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nasal bones can be corrected 3–6 months postoperatively; however, it is best in all cases to be patient
and let more edema resolve. A good rule of thumb
is to wait at least 6 months to correct any pyramid
abnormality. Although Webster usually waits 3 years
to perform revision surgery of the nasal tip, many
issues that show up in the first year can be corrected
Figure 6-2. Frontal view of a patient with visible alar
batten grafts requiring revision.
after one year of healing, at which time the scar tissue of the nasal lobule has softened, allowing the
surgeon to perform the secondary procedure.
rhinoplasty or a secondary revision procedure, to
be honest and straightforward with the patient in
the consultation, outlining the likelihood that a
secondary or revision surgery may be required to
gain the best long-term aesthetic and functional
result. Forthrightness with the patient in the preoperative consultation prepares the patient for the
possible need for revision and makes the patient
more likely to retain confidence in the primary surgeon, allowing the surgeon to perform the revision
and keep a satisfied patient. However, if a patient is
left to assume that one operation will achieve the
desired result with no need for revision surgery,
when a small postoperative deformity occurs, the
patient may lose confidence in the primary surgeon
and begin shopping for another surgeon to correct
an otherwise good and normal postoperative result.
The timing of revision surgery is extremely
important and the patient needs to know this in
advance as well. Webster reports that many patients
may be able to determine whether the patient’s nasal
tip is ready for revision surgery by palpating the tip.
If the tip is firm and unyielding, then revision surgery should be postponed. Premature attempts at
revision surgery may result in improper diagnosis,
unnecessary surgery, or increased postoperative
scarring. The difficulty of even elevating the skin
envelope may preclude what could be an otherwise
satisfactory operative procedure. It is incumbent
upon the surgeon to follow the rhinoplasty patient
at intervals of 1 month, 3 months, 6 months, and 1
year. Between 1 and 3 months, if one palpates thickness developing in the supratip area due to scarring, thickness of the nasal skin, or the like, one can
intervene by injecting intralesional steroid, such as
Kenalog 10 mc/cc. Up to 0.1 cc can be placed once
or twice to resolve the developing fibrous tissue and
gain the expected tip definition. The steroid reverses
the formation of the fibrous tissue and forestalls the
need for revision surgery in the future.
request revision surgery well before they attain their
final result from the first surgery.
3
It is this author’s
for revision lobular reconstruction are:
experience that patients may, in fact, begin indicating that they are going to need revision surgery as
1. Failure to diagnose and to correct by tipearly as 1–3 months postoperatively, despite their
having being counseled in advance that it takes
nearly a year to be able to appreciate the final results
of the primary surgery. The final contour of the
upper third of the nose can be seen relatively soon
after surgery, but even irregularities of the nasal
pyramid may show up after 6–9 months of healing. Palpable irregularities may be identified but are
2. Lack of identification of the tip-support mechanot visible until the edema resolves. No only does
it take a year for changes in the nasal tip to show
up, but also in many cases nasal tip irregularities
3. Over-resection of the alar cartilages and/or the
or asymmetries may not show up until years later.
Occasional contour irregularities of the nasal pyra-
4. Failure to recognize inherent weakness or anatomid, particularly in the midnasal vault, do not show
up for 3–5 years postoperatively if the middle nasal
vault has not been supported (Figure 6-3). Irregularities of the upper third of the nose, particularly
ones related to incomplete osteotomies or faulty
3
One
12
To summarize, the five most common reasons
sculpting techniques the pre-existing displeasing
and disharmonious preoperative appearance of
the nasal lobule. Failure to adequately correct
the aesthetic deformities of the medial and
lateral crura as well as caudal septum can result
in an only marginally improved result and a
dissatisfied patient.
nisms and failure to reconstitute and/or reconstruct these vital lobular supports.
caudal septum.
mical deviations, such as cephalic malposition
of the alar cartilages, leading to the long-term
results of recurvature of the alar cartilages into
the nasal airway, external valvular collapse, and
alar retraction.
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A B
Figure 6-3.
4 years after hump-reduction
rhinoplasty with middle nasal vault
narrowing corrected by placement of
spreader grafts.
5. Failure top account for skin thickness or thinness
in performing proper surgical techniques so as to
prevent abnormalities (such as the “shrink wrap
phenomenon” or an amorphous nasal lobule
created by extremely thick skin).
