Secondary Rhinoplasty

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Chapter 12 Secondary Rhinoplasty

Bahman Guyuron, David Stepnick

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).

Summary

1. The incidence of body dysmorphic disorder is higher on secondary rhinoplasty patients and it should be considered carefully in evaluating this group of patients.
2. Secondary rhinoplasty patients require more consultation time.
3. Patients seeking a secondary rhinoplasty often are persistent in learning about the mishaps during the initial surgery that necessitated a secondary rhinoplasty. Any unfounded statement, hint, or gesture, indicating fault on the part of the previous surgeon(s) is unfair and unethical.
4. Supra-tip deformity could be the result of under-resected or over-resected caudal dorsum with resultant scar tissue, postoperative loss of tip projection, or a combination of these factors.
5. Careful internal nose examination is crucial to detect any nasal valve dysfunction, residual septal deviation, enlarged turbinate septal perforation or synechia.
6. The radix can be deepened by removal of the excessive bone using a guarded burr with gentle side-to-side motion.
7. Both an inverted V deformity and internal nasal valve dysfunction would be improved or eliminated by placement of spreader grafts.
8. One may have to remove a wedge of bone between the septum and lateral portion of the nasal bone on wide secondary noses to be able to narrow the vault.
9. An inadequate tip projection can be corrected with an onlay tip graft when the infratip lobule is deficient, by a columella strut if the columella is short, or a combination of these techniques if both of these deficiencies are co-existent.
10. During secondary rhinoplasty, a minor alar retraction is corrected with an alar rim graft, a moderate retraction is corrected using a rim graft and lateral crura strut, and the severe deformity requires V-Y advancement of the nasal vestibular lining and rim graft or composite graft.

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.

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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.

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

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

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

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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).

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Fig. 12.6 Profile view of patient exhibiting supratip deformity.

An obtuse nasolabial angle (over-shortened nose) was the hallmark of rhinoplasties performed during the 1970s and early 1980s. Suboptimal tip rotation is fairly common today due to repeated pleas for conservatism by rhinoplasty educators. The columella may appear too caudal in relation to the alar rim in many of the secondary rhinoplasty candidates as a result of alar retraction, protrusion of the caudal septum (Fig. 12.7) or, more commonly, due to placement of a columella strut. The ideal amount of columella visible on lateral view is between 2 mm and 3 mm. Excessive columellar show is displeasing and requires correction. Conversely, the columella may ostensibly appear retracted as a result of excess caudal extension of the alar rim or could be truly retracted as a consequence of a short anterior septum.

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Fig. 12.7 Patient with hanging columella.

In a basilar view, one can appreciate any asymmetry of the domes or nostrils, infratip lobules/nostril discrepancy, and abnormalities of the nostril shape. An overhead view may reveal a deviation of the nose more clearly.

The nasal valves should be observed during inspiration. Collapse of the nasal valves was a common sequelae of the rhinoplasties per-formed before 1980, when many noses underwent aggressive resection of the midvault. This problem, although still existent, is less common today. Intranasal examination may also reveal inadequate correction of the preexisting septal deviation, septal perforation, enlarged inferior turbinates, synechiae, or neglected polyps.6,7

Because of the variety of nasal imperfections possible in patients undergoing secondary rhinoplasty and the precision required to define and correct these deformities, patient assessment using digital life-sized photographs becomes even more critical than in planning a primary rhinoplasty.13 Life-sized photographs provide a blueprint for surgery and ensure synchronicity between the surgeon’s and patient’s goals.

Indications and Contraindications

In general, the secondary rhinoplasty should not be performed until at least 1 year has elapsed since the primary rhinoplasty. On occasion, the patient’s anxiety and the degree of deformity are such that the surgeon cannot justify delaying the secondary rhinoplasty an entire year. In this instance, the patient and physician should be aware that unpredictable factors, such as swelling and scar tissue from the initial surgery, may distort the predicted results despite good surgical judg-ment, necessitating additional revision after healing is complete. More than one office visit may be required to ensure a clear mutual understanding between the surgeon and the patient before the surgery plans are finalized. This will afford more time for healing before the surgery is performed.

