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58 / Posttraumatic Nasal Deformity and Nasal Fracture Management
https://t.me/medicina_free
AB
Figure 5-1. Severe saddle nose
deformity sustained from direct
blow to nose by baseball bat.
(A) Pre op post traumatic
saddle nose in 10 year old.
(B) Post operative repair of
acute nasal fracture with rib
cartilage grafting.
to septal hematoma following blunt trauma. Unfortunately, childhood nasal trauma is often underappreciated and nasal fracture and/or septal injury is
overlooked, resulting in external and internal nasal
deformities in adulthood.
Mechanism of Injury
Murray’s seminal work detailing the pathophysiology of nasal bone fractures in fresh cadaver specimens provided valuable insight into the mechanism
of injury in nasal trauma.6 Nasal fractures are most
commonly due to a lateral force, which results in
two fracture lines running parallel on the ipsilateral
thin nasal bone along the dorsum and meeting at
the junction of the thick and thin bones. In this type
Nasal bone
High velocity
fracture
Septal
cartilage
Anterior
nasal spine
Low velocity
fracture
Maxillary crest
of injury, the nose may appear deviated due to the
depression of the unilateral bony fragment.
Frontal force must be of greater magnitude to
produce a nasal fracture because the nasal bones are
buttressed by the frontal process of the maxilla, the
nasal spine, and the perpendicular plate of the ethmoid. The resultant injury includes not only a nasal
bone fracture (which may be comminuted), but also
a C-shaped fracture in the septum extending from
just beneath the dorsum of the nose, inferiorly and
posteriorly through the perpendicular plate of the
ethomid, and curving anteriorly to the inferior cartilaginous septum near the maxillary crest and the
angle of the vomer. Frequently, the inferior end of
the septum becomes dislodged from its groove and is
deflected obliquely into the nasal cavity (Figure 5-2).
Figure 5-2. The nasal septum and patterns
of septal fractures. The septal (quadrangular)
cartilage articulates with the anterior nasal
spine caudally, the perpendicular plate of the
ethmoid posteriorly, and the vomer inferiorly;
the vomer articulates with the maxillary
and palatine crests. The septal cartilage
Vomer
typically rests along a groove at the midline;
this is known as the vomerine groove. The
most common septal fracture is along this
junction between the vomerine groove and
quadrangular cartilage. A high-velocity injury
or frontal impact results in a more extensive
septal fracture through the thin central region
of the septal cartilage and extending to the
bony cartilaginous junction.
Posttraumatic Nasal Deformity and Nasal Fracture Management / 59
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As a result, the ala and nostril on the deflected side
are widened, while the opposite side is flattened and
narrowed.
High-impact frontal force injury to the nose,
such as that sustained during a motor vehicle accident, may produce comminuted or compound nasal
fractures. If a patient sustains this type of injury,
one must rule out a nasal orbital ethmoid (NOE)
complex fracture after the cervical spine, skull, and
ophthalmic injuries are cleared (Figure 5-3). Signs
of NOE complex fractures include telecanthus, epiphora, periorbital emphysema, clear rhinorrhea
secondary to cerebrospinal fluid leak, and a flattened nasofrontal root. Surgeons should have a low
threshold for requesting a non-contrast CT of the
facial skeleton if the slightest clinical suspicion for
an orbital or facial fracture arises. Further work-up
and management of NOE injuries is beyond the
scope of this chapter.
Diagnosis
Identification of a nasal fracture is primarily a clinical diagnosis and plain radiographs are rarely, if ever,
necessary. Patients may experience epistaxis, edema,
ecchymosis, and nasal obstruction. Upon palpation,
tenderness, crepitus, and step-off deformities may
be found. An obvious deformity may be appreciated, such as a conspicuous concavity or convexity of the nasal bones resulting in a twisted nose
appearance. In the acute setting, evidence of nasal
deformity may be hidden by edema.
A1
B1
Figure 5-3. Severe naso-ethemoid impaction fracture sustained in motor vehicle accident before (A) and
after (B) reduction of nasal bone and septal fracture.
A2 A3
B2 B3
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A
B
Figure 5-4. (A) pre operatively
acute fracture with deviation from
a blow to the nasal pyramid.
(B) Post operatively corrected by
open reduction fixation with the
sue of spreader grafts to correct
alvulsion and concavity.