Frontal view of patient
CD
Indications for Revision
Nasal Surgery
Abnormalities, Irregularities,
or Deformities of the Nasal
Bony Pyramid
1. Residual bony hump or bump
2. Over-resected bony dorsum
3. Collapse of rhinion with saddle deformity
4. Dorsal bony ridge
5. Open-roof deformity or depression
6. Incomplete osteotomy that has left the nasal
pyramid too wide, angulated, overly narrow, or
with a step-off deformity
Deformities of the Midnasal Vault
1. Persistent curvature or deviation of the dorsal
nasal septum
2. Curved or crooked nose with collapse or
depression of upper lateral cartilage
3. “Pinched look” with “hourg lass deformity” secon-
dary to retracted and collapsed upper lateral
cartilages
4. Under-resection of cartilaginous dorsum with
residual hump and/or “pollybeak” deformity
5. Supratip saddle deformity
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Overly Short Nose/Over-Rotated
Nasal Lobule (see also Chapter 7,
“Lengthening the Short Nose”)
1. Irregularities, asymmetries, warping, absorption,
or infection of dorsal nasal grafts and/or implants
2. Abnormalities/asymmetries of grafts of the nasal
lobule
3. Over-projected nasal tip
4. Under-projected nasal tip
5. Under-rotated nasal lobule
Indications for Total Lobular
Reconstruction
Problems to be resolved in lobular reconstruction
include:
1. Asymmetries of the tip
2. Asymmetries of the ala
3. Unusual bossa
4. Alar-columellar disproportion
5. Alar collapse and retraction
6. Over-rotation of the nasal tip
7. Under-projection of the nasal tip
entire nasal lobule, then can be accomplished in a
bimanual fashion under direct vision.1 This ensures
not only the position of the grafts but also the
restored fibrous and structural support to the lobule.
Execution of the open approach using the external columellar incision is somewhat different than in
primary rhinoplasty. The same marginal incision is
made and then is connected to an external columellar incision. The elevation of the flap is much more
difficult and may be tedious because of adherence
of the skin envelope to the alar cartilages after having been elevated in the primary surgery. Careful
and meticulous attention to elevating the skin envelope following the contours of the existing nasal ala
is imperative so as not to perforate the skin while
elevating the skin cephalically. Whatever approach
is chosen for revision rhinoplasty, one must understand that it is only the approach, not the technical
methods used, that allows one to diagnose accurately
the deformities requiring correction and the performance of the multitude of techniques required to
achieve a satisfactory aesthetic and functional result.
Systematic Approach to Defects
Surgical Approach to the Nose
The surgical approach to be used in revision or
secondary lobuloplasty is dependent upon the
severity of the aesthetic and functional deformities identified. Although occasional minor aesthetic
deformities can be corrected using “closed” endonasal approaches, creating pockets for grafts, closed
approaches are usually used either for camouflaging concavities or deformities or for providing alar
batten support to a collapsed ala. Closed approaches
can use either intercartilaginous incisions or marginal incisions. The incisions may be used to trim
excess cartilage, to rasp an irregularity of the nasal
pyramid, or to place specific grafts either as onlays
to the pyramid or in precise pockets in the nasal lobule. In most cases, precise pocket grafting is designed
to camouflage deformities and is not intended to
reconstruct the existing primary structural defect.
In secondary rhinoplasty for major aesthetic and
functional problems due to structural deformities,
the open or external columellar incision approach is
most commonly utilized, to provide excellent exposure, easier elevation of the lobular skin envelope,
and accurate diagnosis of defects from the previous
surgery. Direct placement and suturing of appropriate grafts, either to the middle nasal vault or the
Nasal defects seen in secondary rhinoplasty can be
categorized into two major types, incomplete primary nasal defects and over-reductive nasal defects.
Incomplete primary nasal defects are the result of
inadequate surgery performed during the previous
nasal operations(s). Correction of these deformities
usually requires additional tissue excision or reorientation of tissues. Over-reductive nasal defects
usually result from previous over-resection of supportive structures, causing deformity. Correction of
these deformities usually involves cartilage grafting
to replace over-resected supportive structures and
to create improved contour. In many cases, septal
cartilage is not available, necessitating the harvesting of auricular cartilage.
