Introduction

The patient was unhappy with the functional and aesthetic results of a previous rhinoplasty performed elsewhere. Functional problems were caused by residual septal deviation, internal valve stenosis, and inferior turbinate hypertrophy.

Findings

Frontal inspection showed disharmony of the brow-tip aesthetic lines and a conspicuous inverted-V deformity ( Fig. 18.2a ), suggesting that the upper lateral cartilages had been separated from the bone in the previous rhinoplasty. The bony pyramid was wide and asymmetrical. A deep nasal root and bony hump were noted in the profile view ( Fig. 18.2b ). The nasal tip was wide and bulky, asymmetrical, and not well defined ( Fig. 18.2a, b ). Endonasal inspection revealed a deviated septum, especially at the anterior nasal border; the rest was deviated and round bodied ( Fig. 18.2g, h ). On examination with a glass probe, manual expansion of the anterior nasal valve produced an immediate sensation of improved breathing, confirming that the internal valve was stenotic and required reconstruction.

Surgical Procedure

An open approach was performed through a standard inverted-V midcolumellar incision. Analysis showed that the anterior septal border was deviated and the whole septal cartilage was under tension. Therefore, we decided to remove the septum ( Fig. 18.2g, h ) and perform an extracorporeal septal reconstruction. We smoothed out all irregularities, particularly addressing the thickened area at the junction of the bony and the cartilaginous septum.

The rest of the septum was then rotated 180 degrees to obtain a straight residual septum. A thinned perpendicular plane was sutured to the new anterior septal border to support the cartilage piece ( Fig. 18.2i ). We sutured spreader grafts made of septal cartilage to the dorsal part of the new septum to restore the integrity of the internal nasal valves, reestablish the dorsal aesthetic lines, and increase the stability of the framework ( Fig. 18.2i, j ). Lateral, paramedian, and transverse osteotomies were performed on both sides following reduction of the bony hump. The new straight septum was repositioned and anchored to the upper lateral cartilages with multiple back-and-forth sutures. Anterior fixation was achieved with several sutures passed through a small drill hole in the anterior spine. A cartilage graft was placed on the nasal root. The dorsum was additionally covered with a layer of homologous fascia lata. For correction of the nasal tip, the cephalic portions of the lower lateral cartilages were resected and the dome area was reconstituted with transdomal sutures. A spanning suture was placed to control flaring, and a tip suspension suture stabilized the nasal tip in the ideal position.

Psychology, Motivation, Personal Background

The previous operation had been done elsewhere to correct functional problems, but the septum was still deviated. Additionally, the upper lateral cartilages had been separated from the bone in the previous operation, narrowing the internal valves and exacerbating the airway problems. The patient also suffered from aesthetic deformities including a conspicuous inverted V, a hooked nose, and a broad, undefined nasal tip. Thus, the patient could reasonably expect functional and aesthetic improvements from the revision surgery. When seen 18 months postoperatively, the patient was satisfied with the aesthetic and functional outcome ( Fig. 18.2d–f ).

Discussion

It is reasonable to ask whether the septal cartilage could have been straightened without removing the entire septum. The most important issue involves the outer framework of the septum: Is at least a straight L-shaped framework present, or is the outer framework deformed? In this case the framework, especially the anterior septal border, was not straight. A straight septal framework is essential for a straight nose. Therefore, every effort was made to straighten the septum.

Introduction

A 32-year-old woman presented 10 years and 8 months after undergoing a septorhinoplasty at another hospital. She worked as a waitress at a popular resort on the Baltic Sea and desired a rapid and permanent improvement of the primary outcome.

Findings

Frontal view ( Fig. 18.3a ) shows an inverted-V deformity with undercorrection of the cartilaginous nasal dorsum. Oblique ( Fig. 18.3b ) and profile views ( Fig. 18.3c ) show a residual hump, irregularities all along the nasal dorsum, and incomplete removal of a nasal hump with a cartilaginous polly beak.

Follow-up views after revision rhinoplasty show the findings at 2 years ( Fig. 18.3d–f ) and at 10 years ( Fig. 18.3g, h ).

Psychology, Motivation, Personal Background

The patient felt that the result of the primary operation was worse than her original nose. She was highly motivated to seek a maximal degree of improvement.

Surgical Procedure

A 4 × 12-mm cartilage strip was harvested from the lower septum through an open approach. Cartilage remnants were removed from the septum, the upper lateral cartilages were detached, the dorsal septal margin was shortened, bilateral spreader grafts were placed, and medial and lateral curved osteotomies were performed on both sides. The entire nasal dorsum was camouflaged with allogeneic human fascia lata.

Discussion

The nasal dorsum was augmented with allogeneic, devitalized, freeze-dried fascia lata. Fascia is a useful material for dorsal nasal camouflage, although its tendency to expand in vivo leads to protracted swelling that may last for months. It should be decided on a case-by-case basis whether autologous tissue would be a better option than allografts.

Introduction

The patient presented at 41 years of age with nasal airway obstruction and aesthetic complaints. She sought correction of the nasal dorsum, correction of the dorsum-tip junction, and narrowing of the tip.

Findings before Primary Rhinoplasty

Frontal view ( Fig. 18.4a ) shows a prominent nasal dorsum with a plateau in the supratip area and a broad nasal tip. Profile view ( Fig. 18.4b ) shows a bony and cartilaginous hump with overprojection and a small nasofrontal angle. Oblique view is shown in Fig. 18.4c .