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46. Secondary Rhinoplasty
Sammy Sinno, Michael E. Nissan, Simon Moradian
See Essentials of Aesthetic Surger y, pp. 620–633
ENDONASAL/CLOSED APPROACH
1. Which of the following applies to the endonasal/closed approach in secondary rhinoplasty?
A. It results in increased postoperative edema and scarring.
B. It is effective when changes to the overall framework of the nose are required.
C. It can be used in patients with multiple prior nasal incisions.
D. It is the preferred approach for secondary rhinoplasty, in general.
E. It is the preferred approach for situations that require addressing multiple underlying framework issues.
EXTERNAL/OPEN APPROACH
2. Which of the following applies to the external/open approach to secondary rhinoplasty?
A. The transcolumellar incision should always be placed over the original scar.
B. If the or iginal transcolumellar scar is inconspicuous but incorrectly located, it should be ignored, and a new
incision should be placed at the correct location.
C. It is more difficult to achieve hemostatic control when compared with endonasal/closed rhinoplasty.
D. External/open rhinoplasty provides limited tissue exposure.
E. Results in decreased postoperative edema.
BODY DYSMORPHIC DISORDER
3. Which of the following is a consideration when treating rhinoplasty patients who have body dysmorphic
disorder (BDD)?
A. BDD is more prevalent in secondary rhinoplasty patients than primary rhinoplasty patients.
B. A patient who is experiencing significant stress due to a visually apparent nasal deformity after primary rhi-
noplasty is likely to have the diagnosis of BDD.
C. Psychiatry consultation is rarely helpful for BDD patients.
D. The nose is rarely the primary complaint of BDD patients.
E. The nose is the primary complaint in 25% of BDD patients desiring secondary rhinoplasty.
ROCKER DEFORMITY
4. Which of the following maneuvers is most likely to result in a rocker deformity?
A. Inadequate placement of medial osteotomy.
B. Overresection of dorsal midvault and upper lateral cartilages.
C. Overresection of the noncartilaginous caudal dorsum or underresection.
D. Underresection of the cartilaginous nasal dorsum.
E. Disruption of lateral crural support.
INVERTED-V DEFORMITY
5. Which of the following maneuvers is most likely to result in an inverted-V deformity?
A. Inadequate alignment of bones after osteotomy.
B. Overresection of dorsal midvault and upper lateral cartilages.
C. Unplanned osteotomy fracture sites.
D. Incorrect placement of transcolumellar incision.
E. Disruption of lateral crural support.
Chapter 46&Secondary Rhinoplasty 329
POSTOPERATIVE DEFORMITY
6. Overresection of the noncartilaginous caudal dorsum and underresection of the cartilaginous nasal dorsum
are most likely to result in which of the following deformities?
A. Boxy tip deformity.
B. Pinched nasal tip deformity.
C. Alar retraction.
D. Alar notching.
E. Polly beak deformity.
ALAR DEFORMITY
7. Which of the following is crucial in understanding and assessing alar deformities?
A. Alar rim collapse is usually caused by loss of upper lateral cartilage integrity.
B. Alar rim collapse can be assessed clinically by palpating resistance of alae to gentle compressive force.
C. Alar flaring is characterized by a narrowed base.
D. Alar notching is more likely when supporting alar grafts are used.
E. Alar rim collapse can result in impaired internal nasal valve competency.
PATIENT CONCERNS
8. Which of the following is the most common complaint in patients presenting for revision?
A. Nasal deviation.
B. Supratip deformity.
C. Tip deformity.
D. Alar deformity.
E. Breathing difficulty.
SURGICAL PLANNING
9. A patient presents to the clinic 60 days after primary rhinoplasty with asymmetry concerns. When is the earli-
est possible time to reevaluate for revision rhinoplasty?
A. 3 months.
B. 6 months.
C. 9 months.
D. 12 months.
E. 18 months.
EARLY INTERVENTION
10. In the case of the presence of a gross anomaly or a surgical error, when the surgeon must intervene within?
A. 2 days.
B. 10 days.
C. 12 days.
D. 20 days.
E. 40 days.
SUPRATIP
11. What differential height between the tip and the septum must be present in order to have an appreciable
supratip break for desirable results?