Incomplete Primary Nasal Defects
Overly Bulbous or Wide Nasal Tip
The overly bulbous or wide nasal tip usually results
from inadequate volume reduction or improper
choice (or execution) of the tip-narrowing technique. In some cases, a thick skin/subcutaneous tissue complex acts as a limiting factor and may result
in a persistent bulbous tip. Excessive scar formation
may compound the problem. Failure to correct an
obtuse angle between the medial and lateral crura
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(domal angle) will result in a persistent bulbous
or wide nasal tip. Correction of this deformity
using cephalic reduction alone may result in exces-
sive resection of lateral crura. Correction usually
requires a technique that will narrow the domal
region (create a more acute domal angle) and cor-
rect excessive interdomal distance. A graduated
approach, beginning with an interdomal suture and
ending with dome division, can be used.
13
In addition to narrowing the domal region, the vertical
height of the lateral crura may need to be reduced.
However, in most noses previously operated on,
there is little need for further volume reduction.
All of these maneuvers can be performed through
a delivery approach (bilateral chondrocutaneous
flaps), but the open approach may allow more accurate diagnosis and symmetric execution of the corrective techniques.
Under-Projected, Under-Rotated Nose
The ptotic nose is usually a result of iatrogenic loss
of support of the medial crural component (for
example, buckling of the medial crura) of the lower
lateral cartilages, or inadequate correction of overlying long lateral crura that are pushing the nasal tip
down. To correct the deformed medial crura, a cartilage strut can be sutured between the medial crura
to provide support, correct buckling, and lengthen
14
this leg of the alar cartilages.
If the lateral crura
are overly long, they can be shortened by dividing
them laterally and either resecting a segment of
cartilage or overlapping in a lateral crural flap overlay technique (Figure 6-4). The lateral crural flap
overlay technique provides additional support and
strength to the lateral crus while rotating the lobule
cephalically.15 This is a very powerful maneuver that
can create upward rotation and correct the ptotic
nose deformity, but it may also de-project the nasal
lobule, and one needs to account for this as well.
Further plumping of the nasolabial angle may be
required to improve the aesthetic relationship of the
nose to the upper lip. Tip grafting may be required
to increase the height of the tip projection, in addition to the upward rotation.
A
BC
Figure 6-4. (A) Artist illustrative view of lateral crural flap overlay. (B) Intraoperative photos of the lateral
crural flap overlay.
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AB
Figure 6-5. Pre- and
postoperative lateral views of
a patient with postoperative
over-projected nasal tip.
Persistent Over-Projected Tip
A persistent over-projected tip results from inaccurate anticipation of postoperative changes. In some
cases, the cartilaginous dorsum settles lower than one
anticipates, leaving the tip relatively over-projected
(Figure 6-5). Additionally, tip retroprojection after
a transfixion incision may be inadequate because of
strong, overly long, medial crura. In such cases, the
first maneuver to decrease an overly long medial
crura is to perform a Lipsett procedure.
be a medial crural excision with direct suturing and
lowering the height from 1 to 3 mm, leaving the nasal
16
This can
dome intact, or, as performed similarly for the lateral
crura, the medial crural overlay technique can be used
in suturing the transected intermediate crura upon
itself in a mattressing fashion, directly decreasing the
projection (Figure 6-6). If this maneuver does not
produce enough reduction of the overly projected
nose, one may find it necessary to perform domal
17
truncation, lowering the domes directly.
One must
take into consideration the thickness of the nasal skin
and soft tissue, and overlay grafts may be required to
cushion the sharp edges left by performing domal
truncation.
ABC
Figure 6-6. (A) Drawing of Lipsett maneuver with intraoperative photo. (B) Pre- and postoperative views of a
patient with persistent over-projected nasal tip corrected by Lipsett maneuver.
Figure 6-7. Preoperative lateral
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view of a patient with pollybeak
deformity and postoperative view
of revision.
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AB
Pollybeak Deformity with
Adequate Tip Projection
Pollybeak deformity usually occurs because of
inadequate reduction of the cartilaginous dorsal profile and over-reduction of the bony profile
(Figure 6-7). It may also occur because of excessive
postoperative edema and scar tissue formation in
the supratip area. This is more common in patients
with thick nasal tip skin. If a cartilaginous pollybeak exists, the excess cartilage of the nasal dorsum, particularly in the region of the anterior nasal
spine, can be resected through an intercartilaginous
incision, correcting the deformity immediately.
