inadequate resection of the caudal aspect of the dorsum, but it is more commonly the result of excessive dorsal resection, loss of tip projection during healing, or a combination of factors.¹² As stated previously, overresection of the caudal dorsum may result in scar formation and contraction, which ultimately create fullness in the supratip area (Fig. 12.6).

Fig. 12.6 Profile view of patient exhibiting supratip deformity.