A. 0–2 mm.
B. 2–6 mm.
C. 6–10 mm.
D. 10–12 mm.
E. 12–14 mm.
330 Part VII&Facial Surgery
GRAFTS
12. A patient has a short columella but sufficient infratip volume. Which graft is most appropriate to address
this deformity?
A. Columellar strut.
B. Tip graft.
C. Spreader graft.
D. Alar spreader graft.
E. Dorsal onlay graft.
OVERRESECTION OF DORSUM
13. Which of the following is most appropriate for correction of an overresected dorsum that requires little (less
than 3 mm) augmentation?
A. Dorsal rib graft.
B. Extended spreader grafts.
C. Septal extension graft.
D. Columellar strut graft.
E. Cantilever bone graft.
ALAR RETRACTION
14. Alar retraction is identified in a secondary rhinoplasty patient. There is minimal vestibular lining loss and 5
mm of residual lower lateral cartilage rim. Which of the following is the most appropriate corrective
maneuver?
A. Alar contour graft.
B. Alar spreader graft.
C. Lateral crural strut graft.
D. Intercartilaginous graft.
E. Z-plasty scar revision of the internal nasal mucosal lining.
PROSTHETIC COMPLICATIONS
15. A dorsal prosthetic implant becomes palpable and visible beneath the skin. What is the most appropriate
corrective action?
A. No action is needed unless the prosthetic is extruded.
B. External repositioning of the implant.
C. Starting a short course of antibiotics.
D. Removal of the implant and replacement with a new prosthetic.
E. Removal of the implant and replacement with autologous tissue.
RIB GRAFT
16. Injury to the parietal pleura is identified during rib graft extraction. What is the correct course of action by
the surgeon?
A. Consult general surgery for assistance immediately.
B. Close the pleura and overlying tissues in layers and obtain chest radiograph postoperatively.
C. Insert a chest tube and close the overlying layers.
D. Place red rubber catheter into the cavity, close the incision in layers, and remove catheter with suction while
providing positive pressure ventilation.
E. Do not attempt repair but have anesthesia increase FiO
to 100% and obtain an upright CXR in the PACU.
2
Chapter 46&Secondary Rhinoplasty 331
Answers
ENDONASAL/CLOSED APPROACH
1. Which of the following applies to the endonasal/closed approach in secondary rhinoplasty?
C. It can be used in patients with multiple prior nasal incisions.
There are two surgical approaches for secondary rhinoplasty: the endonasal/closed approach and the external/open approach. For secondary rhinoplasty, the external/open approach is preferred for its complete
advantages, as it results in less edema and scarring due to its decreased disruption of the nasal anatomy.
For this reason, it can be used to address isolated deformities that do not require changes to the overall
nasal framework. Additionally, it is preferred in the case of a severely scarred nose in which additional
incisions and scarring from open rhinoplasty may further compromise vasculature.
REFERENCE
1. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg 1987;80:161
EXTERNAL/OPEN APPROACH
2. Which of the following applies to the external/open approach to secondary rhinoplasty?
B. If the original transcolumellar scar is inconspicuous but incorrectly located, it should be ignored, and
a new incision should be placed at the correct location.
The advantage of the external/open approach is the surgeon's ability to reflect the skin superiorly, providing
increased tissue exposure, greater ability to manipulate the underlying nasal framework, and increased ease
of achieving hemostasis under direct visualization. For the external/open approach, the transcolumellar
incision should be strategically placed to provide adequate tissue visualization and to leave an inconspicuous
scar postoperatively. In the case of a previously incorrectly placed transcolumellar scar that is well-hidden, a
new incision should be placed in the correct location.
1
However, the endonasal/closed approach does have some
1
1
REFERENCE
1. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg 1987;80:161
BODY DYSMORPHIC DISORDER
3. Which of the following is a consideration when treating rhinoplasty patients who have body dysmorphic dis-
order (BDD)?
A. BDD is more prevalent in secondary rhinoplasty patients than primary rhinoplasty patients.
Surgeons should screen for BDD in all patients prior to operation, particularly for secondary rhinoplasty;
incidence of BDD is 12% (not 25%) for secondary rhinoplasty and 2 to 7% for primary cosmetic consultations.
In half of patients with BDD, the nose is the primary concern.