Avulsion of the upper lateral cartilage attach-
ments may also result in a concave appearance of the
middle third of the nose (Figure 5-4). The cephalic
portion of the upper lateral cartilage is attached to
the caudal border of the nasal bone. The medial
portion of the upper lateral cartilage is attached to
the dorsal cartilaginous septum; this attachment
constitutes the internal nasal valve and has been
described as a 10–15 degree angle on intranasal
examination.7 Placement of a cotton-tipped applicator in the region of the internal nasal valve with
subsequent improvement in nasal airway function
confirms the diagnosis of internal nasal valve collapse. Closed reduction of the fractured nasal bone
may re-approximate the avulsed upper lateral cartilage to the caudal border of the nasal bone. However,
avulsion of the upper lateral cartilage from the dorsal cartilaginous septum may require placement of a
spreader graft to address the concavity of the middle
third of the nose as well as improve nasal function by
reconstituting the internal nasal valve.8 (Figure 5-5)
Intranasal examination should be performed
after decongesting the nasal cavities. Topical oxymetazoline is effective and, when mixed with 4%
topical lidocaine, can achieve both decongestion
and anesthesia. Intranasal examination is performed
to evaluate the status of the septum and to identify
mucosal injuries. If a bulge is appreciated along the
septum, it may signify a septal hematoma. If a septal hematoma is suspected, a helpful maneuver is to
palpate the intranasal bulge with a cotton-tipped
applicator and, if it is compressible, fine-needle
Figure 5-5. (A) Preoperative nasal
fracture from an accidental blow
with a car tire jack from right to left
across the the nasal dorsum. (B) post
BA
operative from a closed reduction
nasal fracture repair.
Posttraumatic Nasal Deformity and Nasal Fracture Management / 61
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aspiration is diagnostic. In the pediatric patient, the
nose tends to buckle and twist rather than fracture.
Therefore, there is a higher incidence of separation
of the perichondrium from the septal cartilage and
subsequent potential for hematoma formation. Digital photography of the subsequent nasal deformity
is obtained for the medical record.
Treatment
Timing of Repair
Some controversy surrounds timing of repair for
the acute nasal fracture. Edema follows shortly after
the initial injury, making it difficult to allow for precise reduction. Therefore, it is best to institute conservative measures to minimize edema and to allow
for proper analysis of potential deformity three
to five days after injury.
ures include: soft diet, elevation of the head of the
patient’s bed, and the application of an ice compress
to the area of injury. Definitive treatment can be
carried out five to twelve days after the initial injury.
During this period, the fractured components of
the nasal bone can be easily manipulated. However,
if definitive treatment is delayed beyond this time
period, fibrosis may cause decreased mobility of the
nasal bones, making closed reduction of the fracture
more challenging.
Anesthesia
Another area of controversy in the management
of the acute nasal fracture is the type of anesthesia administered during the surgical repair.
anesthesia with IV sedation, for instance, minimizes
the potential risks of general anesthesia, such as
nausea. General anesthesia, however, provides the
benefit of a controlled airway as well as the opportunity for uncompromised nasal examination, reduction, and manipulation. Typically, a topical
vasoconstrictive agent, such as oxymetazoline or
4% liquid cocaine, is applied to cottonoid pledgets
that are then placed in the nasal passageway to minimize bleeding while a local anesthetic, such as 1%
lidocaine with epinephrine (1:100,000), provides
further anesthesia and vasoconstriction.
Several factors should be weighed when deciding
between local or general anesthesia for the management of nasal fractures. The first consideration is
the patient’s airway. If the surgeon anticipates significant bleeding following reduction of the nasal
fracture, then the surgeon should consider the use
9
The conservative meas-
10
Local
of a short-acting general anesthetic while the airway
is secured and protected.
Another consideration is the severity of the nasal
fracture, as well as the presence of an associated septal fracture. Since one of the most common causes
for persistent nasal deformity following closed
reduction of a nasal fracture is unrecognized septal fracture or inadequate reduction, the surgeon
should consider the use of a short-acting general
anesthetic, which allow the opportunity to properly
address the causes of the nasal deformity.
11
Pediatric patients should undergo reduction of the nasal
fracture under general anesthesia since they are not
able to comply with local anesthesia. Finally, patient
comfort should also be considered. While some
patients may tolerate reduction of nasal fracture
under local anesthesia, other patients may prefer a
short-acting general anesthetic.
