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Revision Rhinoplasty

If rhinoplasty is a challenging performance, revision rhinoplasty is taking that challenge to a whole new level. Rhinoplasty is one of the most difficult aesthetic surgery procedures with a high rate of revision.

Francois Le Berre

PhD Bio-Science, Plastic Surgery Coordinator, Metro Beauty Centers

If rhinoplasty is a challenging performance, revision rhinoplasty is taking that challenge to a whole new level. Rhinoplasty is one of the most difficult aesthetic surgery procedures with a high rate of revision. When a plastic surgeon has to work on a nose that has been previously operated on, it is usually because the patient is unsatisfied with the previous work. Aside of a disappointing cosmetic rendition, additional functional problems may have arisen, such as difficulty in breathing through the nostrils, or protruding bumps as time goes by. Upon performing a revision rhinoplasty, a great surgeon will have 3 things in mind: the patient’s native anatomy, the structures that have been previously altered (or removed), and the parts that need reconstruction.

On the primary open rhinoplasty (the first surgery that requires opening the columella of the nose to work on its tissues), the surgeon will have a clear view on the nasal cartilages. These will be easy to see, intact, smooth and regular. Even though every nose is different, the various elements are there, and the surgeon can see what is what. When a nose has work done on it, it will respond to surgery by making a scar underneath the skin. With proper technique, this scarification is not expected to interfere with the appearance of the organ nor to stand in the way of achieving the desired results. The surgery is successful and the results delivered. For a surgeon performing a revision rhinoplasty, even with the previous written operation report in hand, uncertainty is the word.

During a revision rhinoplasty, the very first thing the surgeon will see, upon dissecting, is a mass of scar tissue on the cartilage. It usually hides away the underlying elements and alterations that have been done to the structure of the anatomical elements supporting the nose. In such a case, the textbook approach to nasal anatomy does not apply, because usually what the surgeon sees does not meet its expectation of a functional nose. The surgeon must carefully scrap through the scarred tissues to evaluate what is there, and in what shape, if ever.

As word of caution, it should be to keep in mind that no rhinoplasty goes perfectly. Even in the best hands. Every nose inside, has a peculiarity that obliges the surgeon to give way or to compromise, and that might present a difficulty, even to the best expert. But a good plastic surgeon will know what techniques to use and will execute them with finesse. Great surgeons do experience complications too, but to a lesser extent and with milder consequences. And this is why rhinoplasty revision is such a difficult task. You never know what you are going to find.

For any surgeon performing a rhinoplasty, familiarity with the patient’s ethnicity, sex and age, morphology and potential variations for each structure is essential. Most of the time, revision rhinoplasty must be performed to alter some part that has been over or under done. One of the objectives for a surgeon approaching secondary rhinoplasty, is to restoring the structural support of the nose and replacing the lost volume of soft tissues. To achieve this purpose, the surgeon must rely on grafts, that will determine the final aesthetic outcome. Even more so in the case of a rhinoplasty revision, where missing structures must be at times reconstituted and replaced.

Nasal grafts are to a rhinoplasty surgeon what wood is to a carpenter

There are three kinds of grafts: bone and cartilage, that are used for structural support, and skin, to add volume or to hide minor irregularities. Autograft material can be found on the patient, but in the case of cartilage, in limited supply. Cartilage from the ear, septum of the nose, from the chest wall have different peculiarities and best uses. Skin grafts from the shoulder, and samples of soft tissue underneath the scalp, carved from the tough film surrounding the temporal muscle, the Fascia temporalis. Finally, the bone grafts: those carefully trimmed from the neurocranium are preferred to those from the iliac crest on the pelvic bone, as they tend to show more resorption. The most common indication for the use of bone in nose surgery is for dorsal augmentation.

How to see and understand the nose

The anatomy of the nose is basically divided in three areas. The upper third is supported by nasal bones that are immobile and rigid. The medium third is semi-mobile and its structure is supported by the upper lateral cartilages. The lower and third part is very mobile, and made of what are called the lower lateral cartilages. The nose is composed of three layers, from the inside out, we find the intranasal lining, then the cartilage and bony structure, finally the muscle, fat and skin envelope.

In revision rhinoplasty, the limiting factor in correcting a previously operated nose is frequently the quality, degree of contraction, and lack of elasticity of the soft tissue skin envelope and the inner mucosal layer. In the case of rhinoplasty revision, the tip of the nose is the most difficult part to modify with precision.

In conclusion

Sophisticated grafting techniques are an indispensable tool to a skilled surgeon in rhinoplasty revision. They play a capital role in achieving optimal, durable surgical outcomes in rhinoplasty. The loss of structural integrity following a suboptimal reductive rhinoplasty put the emphasis on the importance of this framework. Skilled plastic surgeons will have recourse to grafts so as to maintain and augment nasal support mechanisms, and to enable the nasal skeleton to resist the contractile forces of healing, that would otherwise compromise functional and cosmetic results.

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