BDD, and psychiatry consult can help to improve the condition. The condition is characterized by an
extreme preoccupation with an imagined or minor physical deformity. In the case of a patient experiencing significant stress due to a visually apparent nasal deformity, BDD is not a likely diagnosis because the
deformity is significant enough to be visible.
1,2
Reoperation should be avoided in cases of
REFERENCES
1. Constantian MB. Identify BDD patients prior to rhinoplasty. Cosmetic Surgery Times, June 2001
2. Constantian MB. Emotional matters. Presented at the Rhinoplasty Symposium at the Annual Meeting of the
American Society for Aesthetic Plastic Surgery, New York, April 2007
332 Part VII&Facial Surgery
ROCKER DEFORMITY
4. Which of the following maneuvers is most likely to result in a rocker deformity?
A. Inadequate placement of medial osteotomy.
Rocker deformity is a defect in the nasal bony pyramid, resulting from inadequate placement of medial
osteotomy. The result is a wide upper dorsum due to the incorrectly placed nasal bone fracture (Fig.
46.1). Overresection of the dorsal midvault and upper lateral cartilages may result in an inverted-V deformity. Overresection of the noncartilagenous caudal dorsum or undersection may result in a polly beak
deformity. Underresection of the cartilaginous nasal dorsum may result in a persistent dorsal hump or
contour irregularity. Disruption of the lateral crural support may result in a pinched nasal deformity.
1,2,3
Fig. 46.1 Rocker deformity. (Source: Medial Osteotomies. In: Rohrich R, Adams W, Ahmad J, Gunter J, ed. Dallas
Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York: Thieme; 2014.)
REFERENCES
1. Byrd HS, Constantian MB, Guyuron B, et al. Revision rhinoplasty. Aesthet Surg J 2007;27:175
2. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg 1987;80:161
3. Constantian MB. The two essential elements for planning tip surgery in primary and secondary rhinoplasty:
observations based on review of 100 consecutive patients. Plast Reconstr Surg 2004;114:1571; discussion 1582
INVERTED-V DEFORMITY
5. Which of the following maneuvers is most likely to result in an inverted-V deformity?
B. Overresection of dorsal midvault and upper lateral cartilages.
Inverted-V deformity is a defect in the nasal midvault, in which collapse of the midvault causes visibility of
the caudal edge of the nasal bones, forming an upside-down V (Fig. 46.2). This is a result of overresection of
the dorsal midvault and upper lateral cartilages or inadequate infracture of the nasal bones. Inadequate
alignment of bones or unplanned osteotomy fracture sites after osteotomy may result in an unfavorable
narrowing or convexity, irregularity, step off, or rocker deformity. Disruption of the lateral crural support
system may result in a pinched nasal deformity due to collapsed alar rims.
1,2,3
Chapter 46&Secondary Rhinoplasty 333
Spreader graft
Septum
Collapse of
midvault . . .
. . . with narrowing
of internal valve
a
b
AfterBefore
Upper lateral
cartilage
Widening of
internal valve
Fig. 46.2 (a,b) Inverted-V deformity. (Source: Comprehensive Nasal and Facial Analysis. In: Janis J, ed. Essentials of
Aesthetic Surgery. 1st Edition. New York: Thieme; 2018.)
REFERENCES
1. Byrd HS, Constantian MB, Guyuron B, et al. Revision rhinoplasty. Aesthet Surg J 2007;27:175
2. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg 1987;80:161
3. Constantian MB. The two essential elements for planning tip surgery in primary and secondary rhinoplasty:
observations based on review of 100 consecutive patients. Plast Reconstr Surg 2004;114:1571; discussion 1582
POSTOPERATIVE DEFORMITY
6. Overresection of the noncartilaginous caudal dorsum and underresection of the cartilaginous nasal dorsum
are most likely to result in which of the following deformities?
E. Polly beak deformity.
Polly beak deformity, a supratip deformity, is a convexity located just superior to the nasal tip (Fig. 46.3). It is
a result of overresection of the caudal nasal dorsum.
involves vigorous taping of the supratip area and triamcinolone injections deep into the supratip if taping
alone does not prevent the deformity. Boxy tip deformity may be a result of an inadequate cephalic trim
of the lower lateral cartilages (LLCs). Pinched nasal deformity results from disruption of the lateral crural
support after collapse of the alar rims. Alar notching is a resultof inadequate placement or closure of previous incisions, scarring, and failure of supporting grafts. Alar retraction may result from a widened alar
base.