When discussing the procedure and risks, it is important for the surgeon to inform the patient of routine general complications, such as infection and bleeding, as well as those specific to rhinoplasty. Unpredictability and possible failure to achieve the goals should be revisited with the patients. The limitations that result from the presence of scar tissue, the finite supply of available and suitable cartilage grafts, shrinkage of the skin, and telangiectasis must be explained to the patient. The potential use of conchal or costal cartilage also should be reviewed, depending on the surgical circumstances. Abnormal healing, along with the potential for decrease in nasal airflow should be reviewed.

Patients who seem to have a clear understanding of the surgery and the anticipated realistic outcome are the best candidates for surgery. Patients who seem unrealistic, make the surgeon uncomfortable, demand perfectionism, have difficulty in understanding the limitations of surgery, or make incessant disparaging remarks about the previous surgeon may not be proper candidates for secondary rhinoplasty.

Surgical Techniques

Correction of secondary nasal deformities may require either a minor intermediate, or a major rhinoplasty. Minor revisions, such as insertion of an isolated tip, dorsal, or spreader grafts can preferentially be performed under local anesthesia with intravenous sedation. Whenever possible, intermediate and major revisions or a full secondary rhinoplasty should be optimally conducted with the patient under general anesthesia because most of these patients have developed significant scar tissues that render the diffusion of local anesthetic more difficult, uneven, and less predictable. Furthermore, dissection of the septum and soft tissue is more time consuming and onerous, demanding significant concentration. A patient sedated deeply enough to be comfortable may aspirate blood present in the pharynx, whereas a lightly sedated patient may experience discomfort, converse; and often become garrulous during surgery, thereby distracting the surgeon.

Incision

Minor revisions can be performed using an endonasal approach. However, an exonasal approach through a columellar step incision is preferred for major revisions or a full secondary operation.14,15 This approach affords the surgeon a better exposure and opportunity for identification of the anatomy and pathologic conditions. If the patient’s initial surgery or previous revisions were performed using an open technique, a slight delay phenomenon will have occurred, providing more safety for the second operation with respect to the soft tissue circulation. If an endonasal approach has been used previously, the secondary procedure can still be performed successfully using an open technique.

The key to a successful surgery is the ability to identify the imperfections and adequate exposure, regardless of the technique. Most of the deformities can be detected readily during the external examination. However, it is not always possible to fully delineate the structural flaws, especially in the tip area, during physical examinations; thus the surgeon may experience some unexpected findings during surgery and one has to be prepared to deal with these.

Following induction of anesthesia, the nose is packed with gauze containing 4% cocaine or neosynephrine. Lidocaine containing 1:200 000 epinephrine is infiltrated. If turbinectomy is a planned part of the procedure, they are injected first. After waiting a short period for initial vasoconstriction the nose is injected profusely with xylocaine containing 1:100 000 epinephrine to cause more intense vasoconstriction and facilitate the surgical dissection. These two injections given several minutes apart will maximize the vasoconstriction yet cause minimal systemic effects. A step or inverted V incision is made in the columella. The soft tissues are elevated with the dissection being conducted at the interface between the nasal frame and overlying soft tissue, until the entire dorsum is dissected free.

Alteration of the radix

An under-corrected radix can be rectified by removal of bone from this area using a guarded burr.16 This tool is safe and extremely effective if used properly. After the skin and soft tissue in the nasion area have been adequately elevated, the guarded burr is introduced into the site (Fig. 12.8). The surgeon can lower the nasion in an incremental fashion by gently moving the rotating burr from side to side. If the dorsal hump is large, removing it first may facilitate insertion of the guarded burr between the skin and the bone of the radix. Occasional soft tissue interference with the movement of the burr should not discourage its use. Repeated, judicious use of this tool will achieve the intended objectives. However, caution should be exercised because this tool is very powerful and may result in excessive bone removal if used too zealously.

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Fig. 12.8 Guarded burr is used to lower radix.

