Revision Rhinoplasty

Introduction

Revision rhinoplasty is considered to be among the most difficult and challenging operations for plastic surgeons. The difficulty in rhinoplasty lies in the understanding of the three-dimensional configuration of the osseocartilaginous framework and its translation into external contour; minor rhinoplasty maneuvers may lead to significant contour deformities and functional problems if not executed properly. To perform revision rhinoplasty, a thorough understanding of nasal anatomy and function is crucial. Realistic expectations have to be set with the patient in a comprehensive preoperative consultation. Owing to significant structural damage, revision rhinoplasty frequently becomes a reconstructive operation rather than an operation of minor adjustments.

Patient Interview

The initial patient consultation is critical in determining a patient's candidacy for revision surgery, to assess both the difficulty of the operation and the patient's expectations. Many revision patients are more knowledgeable and demanding of the result and the surgeon's time. In general the expectations can be dramatically higher. Setting realistic surgical goals with the patient is critical, as patients must understand the limitations of secondary surgery due to underlying structural damage and scarring.

Preoperative evaluation should include:

• Assessment of patient goals

• Surgeon review of prior records and operative reports

• Comprehensive medical and surgical history

  • History of bleeding disorders or coagulopathy

  • Previous surgical history

  • Active tobacco and alcohol use, as this may compromise the postoperative result

  • Previous placement of alloplastic implants and composition of the implant

  • History of filler injection to the nose or face, as these may significantly alter surgical anatomy and compromise vascularity

• Preoperative photography and computer imaging

  • Standard rhinoplasty photography should be performed, including frontal, oblique, lateral, and base views; close-up frontal, lateral, and oblique views are helpful as well.

  • Computer imaging is often essential for patients to garner a reasonable expectation for results following surgery. The surgeon must be careful to provide a reasonable expectation postoperatively, and it is important to discuss the limitations of computer imaging, especially in the nasal tip and dorsum. Computer imaging should be used primarily as a teaching tool rather than a predictive one.

• Discussion and evaluation of functional considerations

  • The NOSE survey is a powerful adjunct and can be used to track long-term results after surgery.

• Surgical consent

  • At the conclusion of the patient interaction, a robust surgical consent should be obtained and, in revision surgery, must be inclusive of all possible intraoperative needs.

Following the patient interview, a robust physical examination should be performed that can then lead toward discussion of revision surgery and expectations.

Physical Examination

A thorough and systematic physical examination with accurate diagnosis is critical to the success of the operation. The general shape, horizontal thirds, and vertical fifths of the face should be analyzed. Global assessment of nasal deformities in context with the remaining facial features often shows one or two readily noticeable problem areas. These deformities should ultimately be prioritized during surgery, as modification of any nasal structure influences the appearance of other structures; that is, a given structure is modified based on the status of its neighboring structure.

Specific to the external and intranasal examination of the nose, the following should be noted and documented:

• Skin thickness

  • Thin skin

    • Thin skin can be very problematic if not approached properly.

    • Most minor irregularities in the structural framework of the nose will show over time as the skin–soft tissue envelope (SSTE) contracts.

    • Specific maneuvers must be taken during surgery to prevent long-term complications in a thin-skinned nose.

  • Thick skin

    • While thick skin will conceal minor irregularities of the skin, prolonged postoperative edema may result, which must be predicted. The patient must be counseled on this preoperatively.

    • Thicker-skinned patients require the cartilaginous framework to project into the SSTE to provide definition to the nose; otherwise, significant scarring may occur in dead space, exacerbating SSTE thickness. This can ultimately lead to an amorphous, unrefined appearance or pollybeak deformity.

• Skin quality and scarring

  • Existing scars should be noted and, if possible, corrected during surgery.

  • Patients who have undergone previous rhinoplasty may have thinned, damaged, or devascularized SSTE.

    • Extensive dissection and electrocautery should be kept to a minimum in such patients to decrease the risk of ischemia and soft tissue necrosis.

    • Shortage of vestibular lining or vestibular stenosis should be noted on the preoperative visit. This may require auricular composite grafts for tension-free closure so as not to distort the alar margin.

• Assessment of the upper, middle, and lower thirds of the nose

  • The nose should be systematically inspected for width, deviation, irregularities, and asymmetries.

  • Palpation is important to assess the nasal skeleton for shape, strength, and symmetry, as well as resistance and recoil of the tip and SSTE.

  • Upper one-third of the nose should be particularly inspected for nasal bone length, deviation, and the need for any dorsal augmentation.

  • Middle one-third of the nose contains the middle nasal vault, which can be pinched and deviated. This must be noted preoperatively to prevent potential pitfalls with nasal obstruction.

  • Lower one-third evaluation should note the presence of supra-alar pinching, tip support, nostril retraction, and the alar-columellar relationship. These factors play a significant role in cosmesis and function and must be addressed for a satisfactory outcome. The caudal septum should be palpated to assess position and integrity.

• Aesthetic evaluation

  • Frontal view

    • The brow-tip aesthetic line should be a subtle, hourglass-shaped curvilinear line between the medial brow and nasal tip. It should follow a pattern of relative width at the bony vault with a slight narrowing at the middle vault and relative width again at the nasal tip.

    • The transition from the columella to the alar margins should have a gentle “gull-in-flight” configuration.

  • Base view

    • The nasal base should have a triangular shape without pinching or concavities between the tip and alar lobules.

    • The surgeon should note the presence of alar pinching, notching, tip irregularities, and caudal septal deviation.