If a soft-tissue pollybeak occurs because of excessive postoperative edema, triamcinolone acetonide
(Kenalog, Westwood-Squibb, Buffalo, NY, 10 mg/
ml) can be injected into the subdermal tissues of the
supratip.
tissue excision may need to be performed through
an intercartilaginous incision or the open approach.
When performing soft-tissue excision, the muscle
layer of the skin flap should be left intact to avoid
excessive edema, scarring, or possible flap necrosis.
1,18
If these injections are not effective, soft-
Alar-Columellar Disproportion
and the Hanging Columella
This deformity is usually the result of alar retraction, caudally protruding medial crura, caudally
protruding nasal septum, or a combination thereof
(Figure 6-8). The open approach can be used if
the caudal margin of the medial crura needs to be
reduced, although marginal incisions may be adequate. Trimming the caudal margin in the medial
crura will result in only subtle changes in the alarcolumellar relationship, and in most cases some
other maneuver must be performed to correct this
deformity. First, if palpation of the caudal septum
reveals an overly long caudal septum, the caudal
septum may be shortened to allow the columella
to occupy a more cephalic position. Excising the
membranous septum is required, which will assist
in suturing the hanging medial crura back to the
septum, correcting the aesthetic deformity. If the
medial crura themselves are quite curved, they may
need to be divided directly and then sutured back
to the caudal septum, straightening the columella
aesthetically, improving the alar-columellar proportion, and diminishing the columellar show. If alar
retraction is the persistent issue affecting the alarcolumellar harmony, correction of the alar retraction is needed (this is covered in the section on
over-reduced nasal defects).
Wide Nostrils and Alar Base Flaring
Overly wide or flared nostrils may tarnish an
otherwise aesthetically pleasing rhinoplasty result
(Figure 6-9). Failure to anticipate the amount
of postoperative loss of tip projection may result
in flared nostrils as the tip settles in the first 3 to
6 months after surgery. The treatment for this
deformity is alar base reduction or nostril narrowing if tip projection is acceptable. If tip projection
is inadequate, the tip can be re-projected, possibly
eliminating the need for alar base modification.
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Figure 6-8. Pre- and
postoperative lateral and oblique
views of a patient with alarcolumellar disproportion and
after revision surgery.
Figure 6-9. Pre- and
postoperative basal views of a
patient with residual flared nostrils
corrected by alar base narrowing.
Figure 6-10. Pre- and postoperative frontal
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views of a patient with asymmetrical,
very visible bossae secondary to complete
resection of the lateral crura.
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Over-Reduced Nasal Defects
Bossa Formation of the Nasal Tip
Bossae are knob-like protuberances in the dome
region that usually occur due to over-resection of
lower lateral cartilage near the domes8 (Figure 6-10).
Bossae occur in both intact and interrupted strip
techniques. They are one of the most common complications of cartilage-splitting or retrograde (intracartilaginous) approaches inappropriately performed
in patients with thick cartilages, wide interdomal
distance (bifidity), and thin skin.4 The deformity
tends to worsen over time as scar contracture exerts
its forces on the weakened domal cartilage strip.
Treatment of bossae can be performed through a
delivery or open approach. Once the domes are freed
of the surrounding soft tissues, cartilaginous asymmetries are corrected either by suturing the domes
together with a 5-0 clear polypropylene suture or by
camouflaging the asymmetries with an onlay graft.
If excessive cartilage has been previously resected,
soft auricular cartilage alar grafts can be sutured as
batten grafts to stabilize the lower lateral cartilages.
A small (morselized) cartilage graft or a sutured-inplace shield-shaped tip graft can be used to camouflage the domal region and provide additional
19
support
(Figure 6-11). The open approach provides excellent exposure for accurate suture fixation
of grafts placed in the domal region.
Secondary Rhinoplasty for
Correction of Errors of Commission
Errors of commission are the most common problems encountered in secondary rhinoplasty practice.