Dorsal hump

A residual dorsal hump can be removed easily with a rasp. Use of an osteotome, although advocated by some, may not be advisable because of the inherent difficulties in orientation and the irregular density of the residual bony prominence, which behaves totally different than an intact hump. It is crucial to elevate the soft tissues overlying the dorsum as thoroughly as possible to prevent thinning of the dorsal skin tissues. Removal of the hump may result in a wide-appearing dorsum, requiring an osteotomy that may or may not have been planned. If septoplasty is indicated, it is performed at this time through an open technique and the needed cartilage is harvested. If there is no hump to be removed, or dorsal surgery does not lead to an open roof, the septum can be corrected through a closed incision.

Nasal bone osteotomy

Lateral osteotomies can be performed percutaneously or through a stab wound in the vestibule. If the latter is selected, elevation of the periosteum may not be achieved as easily during the secondary rhinoplasty as it is during the primary surgery because the periosteum adheres more intensely to the bone after the initial procedure. On the other hand, the secondary osteotomy is often easier to perform if the previous osteotomy site can be utilized since usually there is not a great deal of bone deposited in this site, even long after the previous osteotomy. Commonly, however, the initial osteotomy is performed too anteriorly, resulting in a step deformity which necessitates a new secondary osteotomy more posteriorly. In patients who have experienced repeated trauma, osteotomy can be difficult. Medial, vertical percutaneous and/or internal osteotomy may be necessary. A common reason for the failure to optimally reposition the nasal bone medially is excessive bone between the septum and nasal bones. This can readily be corrected by removal of a wedge of bone from this site. To do so, a medial osteotomy is first begun along the medial aspect of the nasal bones, aiming cephalically and medially. The second osteotomy is started immediately lateral to the septum and midline bone, aiming cephalically and laterally. The two osteotomies are joined at the nasion and a wedge-shaped extra bone is removed. When the lateral osteotomy, including a percutaneous, anteroposterior, or a lateral low-to-low osteotomy is completed, the nasal bone can be repositioned as a unit, avoiding an unfavorable segmentation.

A small lateral depression over the nasal bone can be camouflaged by using a cartilage graft, or even a fat graft, as long as the airway has not been narrowed significantly by the medial displacement of the nasal bone and the upper lateral cartilage and the internal valve remains competent. If the patient experiences difficulty breathing, it may be necessary to correct the nasal valves by out-fracturing the nasal bones, which will reposition the upper lateral cartilages and improve the airway. This maneuver, however, is not predictable. Addition of a cephallically extended spreader graft may prove helpful in maintaining the nasal bones in the desired position.

Correcting the dorsal deficiency

A depression resulting from over-resection or asymmetric resection of the midvault is a common finding during secondary rhinoplasty. This will often require a cartilage graft. Septal cartilage is the preferred graft source to rectify an over-resected dorsum. If the patient has undergone septoplasty previously, the available septal cartilage may be insufficient. However, the mere history of septoplasty should not cause the surgeon to avoid exploring the septum. If available, the septal cartilage graft is prepared and gently crushed, and the margins are beveled to prevent a harsh dorsal line or step (Fig. 12.9). The graft is sutured to the dorsum to avoid shifting. It is important to dissect the soft tissues adequately to avoid forcing the graft out of desired position while healing. The caudal portion of the graft should be narrower than the central portion (fusiform).

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Fig. 12.9 Gently bruised septal cartilage in one to two layers is optimal choice for dorsal augmentation.

Conchal cartilage graft is the second choice for correcting minor deficiencies of the dorsum; for correction of major deficiencies, a costochondral graft is preferred.

Harvesting conchal cartilage graft

The ear is infiltrated medially and laterally with xylocaine containing 1:100 000 epinephrine. Using a 25-gauge needle and brilliant green, the site of the incision is planned, tattooing across the full thickness of the ear within the conchal fossa while adequate cartilage is being maintained for ear support. A postauricular incision is made and the skin is carefully dissected away from the conchal cartilage leaving the perichondrium on the cartilage graft. Guided by the tattoo marks, an incision is made in the cartilage. The perichondrium is separated from the lateral aspect of the conchal cartilage to be harvested. The cartilage is removed, encompassing most of the conchal fossa, leaving sufficient frame for support of the ear. The wound is irrigated. A 5-0 plain catgut suture is passed through the upper portion of the conchal fossa, taken through the mastoid fascia, and brought out through the lower portion of the fossa and clamped, leaving adequate suture loop. The post-auricular incision is then repaired using running locked catgut 5-0 plain sutures. A cotton dressing is applied to the conchal fossa and the previously placed suture of 5-0 catgut sutures is tied over it to eliminate the dead space.

