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Structural Reconstruction in Difficult Secondary Cases
The Problem
Secondary rhinoplasty presents a unique challenge, testing the surgeon’s artistry, judgement, and ingenuity. Deformities arising from a primary rhinoplasty can range in severity from mild asymmetry on the dorsum or nasal tip to severe distortion and collapse of the osteocartilaginous structures. The most complex secondary rhinoplasty cases are those where structural elements of the nose were overresected. Aggressive resection and weakening of the nasal skeleton, including the major support structures of the nose can lead to aesthetic deformities and functional problems. In secondary rhinoplasty, reconstruction of the nasal framework to produce an aesthetic and functional improvement should be the goal. Following structural rhinoplasty principles, functional deformities are treated to give the nose a more normal and balanced shape, reestablish nasal support, restore tip projection, and treat airway problems.
Systematic analysis of the nose and determination of the deformities are essential for a successful reconstruction. After the diagnosis is made, the goals of the surgery are established, and a treatment plan is formulated. The surgical plan is individualized for each patient according to the present deformities. The formulation of the treatment plan includes repositioning displaced anatomic structures and replacement of missing structures. Anatomic reconstruction of the weakened or interrupted cartilages and reconstitution of a stable nasal framework must be performed for a predictable outcome. The newly reconstructed cartilaginous framework should be strong enough to withstand the even greater forces of wound contraction during the healing period.
Surgical Technique
Open approach allows full exposure of the nasal structures, deficiencies are accurately determined, and necessary changes are executed under direct vision.
Autologous cartilage grafts are the preferred material to replace missing structures in secondary rhinoplasty. When significant grafting and support of structural elements are needed, autologous rib cartilage is the graft of choice. Rib offers an unlimited amount of cartilage for structural grafting. Long and straight struts can be prepared from rib cartilage for reinforcement or reconstruction of the septum and the alar complex.
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