Closed Reduction of Acute Nasal
Bone Fracture
The authors prefer the use of the Boise elevator
to perform closed reduction of acute nasal bone
fractures. The Boise elevator is placed intranasally
and the impacted nasal bone is reduced, thus restoring the nasal length. The thumb of the contralateral
hand is placed over the nasal bone externally to palpate subtle osseous movements (Figure 5-6). If the
impacted nasal bone is locked under the ascending
process of the maxilla, the Boise elevator is used
in an upward and outward motion to reduce the
fractured nasal bone; the instrument must not be
inserted too deeply, as it may rest under the nasal
process of the frontal bone and will be of no value.
An external splint is always utilized. Additionally,
in an effort to minimize the possibility of repeat
impaction of the recently reduced nasal bone, an
internal nasal splinting can be provided in the form
of nasal packing. A small amount of absorbable
packing (Gelfoam®, Pfizer) covered with antibiotic
ointment strategically positioned intranasally along
the medial aspect of the nasal bone usually suffices
in maintaining the position of the reduced nasal
bone; it is well tolerated by the patient and does not
require removal, since it is dissolvable. While a variety of dorsal nasal splints are available, the authors
prefer the use of Aquaplast®. First, liquid adhesive
(Mastisol®) is applied to the skin. Then, the soft tissues of the nose are taped using
taping begins at the supratip break to drape the soft
tissue in this location intimately to the underlying
1
inch paper tape;
4
/
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Nasal Bone
Figure 5-6. Reduction of nasal fracture.
The Boise elevator is placed transnasally.
The surgeon’s contralateral thumb is
used to palpate the nasal bone to ensure
adequate reduction.
skeleton. Strips of different lengths are then applied
in a transverse fashion over the nose, avoiding excessive pressure. The Aquaplast® splint is then applied.
The external dorsal splint remains in place for one
week.
Repair of Septal Fracture
If the septum is deviated, it can be reduced with
either an Asch forceps or the Boise elevator to
relocate the displaced base to the midline. Next,
the septum should be re-evaluated to ensure that
proper reduction has been achieved. If the septum
remains posteriorly displaced or irreducible, then
the authors proceed with an open approach to the
septum via a hemitransfixion incision. Once bilateral mucoperichondrial flaps are elevated, complete
visualization of the septum provides the opportunity to properly identify the extent of the septal
injury. In the authors’ experience, a small hematoma
may be identified at the bony-cartilaginous junction; this is evacuated with suction. If the inferior
aspect of the quadrangular cartilage remains dislodged from the vomerine groove, an inferior strip
of quandrangular cartilage can be resected, the septum can be re-positioned into the vomerine groove
in a swinging-door fashion, and a figure-of-8 suture
with 5-0 Monocryl can be used to keep the posterior
caudal septum attached to the anterior septal spine
in the midline. Once the hemitransifixion incision
is re-approximated using interrupted 5-0 plain
gut sutures, internal nasal septal splints are placed.
Silicone septal splints are favored to ensure atraumatic placement and removal. Prophylactic grampositive antibiotic coverage (typically cephalexin)
is prescribed postoperatively and is continued until
the silicone splints are removed on postoperative
day seven (Figure 5-7).
Immediate Septorhinoplasty
In the literature, some authors advocate an open
approach to the nasal pyramid at the time of initial repair, utilizing accepted rhinoplasty techniques,
including rasping, osteotomies, and cartilaginous
resection or augmentation of the dorsum.12 However, the variables involved in an acute nasal fracture, such as irregularity and/or comminution, may
make the nasal bones not easily controlled via the
external approach. Also, the healing process and
unavoidable fibrosis following surgical repair of the
acute nasal fracture may cause shifts in the nasal
structures. Ultimately, the absence of a detailed
preoperative consultation and the imposition of a
time-pressured decision for surgery may generate a
series of expectations and obscure the transparency
required in the patient’s decision to go through an
elective aesthetic procedure. Therefore, for patients
with acute nasal fractures who are interested in cosmetic septorhinoplasty, it behooves both the surgeon and patient to consider delaying treatment
for at least a few months. However, it is clear that
changes will continue to evolve until approximately
1 year after any given traumatic injury.
13
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B
A
C
Figure 5-7. Reduction of septal fracture. Adequate exposure of the fractured septum is achieved via a
hemitransfixion incision. If the septal fracture is along the junction between the vomerine groove and
quadrangular cartilage, a strip of cartilage can be removed (
within the vomerine groove. A figure-of-8 suture anchors the quadrangular cartilage caudally to the anterior
nasal spine at the midline.