Harvesting costal cartilage graft

A submammary or an anterior chest wall incision is made for a female or male patient, respectively. This incision is taken through the rectus muscle using coagulation power of the cautery. The fifth or the sixth rib is exposed and the constochondral junction is identified. The perichondrium is elevated. The dissection is continued medially and circumferentially with a great deal of care to avoid an injury to the pleura using a periosteal elevator. A piece of cartilage graft is harvested approximately 6 cm in length. A valsalva maneuver is conducted to assure the integrity of the pleura. The wound is irrigated copiously. A suction drain is placed in position. Meticulous repair is performed using a combination of 3-0 and 5-0 monocryl, and 5-0 plain catgut. Waterproof dressing is applied.

If the costal cartilage is used to avoid warping the cartilage, the surgeon must follow Gibson’s principles17 or place a permanent Kirschner wire in the center of the cartilage to avoid warping.18 If an osteotomy is necessary to correct asymmetry or excess width of the nasal bones, it is crucial that the surgeon perform the osteotomy first, and then apply the dorsal cartilage graft.

Correction of inverted V-deformity and nasal collapse

It is commonly necessary to restore the competency of the internal valves on secondary rhinoplasty patients by repositioning the upper lateral cartilages. Collapse of the upper lateral cartilages disturbs the function of the nose and engenders an undesirable nasal form known as an inverted V deformity, as referred to earlier.4 Less severe deformities can be corrected by using a spreader graft;4 more significant deformities require the use of a splay graft.19

To insert the spreader graft, the upper lateral cartilages and muco-perichondrium are separated from the septum. An appropriately sized graft extending from the junction of the nasal bone and the upper lateral cartilages (Keystone area) to the caudal end of the upper lateral cartilage is prepared. This graft is designed approximately 3 mm wide and 12-15 mm long; its thickness varies depending on the degree of the internal valve collapse (Fig. 12.10). If the graft is too thin to achieve the intended result, two layers are used. The graft is fixed in position using at least two through-and-through 5-0 monocryl mattress sutures. This step is crucial; otherwise, the graft may become dislodged while the splint is being applied, or during healing, which will result in a loss of function and may induce a discernible dorsal irregularity. The upper lateral cartilages are then sutured to spreader grafts and the septum. Placement of the spreader grafts may have more of a positive effect on the creation of optimal dorsal outline than the valve function.

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Fig. 12.10 Artistic illustration of bilateral spreader graft in position and fixed with three sutures.

The splay graft is employed when the lower lateral cartilages are too attenuated or too short to allow a spreader graft to provide sufficient improvement in the valve function and achieve the intended aesthetic goals. The graft is tailored to extend from the posterior extent of one upper lateral cartilage to the opposite side, spanning the anterior septum.19 When the graft is inserted, the splay effect provides significant and enduring competency to the internal nasal valves. The open technique, again, is the preferred approach for the placement of this graft. The mucoperichondrium is separated from the medial aspect of the upper lateral cartilages bilaterally to create a pocket that extends to the posterior limits of the upper lateral cartilage. Preferably, a conchal cartilage graft is harvested, tailored, placed in position, and fixed to the underlying anterior septal border, using 5-0 PDS suture. It may be necessary to minimally bruise the septal cartilage to avoid excessive widening of the lower portion of the nose. After the cartilage is fixed to the septum, the anterior border of the upper lateral cartilages is sewn to the cartilage graft under mild tension to create continuity, strength, and proper contour. If the dorsal projection is considered to be optimal before application of the splay graft, it is necessary to lower the existing dorsal contour commensurate with the thickness of the cartilage graft to avoid excessive projection of the dorsum.