1
Prevention of polly beak deformity postoperatively
334 Part VII&Facial Surgery
Fig. 46.3 Polly beak deformity. Postoperative profile view of a secondary rhinoplasty patient with a supratip
deformity caused by both an underprojected tip and an underresected caudal dorsum.
Rohrich R, Adams W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York:
Thieme; 2014.)
(Source: Case Analysis. In:
REFERENCE
1. Guyuron B, DeLuca L, Lash R. Supratip deformity: a closer look. Plast Reconstr Surg 2000;105:1140
ALAR DEFORMITY
7. Which of the following is crucial in understanding and assessing alar deformities?
B. Alar rim collapse can be assessed clinically by palpating resistance of alae to gentle compressive force.
Alar rim collapse is a deformity in the caudal nose caused by loss of integrity of the lower lateral cartilages
(Fig. 46.4). The degree of alar rim collapse may not be evident by visual inspection alone—for this reason,
it is important to clinically assess the degree of alar collapse by applying gentle compressive force to the
alae when palpating. This will reveal the degree of alar collapse or potential alar collapse. Other alar
deformities include alar flaring, which is characterized by a widened base, and alar notching, which is
caused by inadequate placement or closure of incisions or failure to place supporting grafts. Treatment
for alar notching often involves placement of an alar rim graft. Additionally, alar rim collapse can result
in impaired external nasal valve competency.
1,2
Chapter 46&Secondary Rhinoplasty 335
Fig. 46.4 Alar rim collapse. Alar rim collapse caused by lack of lower lateral cartilage support. (Source: Anatomy.
In: Rohrich R, Adams W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition.
New York: Thieme; 2014.)
REFERENCES
1. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme—a study in
200 consecutive primary and secondary rhinoplasty patients. Plast Reconstr Surg 2005;116:268
2. Constantian MB.The two essential elements for planning tip surgery in primary and secondary rhinoplasty:
observations based on review of 100 consecutive patients. Plast Reconstr Surg 2004;114:1571; discussion 1582
PATIENT CONCERNS
8. Which of the following is the most common complaint in patients presenting for revision?
E. Breathing difficulty.
Breathing difficulty and asymmetry are the most common complaints of patients presenting for secondary
rhinoplasty. A retrospective analysis of 100 secondary rhinoplasty patients showed that 65% of patients
complained of breathing difficulties and 33% complained of nasal asymmetry.
is the most common underdiagnosed and untreated deformity in secondary rhinoplasty. For this reason,
it is important for the surgeon to remain vigilant to preserve or improve the function of the nose while
enhancing its aesthetics.
1
However, airway occlusion
REFERENCE
1. Lee M, Zwiebel S, Guyuron B. Frequency of the preoperative flaws and commonly required maneuvers to correct
them: a guide to reducing the revision rhinoplasty rate. Plast Reconstr Surg 2013;132:769
SURGICAL PLANNING
9. A patient presents to the clinic 60 days after primary rhinoplasty with asymmetry concerns. When is the earli-
est possible time to reevaluate for revision rhinoplasty?
D. 12 months.
Any secondary surgery must be delayed for at least 12 months. This ensures maximal resolution of edema,
scar maturation, and improved vascularity. It is important to explain to the patient that even 60 days after
surgery the nose has not yet reached its final appearance and asymmetry concerns at this time may be due to
residual edema that cannot be fully assessed until 1 year has passed.
1,2
REFERENCES
1. Guyuron B, Bokhari F. Patient satisfaction following rhinoplasty. Aesthetic Plast Surg 1996;20:153
336 Part VII&Facial Surgery
2. Lee M, Zwiebel S, Guyuron B. Frequency of the preoperative flaws and commonly required maneuvers to correct
them: a guide to reducing the revision rhinoplasty rate. Plast Reconstr Surg 2013;132:769
EARLY INTERVENTION
10. In the case of the presence of a gross anomaly or a surgical error, when the surgeon must intervene within?
C. 12 days.
Generally, revision rhinoplasty is not performed until at least 1 year after primary rhinoplasty. However,
there are a few exceptions to this rule: (1) grossly suboptimal nasal appearance that was not apparent at the
time of surgery, (2) significant malposition of parts of the nose, such as a graft shift, and (3) recognition that
an important surgical maneuver was not performed.
these cases in order to remediate the error before the nasal tissues become adherent and difficult to
reposition. This also benefits patients, who are spared the anxiety of waiting 12 months with a suboptimal primary rhinoplasty result.