Repair of the Pediatric Nasal Fracture
While it is unclear whether disruption of the human
pediatric septal growth center affects the development of the nose, there is clear evidence from animal
models supporting the importance of such growth
centers.14 Therefore, closed reduction is the preferred method of treatment of acute nasal fracture
in the pediatric population. In order to facilitate a
thorough examination and complete reduction,
general anesthesia is used for the pediatric patient.
The technique for closed reduction is similar to
that previously described. However, there are a few
caveats. For example, internal splinting is typically
performed with light absorbable packing, such as
Gelfoam®, thus obviating the need for removal during the postoperative period. Finally, the guardians
of the pediatric patient should be properly counseled about the possibility of the child’s developing
delayed nasal deviation and obstruction and may,
therefore, be warned of the possibility of a need for
formal septorhinoplasty in the future.
black dotted line
) and the cartilage repositioned
Complications
Potential complications of repair of the acute nasal
fracture include epistaxis and septal hematoma.
Epistaxis is usually self-limiting; however, if it is persistent, oxymetazoline nasal spray, elevation of the
head of the bed, and application of cold compresses
can be utilized to decrease or stop bleeding. If a septal hematoma is appreciated in the postoperative
period, it is dealt with in a manner similar to that
described earlier in this chapter. Posttraumatic nasal
deformity following reduction efforts is another
potential complication. A review of the medical literature demonstrates the frequency of this complication ranges from 14% to 50%.15 Further analysis
of the data suggests that a possible reason for such
a high complication rate is the use of closed techniques to repair the fractured nasal bone and failure to address septal injuries. Indeed, Rohrich and
Adams demonstrated a much smaller rate, 9%, of
posttraumatic nasal deformity following reduction
efforts when the septum was properly evaluated
64 / Posttraumatic Nasal Deformity and Nasal Fracture Management
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and open treatment of the septum was performed
when indicated.
13
Conclusion
A detailed history, including the mechanism of
injury, and a thorough physical examination provide important information in the treatment of
acute nasal fractures. Soft- tissue edema, which
inevitably accompanies acute nasal fractures, may
limit the physical examination; therefore, decisions
about definitive therapy should be delayed until the
edema has resolved and any underlying acquired
nasal deformity can be fully appreciated. It is important to identify and to treat septal hematoma early
in the process. Definitive treatment should not be
delayed beyond 2 weeks, because fibrosis will make
mobilization of the fractured nasal bones more difficult. While there are different of methods for reducing and treating acute nasal fractures, it is important
not to overlook the septum and to address any existing septal deviations or fractures at the same time
as the bony fractures in order to minimize the incidence of post-reduction nasal deformities requiring
subsequent surgical interventions.
Acknowledgments
The authors acknowledge Nancy A. Rothrock for
her assistance in the preparation of digital images.
References
1. Perkins SW, Dayan SH. Management of nasal trauma.
Aesthetic Plast Surg 2002;26(Suppl 1):S3.
2. Erdman D, Fllmar KE, Debruijin M, et al. A retrospective analysis of facial fracture etiologies. Ann Plast
Surg 2008;60(4):398–403.
3. Guyuron B. Does rhinoplasty make the nose more
susceptible to fracture? Plast Reconstr Surg 1994;93(2):
313–317.
4. Imahara SD, Hopper RA, Wang J, et al. Patterns and
outcomes of pediatric facial fractures in the United
States: a survey of the National Trauma Data Bank.
J Am Coll Surg 2008;207(5):710–716.
5. Hughes CA, Harley EH, Milmore G, et al. Birth
trauma in the head and neck. Arch Otolaryngol Head
Neck Surg 199;125(2):193–199.
6. Murray JA, Maran AG, Busuttil A, et al. A
pathological classification of nasal fractures. Injury
1986;17(5):338–344.
7. Teichgraeber JF, Wainwright DJ. The treatment of
nasal valve obstruction. Plast Reconstr Surg 1994;93:
1174–1182.
8. Fischer H, Gubisch W. Nasal valves: importance
and surgical procedures. Facial Plast Surg 2006;22:
266–280.
9. Ridder GJ, Boedeker CC, Fradis M, et al. Technique
and timing for closed reduction of isolated nasal frac tures: a retrospective study. Ear Nose Throat J 2002;
81(1):49–54.
10. Khwaja S, Pahade AV, Luff D, et al. Nasal fracture
reduction: local versus general anesthesia. Rhinology
2007;45(1):838.
11. Rohrich RJ, Adams WP. Nasal fracture management:
minimized secondary nasal deformities. Plast
Reconstr Surg 2000;106(2):266–273.