Adjustment of the caudal dorsum

The caudal dorsum may appear over-projected as a result of inadequate resection, causing a supratip deformity, which can be easily contoured. After the dorsum is exposed, the upper lateral cartilages are dissected and separated from the antero-caudal septum. It is essential to maintain the mucoperichondrium over the caudal nasal vault intact to prevent collapse of the upper lateral cartilages. These tissues at the antero-caudal area are somewhat rigid after a primary rhinoplasty. On rare occasions this rigidity of the soft tissues after removal of the anterocaudal septum is enough to prevent skin from draping over the newly shaped dorsum and may produce a space, setting the stage for a recurrent supratip deformity. Use of a supra-tip suture will reposition the soft tissue tenting over the caudal septum and will eliminate this dead space (Fig. 12.11). Commonly, the supratip deformity can be the consequence of an over-resected caudal dorsum or the result of leaving a dead space that fills with clotted blood, subsequently becoming scar tissue. When this occurs, the scar tissue is removed, a cartilage graft is applied to the caudal dorsum and supra-tip suture is used.

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Fig. 12.11 Suture technique to approximate supratip issue to underlying cartilage after removal of scar tissue.

Tip refinement

Secondary nasal tip deformity is exceedingly prevalent. The pathology can include over-projection, under-projection, excessive or inadequate width, or asymmetry. All of the principles discussed in the previous chapter apply here as well. Excess width can be controlled with suture technique. If the domal arches are too wide, a transdomal (dome defining suture) would be used. If the domes have proper shape but are positioned further apart, an interdomal suture would be a better choice. Commonly, the continuity of the domes and upper lateral cartilages has been interrupted, rendering the suture technique difficult, if not impossible. Furthermore, the cartilages are more rigid. These factors set the stage for an unpredictable response and asymmetry; thus, more intra-operative trials are necessary for the placement of the sutures than for the primary tip adjustments. Under these conditions, a subdomal graft would control the interdomal distances and a tip graft would restore a better form to the nose.20 Inadequate tip projection can be improved with the suture technique, application of a columellar strut, placement of a tip graft, or a combination of the methods. If the projection deficiency is minimal and the domal arches are too wide, placement of a transdermal suture will achieve both goals. It will narrow the domes and increase projection. If the inadequate tip projection is because of a short columella, a columellar strut is used. If the problem is the deficiency in the lobule, a tip graft will be utilized as an onlay or a shuttle graft (Fig. 12.12). The excess projection can be lessened either by resecting the footplates and the lateral crura using the tripod concept, depending on the nose length and projection, or by removing the domes if they are too wide or distorted to be avoided by using less invasive maneuvers.

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Fig. 12.12 A, Photograph of the onlay tip punch and shield punch. B, The punch is being used to harvest the tip graft. C, A Skin hook is used to facilitate retrieval of the graft from the punch. D & E, The tip graft is in position and fixed using 6-0 Monocryl.

Lateral crura strut

A lower lateral strut can correct the collapse of lower lateral cartilage.18 The lower lateral strut is a piece of cartilage placed under the surface of the existing lower lateral cartilage, extending from the maxilla to the ipsilateral dome.

Correction of protruding columella

Excess caudal projection of the columella can be corrected by resecting a rectangle-shaped piece of cartilage from the caudal septum and a commensurate amount of lining from the membranes of the septum. If an anteriorly based, triangle-shaped cartilage is resected, it will induce cephalic rotation of the nasal tip. If the nose is under-projected and the patient exhibits excessive caudal projection of the columella, the footplates and the medial crura can be overlapped and fixed over the caudal septum.21 This is called the Fred technique.

Placement of a columellar strut

A columellar strut is a better choice when the lobule volume is proportional and the columella is short. This will provide stability to the central portion of the nasal base. A piece of cartilage, usually 2 cm long and 3 mm wide, is prepared. The graft is placed in between the medial crura over the nasal spine and fixed in position symmetrically. This maneuver alone will cause cephalic rotation of the tip, caudal projection of subnasale and increase in tip projection. Additional projection can be achieved by resting the groft on the maxilla.

Tip graft

For patients with a deficient lobule and inadequate tip protection, an onlay or shield type tip graft is the preferred approach. Nasal elongation for correction of an over-shortened nose can be accomplished by adding a cartilage graft to the caudal septum or by placing a strut that extends from the medial crura to the septum, advancing the columella caudally. This strut also may advance the alar rim, as long as the medial crura and domes, and the lateral crura are still in continuity, and the cephalic scar tissue has been released sufficiently. If the alar rims are in an optimal position, an onlay lobule cartilage graft may advance the columella effectively without altering the alar rims. However, this is only applicable when there is minimal deficiency.22 The tongue and groove technique can be used to elongate the short nose of varying degrees.