1
Early intervention within 12 days is important in
REFERENCE
1. Gruber RP. Early surgical intervention after rhinoplasty. Aesthet Surg J 2001;21:549
SUPRATIP
11. What differential height between the tip and the septum must be present in order to have an appreciable
supratip break for desirable results?
C. 6–10 mm.
Patients with weak nasal cartilages are prone to supratip deformities, including weak midvault and plunging tip with polly beak deformity. A study of 20 patients showed that control of the position of the nasal tip
relative to the nasal dorsum can be achieved by septal extension grafts, which helped to maintain tip projection in all but one of the patients.
1
REFERENCE
1. Byrd HS, Andochick S, Copit S, et al. Septal extension grafts: a method of controlling tip projection shape. Plast
Reconstr Surg 1997;100:999
GRAFTS
12. A patient has a short columella but sufficient infratip volume. Which graft is most appropriate to address
this deformity?
A. Columellar strut.
A columellar strut is used when the columella is short. Tip grafts are used when infratip volume is deficient.
Spreader grafts maintain septal alignment, support the upper lateral cartilages, and support the internal
nasal valve. Alar spreader grafts can be used to repair a pinched-appearing tip. Dorsal onlay grafts may be
used for improved dorsal contour.
1,2
REFERENCES
1. Constantian MB. The boxy nasal tip, the ball tip, and alar cartilage malposition: variations on a theme—a study in
200 consecutive primary and secondary rhinoplasty patients. Plast Reconstr Surg 2005;116:268
2. Byrd HS, Constantian MB, Guyuron B, et al. Revision rhinoplasty. Aesthet Surg J 2007;27:175
OVERRESECTION OF DORSUM
13. Which of the following is most appropriate for correction of an overresected dorsum that requires little (less
than 3 mm) augmentation?
B. Extended spreader grafts.
Extensive overresection of the nasal dorsum can result in saddle nose or inverted-V deformity. However,
when there is only minor overresection requiring less than 3 mm of augmentation, correction can be
achieved with extended spreader grafts. Dorsal rib grafts and cantilever bone grafts are reserved for the
nasal dorsum that requires more extensive augmentation. The columellar strut graft corrects a short columella—it has no role in augmentation of the nasal dorsum.
1,2
Chapter 46&Secondary Rhinoplasty 337
REFERENCES
1. Gunter JP, Rohrich RJ. External approach for secondary rhinoplasty. Plast Reconstr Surg 1987;80:161
2. Constantian MB. Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study
based on 150 consecutive secondary rhinoplasties. Plast Reconstr Surg 2005;105:316; discussion 332
ALAR RETRACTION
14. Alar retraction is identified in a secondary rhinoplasty patient. There is minimal vestibular lining loss and 5
mm of residual lower lateral cartilage rim. Which of the following is the most appropriate corrective
maneuver?
A. Alar contour graft.
The deformity described is mild alar retraction, which is characterized by minimal vestibular lining loss
and at least 3 mm of residual lower lateral cartilage rim. Mild alar retraction is an indication for an alar
contour graft, which reestablishes a functional external nasal valve and an aesthetically desirable alar contour (Fig. 46.5).
ate redistribution of forces, this alone would be unlikely to correct this deformity. Alar spreader grafts
and lateral crural strut grafts are used for moderate alar retraction for patients with increased lining
loss or scarring.
eral cartilages when there is even more significant skin or lining deficiency (Fig. 46.6).
1
Although a Z-plasty of the internal nasal mucosal lining may help in a more appropri-
2
Intercartilaginous grafts are used to span the space between the upper and lower lat-
3
Fig. 46.5 (a– d) Alar contour graft. A key element is proper placement and shape of the alar contour graft immediately above the alar rim and spanning the alar notched area. (Source: Alar Contour Graft. In: Rohrich R, Adams
W, Ahmad J, Gunter J, ed. Dallas Rhinoplasty: Nasal Surgery by the Masters. 3rd Edition. New York: Thieme; 2014.)