12. Reilly MJ, Davison SP. Open vs closed approach to
the nasal pyramid for fracture reduction. Arch Facial
Plast Surg 2007;9(2):82–86.
13. Renner GJ. Management of nasal fractures.
Otolaryngol Clin N Am 1991;24(1):195–213.
14. Sarnat BG. Normal and abnormal growth at the
nasoseptovomeral region. Ann Otol Rhinol Laryngol
1991;100(6):508–515.
15. Rohrich RJ, Adams WP. Acute nasal fracture manage-
ment: minimizing secondary deformities. In Gunter
JP, Rohrich RJ, Adams WP (eds). Dallas Rhinoplasty.
St. Louis, Quality Medical Publishing, 2007, pp. 957–971.
Secondary Rhinoplasty
https://t.me/medicina_free
with Total Lobular
Reconstruction
Henry D. Sandel IV, MD and Stephen W. Perkins, MD
6
In primary rhinoplasty, contouring and sculpting the nasal tip may be the most challenging and
technically difficult aspects, and their outcome is
dependent upon the delayed effects of long-term
healing. Factors affecting the results include the
pre-existing anatomy, the specific surgical maneuvers performed, the scar contracture, and the longterm healing. Depending upon what was done in
the primary operation, the long-term effects of scar
contracture and surgically altered lobular cartilages
may cause less than ideal aesthetic and functional
results. Fortunately for those patients who have suffered the adverse consequences of poorly designed
surgical procedures or the effects of overly aggressive excisional surgery of the distal third of the nose,
it is possible to reconstruct the compromised nasal
structure, in most cases. The ability of an experienced rhinoplasty surgeon to dismantle and then
to rebuild the entire lobule is vitally important for
correcting the variety of problems encountered in
revision or secondary surgery of the nasal lobule.
Revisions of the internal and external nasal valve are
often intimately interconnected in secondary rhinoplasty. Correcting deviations and abnormalities
of the nasal pyramid and middle nasal vault often
coincides with the need for total lobular reconstruction in secondary rhinoplasty. Most secondary nasal
reconstructions involve the use of a great amount of
autogenous cartilage: septal, conchal, or rib grafts.
Occasionally, alloplastic materials are used as well
to provide additional contour improvement in
severely deformed nasal pyramids. Alloplastic grafting should never be used in reconstructing the nasal
lobule, however.
Because multiple grafts in the nasal lobule are
required, an external columellar incision or an
open approach is used in nearly all such cases. This
affords direct visualization, allowing the surgeon
to identify anatomical distortions using binocular
vision and bimanual palpation and to suture grafts
in place to restore the dynamic function of the nasal
valves, both internal and external.1 In addition, multiple grafts in the nasal lobule are used to achieve
an aesthetic contour and to restore the tip-support
structures. Using this approach and a series of graduated steps, one can correct both the aesthetic and
the functional components of the adverse results of
a primary rhinoplasty.
The need for revision nasal surgery arises “due to
poor aesthetic judgment on the part of the surgeon,
the surgeon’s inexperience, and the inevitable need
for a secondary operation in a difficult primary rhinoplasty,” according to Converse.
of the distal third of the nose frequently involves
undiagnosed or improperly managed persistent
septal deformities, asymmetries or inappropriate
configurations of the nasal tip cartilages, failure to
recognize inherent weaknesses, failure to recognize
cephalic malposition of lateral crura, and a failure
to recognize and treat nasal valve collapse, with or
without alar contraction (Figure 6-1). According to Webster, “any adverse scar formation and
2
Revision surgery
66 / Secondary Rhinoplasty with Total Lobular Reconstruction
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ABC
DEF
Bilateral alar struts
Single and double
dome sutures
Plumping graft
Columellar strut
G
Figure 6-1. (A) Pre operative patient with cephalic malposition of alar cartilages. (B) Post operative narrowing
the broad trapezoid tip with only single and double dome sutures. (C) Repair of external alar collapse with alar
strut grafts. (D) Pre operative patient with cephalic malposition of alar cartilages. (E) Post operative narrowing
the broad trapezoid tip with only single and double dome sutures. (F) Repair of external alar collapse with alar
strut grafts. (G) Drawing indicating repair of external alar collapse with alar strut grafts.