Footplates

The footplates may be widely displayed or coould be asymmetric. This disharmony is corrected through the posterior portion of the hemitransfixion incision. In the case of an under-projected tip and splayed footplates it is advisable to approximate the footplates, which will strengthen the tip support and narrow the base of the columella. For the short nose, the footplates are resected and the medial crura approximated, resulting in caudal rotation of the tip.

Correction of retracted alar rim

If the retraction is minimal, it can be corrected with placement of analar rim graft.23 A piece of septal, conchal, or even costal graft is crafted3 mm wide, 1 mm or less thick, and 8-10 mm long. A pocket is createdalong the alar rim through an anterior incision. The graft is placed inposition and sutured using 6-0 absorbable catgut.

The V-Y flap is designed internally, based caudally at the alar rim.The flap is elevated, dissected enough to unfold the alar rim, an alarrim graft is placed. The V-Y advancement is then completed using5-0 chromic catgut sutures. Two stents, one internal and one external,are applied to encase the alar rim and suture in position using 5-0 nylon through-and-through suture which is tied lightly. A lower lateralcartilage strut will also advance the alar rim caudally, if the patientexhibits alar collapse, as well as rim retraction.

Alar base abnormalities

Most secondary rhinoplasty patients have a wider alar base than optimal with some degree of asymmetry. Alar base reduction6 can be performed by removing tissue from the nostril sill, the lateral alar base, or a combination of both as dictated by the alar dysmorphology. What is important, however, is that the graceful transition from the alar base to the nostril sill should not be compromised because of a fear of scarring. As the alar base advances medially, the alar rim will relocate caudally to some degree. The alar base incisional scars usually heal favorably unless the patient has thick sebaceous skin or has already demonstrated poor healing potential in the previous surgery. Many patients benefit from a combination of several of the aforementioned techniques (Figs 12.12, 12.13 & 12.14).

image

Fig. 12.13 This secondary rhinoplasty patient underwent the following: through an open technique, a dorsal graft was applied, osteotomies were made bilaterally, a columella strut was placed, a tip graft was applied, and the medial crura were approximated.

image

Fig. 12.14 This secondary rhinoplasty patient underwent the following: through an open technique, the small dorsal hump was removed caudally, a septal cartilage graft was applied cephalically, the cephalic margin of the lower lateral cartilages was trimmed minimally, and a shield graft was applied. The alar bases were narrowed.

Short nostril

The nostril length can be increased by placement of an alar rim graft, a columella strut, a narrowing of the footplate and excision of residual lining from the soft triangle.

Splint and packing

If no osteotomy is necessary, a splint is avoided and adhesive strips are sufficient. Osteotomy mandates the use of a nasal splint; however, Doyle stents will be used if septoplasty is required. Stents are necessary for an extensive secondary or primary septoplasty with secondary rhinoplasty.

The turbinates and septum are evaluated thoroughly before the surgery and, if deemed beneficial, a septoplasty and turbinectomy are performed first. Synechiae are released sharply or by using an electrocautery device with an extended tip. If electrocautery is used for this purpose, the cauterization is mainly conducted on the turbinates to avoid inadvertent septal perforation caused by thermal damage. A Silastictm stent can decrease the likelihood of additional scar formation.

In most patients, minor revision rhinoplasty can be performed with predictable or satisfactory outcome, and patient and surgeon satisfaction. It is the major secondary rhinoplasty that can be somewhat unpredictable and may require additional revision in a small percentage of patients. It is the combination of presence of scar tissue, lack of appropriate sources for a graft (as a result of previous septoplasty or use of grafts), a change in the vascularity of the tissue, and a shortage of lining that makes the results of secondary rhinoplasty less predictable than the primary rhinoplasty.