    • Short medial crural footplates will present as excessive flaring of the columella toward the base and may require correction.

  • Lateral view

    • The dorsum is assessed for smoothness, contour, position of the radix, and the starting point of the nose.

    • The tip is analyzed for projection, rotation, nasal length, nasolabial angle, presence/absence of supratip break, and presence/absence of the double break (columellar-lobular angle).

    • Tip projection can be specifically analyzed using Goode's method:

      • Nasal tip projection—the distance from the alar crease to the tip-defining point—should approximate 55% to 60% of the nasal length—measured from the nasal starting point near the superior palpebral fold to the tip-defining point.

    • The nasolabial angle also must be assessed; an ideal nasolabial angle ranges from 90 to 95 degrees in men and 95 to 110 degrees in women.

• Intranasal examination

  • Both anterior rhinoscopy and rigid nasal endoscopy should be performed for an adequate examination of the turbinates, septum, internal nasal valve (INV), and nasal vestibule.

  • Specific attention should be paid to the nasal vestibule in revision surgery, as significant scarring at the INV can be present due to excessive tension in previous closure or inadequately closed incisions.

  • Presence of residual septal deviation is common and often contributes to deformity. Inferior turbinate hypertrophy or overreduction should be noted, along with the quality of the mucosa and presence of synechiae.

  • A modified Cottle maneuver is performed, placing an instrument underneath the lateral nasal side wall to assess for nasal valve patency and symptomatic improvement in obstruction. Improvement denotes a dynamic collapse that may be improved by strengthening the sidewall with alar batten grafts or lateral crural strut grafts (LCSG).

Surgical Approach

The surgical approach should cater to the deformity and goals of reconstruction. The external approach is most frequently utilized for its superior exposure and opportunity for precise graft placement with suture fixation, particularly in complex deformities.

The external approach combines bilateral marginal incisions with a transcolumellar incision.

• At the start of the operation, external contour irregularities and deformities should be marked, as injection of anesthetic agent can distort or camouflage these irregularities.

• Prior to making incisions, an ample amount of local anesthetic is used for hemostasis, and hydrodissection of scar tissue from the skin and soft tissue envelope.

• Transcolumellar incision

  • In cases of prior external rhinoplasty, the same columellar incisions should be used.

    • If deprojection of the nasal tip is planned, the columellar incision may be placed slightly above the scar. This allows for scar excision at the conclusion of the procedure if skin redundancy is present.

    • In cases where re-projection is anticipated, it is often difficult to excise the scar due to the need for additional skin and soft tissue.

• As the SSTE is raised from the underlying cartilaginous framework, care must be taken to avoid damage to the overlying skin in areas of severe contracture. This is sometimes assisted by additional hydrodissection.

In patients with minor contour deformities, the endonasal approach using marginal or intercartilaginous incisions can be an excellent option. Proponents of the endonasal approach cite lower morbidity and quicker recovery, though it is more difficult to correct major deformities. If structural deformity is not corrected, this can lead to further contracture and deformity over time, which may lead to another revision surgery.

Grafting Material

Structural rhinoplasty requires additional grafting material. Septal cartilage is usually abundant in the primary setting and sometimes in the revision setting depending on the technique of the previous surgeon. However, in most cases, the septal cartilage has been removed and additional grafting material is required. Several options are available for grafting material, including residual septal cartilage, costal cartilage (irradiated or autologous), auricular cartilage, calvarial bone, and alloplasts.

Costal Cartilage Grafts

Costal cartilage may be autologous or homologous (irradiated cadaveric) and is often the preferred grafting material in revision rhinoplasty when septal cartilage is insufficient or structurally weakened. Its advantages include abundant availability, strong, structural support, and decreased risk of infection or extrusion in comparison to alloplasts. Disadvantages include donor site morbidity, postoperative pain/discomfort, pneumothorax, prolonged surgical time (primarily due to graft preparation, placement, and refinement, rather than graft harvest), and warping of cartilage. Careful decisions should be made toward choosing segments of cartilage and predicting warping; splinting of the grafts with slivers of cartilage is often necessary to prevent excessive warping.

The ideal age range for costal cartilage grafting is 30 to 50 years. Younger patients tend to have softer costal cartilage, which makes harvesting and carving easier but is at risk for increased warping ( Figs. 34.1 and 34.2 ). Older patients tend to have more calcification in the rib, which makes the cartilage more brittle. This can lead to higher risk of fracture with manipulation but the tissue tends to warp less. The calcifications within the cartilage produce some brown discoloration ( Fig. 34.3 ).

In harvesting costal cartilage, perichondrium can be harvested as well, which can be invaluable in revision rhinoplasty ( Fig. 34.4 ). It can be used as soft tissue onlay grafts or as an underlay graft for dorsal augmentation to allow for rigid fixation to the nasal bones.

Once the graft is harvested from the chest, the segment of rib is carved into three longitudinal segments with varying thickness depending on the types of grafts needed. Each segment is initially thinned, soaked in a saline solution, and observed for warping while the operation continues. Carving in this manner will allow for warping tendencies to manifest, and the grafts can be splinted as needed prior to implantation in the patient ( Fig. 34.5 ). Homologous cadaveric rib cartilage may be used instead of autologous cartilage. The primary advantage lies in the absence of donor site morbidity and decreased surgical time. Availability is frequently limited in certain geographic areas and typically can be expensive. True neovascularization of implanted cadaveric rib has yet to be shown, and though studies have shown minimal resorption rates, the concern remains that in the long term, cadaveric rib may have higher resorption rates than its autologous counterpart.