Secondary Rhinoplasty with Total Lobular Reconstruction / 67
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inherent weaknesses of the patient’s own cartilage,
or over aggressive resection of alar cartilages, will
ultimately result in the need for revision surgery
given a longer term timeline of healing.”3 The need
for revision surgery may not become apparent for
5 to 10 years postoperatively, but it will ultimately
cause functional and aesthetic deformities. The
quality of the patient’s skin, even in the primary
operation, has direct effects on the results of surgery
and may have a profound effect on the surgeon’s
ability to achieve a satisfactory aesthetic result in
secondary surgery. Thick, oily skin with excessive
scar tissue from previous surgery or overly weak or
over-resected cartilages with thick skin often lead to
loss of definition in the lobular area, as well as valvular collapse. According to Tardy, “The quality of
the tip skin and subcutaneous tissues [is] often the
limiting factor in achieving the desired tip refinement.”4 In an attempt to gain more definition of
the nasal tip, the inexperienced surgeon may overresect the cartilages, ultimately resulting in a contracted, scarred nasal lobule versus one with proper
tip support and structure that the skin envelope can
mold to.
As mentioned, a common cause of a poor result
in primary lobular surgery is the failure to recognize
and to preserve the important tip-support mechanisms. Major tip-support mechanisms include:
(1) the size, strength, length, and resiliency of the
lower lateral cartilages, (2) the attachment of the
medial crural feet to the caudal border of the septum, (3) the attachment of the upper lateral cartilages to the cephalic border of the alar cartilages
(i.e., the ‘returning’), and (4) the fibrous connections between the anterior septal angle and the alar
cartilages (the interdomal ligament).5 Other tipsupport mechanisms include the skin envelope
itself, as defined and described by Dyer in his discussion of “tensegrity.”6 The nasal septum contributes to tip support, as do the anterior nasal spine, the
membranous septum, and the sesamoid cartilage
complex at the piriform aperture. Preservation and/
or the reconstitution of these tip-support mechanisms is critically important to prevent the loss of
tip support, which would ultimately result in a poor
aesthetic and functional result. Often, in secondary
rhinoplasty, the surgeon is faced with disruption
of multiple tip-support mechanisms; the surgeon’s
skills, ability, and experience in rebuilding the entire
lobule and reconstructing tip-support mechanisms
will result in a restored aesthetically pleasing and
functional nasal lobule.
The rate of revision surgery in rhinoplasty has
been debated; rates have been quoted between 5%
and 27% of all rhinoplasties performed. Revision
rates among experienced rhinoplastic surgeons
provide an indication of how complex the primary
operation is and how commonly secondary rhinoplasty is performed. Reese stated that, “A surgeon’s
ideal rate of revision should be in the range of
5–10%.”7 Most studies on revision surgery report a
range of 10% to 12%. Kamer reported in 1988 that,
of all the rhinoplasties he performed over a 3-year
period, his revision rate was between 7% and 9%.8
Although this seems to be a fairly high revision
rate for a highly experienced rhinoplasty surgeon,
most of the revisions were for minor deformities
that required small touchups due to the increasing
sophistication of his patient population. It is this
author’s experience that the rate of revision surgery
is between 5% and 7%: 7% of primary rhinoplasties
on the nasal pyramid required revision surgery and
5% of primary nasal lobular rhinoplasties required
revision surgery.9 Statistics among all studies show
that the largest percentage of patients undergoing
secondary surgery of the nasal lobule required this
because the tip was still too bulbous.” Recently, it
has been suggested that the majority of patients
requiring revision surgery require improvement of
the lateral nasal wall, of recurvature of the alar cartilages, and of frank valvular collapse.10 Lesser, but
important, reasons for lobular reconstruction are
development of bossae and asymmetries of the nasal
tip itself. Kamer’s study also revealed that, while the
majority of patients required only one revision,
almost one-quarter of the patients (23%) required
two revision procedures. He reported that about
45% of patients requiring revision had at least two,
if not three or more, deformities that required correction at the time of the secondary lobuloplasty.9 In
recent years, with the increasing use of the external
columellar approach and the large number of grafts
placed in the lobule, newer indications for revision
surgery are related to the grafts themselves and the
“shrink wrap phenomenon” in the thinning nasal
skin around the newly reconstructed lobule, whether
it be from primary or secondary rhinoplasty procedures.11 While grafts often are required to prevent
collapse of the external nasal valve and for stabilization of the nasal lobule and reconstitution of the tipsupport mechanisms, the grafts become reasons for
revision surgery in themselves when they become
visible (Figure 6-2). Therefore, it is extremely important for the surgeon, whether performing primary
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