1. When in doubt about the ability to satisfy the patient, the choice is to avoid surgery.
2. The majority of patients benefit from the placement of spreader grafts.
3. Tip grafts and columella strut cannot be used interchangeably.
4. Alar rim graft is useful in the majority of secondary rhinoplasties.
5. Placement of a columella strut rotates the tip cephalically, increases the tip projection and advances the columella caudally. These changes should be considered in the aesthetic planning.

Pitfalls

1. Removal of caudal dorsal hump reduces the tip projection and this has to be computed in the overall aesthetic plan.
2. Patients who have telangiectasis at the alar base area are more likely to experience deterioration with repeated surgeries.
3. Repeated surgeries result in loss of dorsal soft tissue thickness, revealing even the smallest dorsal flaws.
4. Use of uncrushed septal cartilage graft as a tip graft may result in harsh and visible cartilage outline on patients with thin skin, even after beveling.
5. Placement of alar rim graft on a patient with hanging ala may worsen this condition.

References

1. Juri J., Juri C. Secondary rhinoplasty. Ann Plast Surg. 1987;18:366-376.

2. Millard D.R. Secondary corrective rhinoplasty. Plast Reconstr Surg. 1969;44:545-557.

3. Peck G.C. Secondary rhinoplasty. Clin Plast Surg. 1988;15:29-41.

4. Sheen J.H. Secondary rhinoplasty. Plast Reconstr Surg. 1975;56:137-145.

5. Szalay L. Early secondary corrections after septorhinoplasty. Aesthetic Plast Surg. 1996;20:429-432.

6. Constantian M. The incompetent external nasal valve: pathophysiology and treatment in primary and secondary rhinoplasty. Plast Reconstr Surg. 1994;93:919-931.

7. Constantian M., Clardy R.B. The relative importance of septal and nasal valvular surgery in correcting airway obstruction in primary and secondary rhinoplasty. Plast Reconstr Surg. 1996;98:38-54.

8. Guyuron B. Nasal osteotomy and narrowing of the airway, Presented at the annual meeting of the American Society of Plastic and Reconstructive Surgeons, San Francisco, 1997. Plast Reconstr Surg. 1998.

9. Guyuron B. Genioplasty. Boston: Little, Brown & Co, 1992.

10. Guyuron B., Michelow B., Willis L. Practical classification of chin deformities. Aesthetic Plast Surg. 1995;19:257-264.

11. Nicolle F. Secondary rhinoplasty of the nasal tip and columella. Scand J Plast Reconstr Surg. 1986;20:489-499.

12. Guyuron B., DeLuca L., Lash R. Supratip deformity: a closer look. Plast Reconstr Surg. 2000;105:1140-1151.

13. Guyuron B. Precision rhinoplasty. I. Role of life-size photographs and soft tissue cephalometric analysis. Plast Reconstr Surg. 1988;81:489-499.

14. Daniel R. Secondary rhinoplasty following open rhinoplasty. Plast Reconstr Surg. 1995;96:1539-1546.

15. Gunter J.P., Rohrich R. External approach for secondary rhinoplasty. Plast Reconstr Surg. 1987;80:161-174.

16. Guyuron B. Guarded burr for nasofrontal deepening. Plast Reconstr Surg. 1989;84:513.

17. Gibson T., Davis W.B. The distortion of autogenous cartilage grafts: its causes and prevention. Br J Plast Surg. 1958;10:257.

18. Gunter J.P., Friedman R.M. Lateral crural strut graft: technique and clinical applications in rhinoplasty. Plast Reconstr Surg. 1997;99:943-952.

19. Guyuron B., Englebardt C.L. The alar splay graft. Presented at the Annual Meeting of the American Society of Aesthetic Plastic Surgeons. 1997. New York, May 5

20. Guyuron B., Poggi J.T., Michelow B.J. The subdomal graft. Plast Reconstr Surg. 2004;113:1037-1040.

21. Fred G.B. The nasal tip in rhinoplasty: use of the invaginating technique to prevent secondary drooping. Ann Otolaryngol. 1950;59:215-223.

22. Hamra S.T. Lengthening the foreshortened nose. Plast Reconstr Surg. 2001;108:547.

23. Guyuron B. Alar rim deformities. Plast Reconstr Surg. 2001;107:856-863.

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