The final surgical result often is the consequence
of a combination aggressive reduction rhinoplasty
with destabilization of the nasal lobule as well as
inadequate resection in other areas, making the
diagnosis challenging. For example, a nose with a
pollybeak deformity may be a saddle nose deformity of the bony vault due to over-resection of the
bony dorsum in combination with under-resection
of the cartilaginous supratip dorsum and loss of
tip projection (Figure 6-12). As mentioned previously, abnormalities in the pyramid can range
from as small a problem as visible ridges or small
bumps that show up several months to a year
postoperatively. Treatment of these problems is
fairly straightforward and can be done through an
endonasal approach with direct shaving of the
cartilage or use of a rasp. The addition of slightly
crushed cartilage as a camouflage onlay may be
beneficial. Disharmonious width or asymmetric
nasal bones are the next most common abnormality of the nasal pyramid requiring minor revision.
The nasal bones may be flared or the dorsum may
be wide, both of which are easy to correct with completion osteotomies. A combination of medial fading osteotomies and lateral osteotomies is used to
correct most deformities. A double osteotomy may
be required on a wide, flared side to straighten the
nose and produce symmetry. More rarely, a transverse root osteotomy is used to straighten the nose
if it remains deviated from the nasion to the rhinion
(Figure 6-13).
Correction of the overly narrowed dorsum or
open-roof deformity may be accomplished by the
20
use of spreader grafts and onlay grafts.
Onlay grafts
are very useful to fill in small open-roof deformities.
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A
B
Figure 6-11. Intraoperative photo with drawing of tip graft and alar replacement grafts.
Figure 6-12. Pre- and
postoperative lateral views of a
patient with pollybeak deformity
corrected with bony dorsal
augmentation and reduction of
residual cartilaginous hump.
Figure 6-13. Pre- and
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postoperative frontal views
of patient with residual wide,
deviated, nasal pyramid corrected
by medial double lateral and
transverse root osteotomy.
Secondary Rhinoplasty with Total Lobular Reconstruction / 77
A
B
Correction of saddle nose deformity requires
augmentation with septal cartilage, rib cartilage,
or alloplastic materials. Septal cartilage is the first
choice, providing smooth, elongated cartilage for
augmentation of the nasal dorsum. Ear conchal cartilage can be used, but it is difficult to bevel and to
keep flattened. It is also not as long as the full nasal
dorsum if the entire dorsum is saddled.
Rib cartilage may be used for large saddle
deformities requiring replacement of the complete
nasal dorsum. However, in most cases, a combination of conchal cartilage with an overlay of alloplastic material, such as Gore-Tex (ePTFE/expanded
polytetrafluoroethylene) sheeting, provides an
excellent cosmetic result and camouflages any irregularities that may show up from the edges of the
conchal cartilage.
21
Grafts used in Secondary
Rhinoplasty for Correction
of Dorsal Deformities
Preferred grafting materials in rhinoplasty include:
1. Septal cartilage
2. Ear conchal cartilage
3. Nasal fibro-fatty soft tissue
4. Crushed or morselized autogenous cartilage
5. Acellular dermal graft or temporalis fascia
6. Gore-Tex sheeting (1 mm or 2 mm)
7. Autogenous rib cartilage
18
Harvesting of Cartilage
Autogenous Grafts
The first choice for cartilage grafting material for
any nasal reconstruction is autogenous septal cartilage or autogenous conchal cartilage.21 This is
particularly true for any reconstruction of the nasal
lobule. Procurement of septal cartilage is done via
septoplasty techniques, assuming there is adequate
cartilage to be removed from the septum for grafting purposes and still maintain dorsal and columellar tip support.
As is the case with many revision reconstructive
nasal procedures, there is often little or no quadrangular cartilage to harvest.
The external auricle is the ideal place for obtaining cartilage grafts for nasal reconstruction. It is in
the head and neck area and does not require the surgeon to move out of the operative region. The cartilage is easily obtainable with minimal to no sequelae
or deformity. Cartilage from one or both ears may
be required for complete lobular reconstruction.
If there is no need to correct alar notching or alar
retraction, the entire cymba and cavum conchae can
be obtained from the posterior approach
6-14). This is the senior author’s preferred approach
because it is quick and efficacious and the scar is
completely hidden. No scars are made anteriorly
and the entire conchal cartilage can be removed for
use in the nose.
When alar composite grafting is anticipated,
however, conchal cartilage grafts may be obtained
1
(Figure
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