History and Examination

The importance of preoperative assessment in patients seeking rhinoplasty surgery in general cannot be overemphasized, but for patients seeking revision, additional considerations have to be undertaken. It is beyond the scope of this chapter to discuss full facial analysis in detail, and it is assumed that the revision rhinoplasty surgeon has a comprehensive knowledge of the relevant concepts.

A complete and discerning history regarding the original cosmesis and function, prior procedures, and accurate chronological detailing of postoperative changes is important. Prior photographs may assist in trying to relate to the patient′s ongoing concerns. Patient anxieties and expectations should be determined early in the consultation, ensuring they are specific rather than general dissatisfaction with the prior result. The evaluating specialist needs to be sure that such expectations are true and that the patient′s desires are realistic and in keeping with predictable likely postoperative outcomes. If any doubt exists, sensitive counseling of the patient and referral for psychiatric review are always prudent, and surgery should be deferred pending this.4,5 Pertinent decisions about indications for surgery and potential improvements can then be made. Approach and technique planning is then discussed with the patient and documented in the notes.

Diagnosis of the underlying anatomical deformity is essential prior to embarking upon the surgical plan. Inspection and palpation are equally important, particularly when assessing the skin–soft tissue envelope and minor dorsal irregularities. The main pillars for documenting such an analysis are length, projection, and rotation of the nose. Specifically, the nose can conveniently be divided into thirds for analysis and deformities evaluated and documented in each area separately. Within these areas, a further subdivision of underlying skeletal support, soft tissue thickness and scarring, and overlying skin texture will help elucidate anatomical and structural deformities. Intranasal examination may be complemented with endoscopic evaluation to identify the presence of residual septal deviations, adhesions, nasal valve problems, and mucosal disease. It is important to check if there is alar collapse on inspiration, but in its absence, valve collapse cannot be excluded. Assessment with the Cottle test ( Fig. 25.3 ) is often advocated but can be nonspecific, and lateralizing the alar cartilage with a probe or cotton bud may be a better evaluator.

Prior retrospective analyses8–10 have identified lower third deformities followed by middle third deformities as the most commonly encountered problem requiring secondary surgery. Specific problems include pollybeak deformities, saddle deformities, asymmetry of the middle nasal third, and a retracted columella.

Documentation

Accurate documentation is made of the findings following a detailed checklist.11 This should include accurate assessment of all the nasal thirds in turn. The osseocartilaginous structure is assessed for asymmetry, deviations are noted, and irregularities are sought. Over-/underresection of the dorsum should be checked. Any tip abnormalities, including alar pathology, are recorded. The nasal turbinates are examined, and the nasal valve narrowing is assessed. Skin quality and scarring are also noted. A surgical plan is formulated to correct the specific deformities. This should be discussed and agreed upon with the patient. Preoperative photography is an absolute requirement for analysis and medicolegal purposes. Standard-view photographs are useful for communicating deformities and potential changes to the patient. They assist in operative planning and are invaluable for reference during surgery. In combination with postoperative images, they are essential for self- and peer-reviewed assessment of results. Standardization of the views taken and the lighting and background conditions employed is critical. Digital single-lens reflex (SLR) photography has now largely replaced 35-mm film, and the new technology lends itself well to computer archiving.

Digital imaging has evolved greatly over the past few years, and simple morphing is possible with inexpensive photoimaging software. More complex programs are readily available with or without archiving capability and have purpose-made user interfaces and more advanced digital manipulation of the images. They can be very useful in showing patients potential changes and postoperative outcomes. This is most useful in detailing profile changes in the lateral view, but with some experience frontal views can be morphed to show potential width reduction and refinement in the nasal tip. Dedicated programs have measurement abilities and can be extremely helpful in operative planning. It is important not to convey unrealistic changes to the patient; this can be a source of dissatisfaction afterward. As a rule, a slight underestimation of the postoperative result is generally favorable. Most surgeons choose not to give the patient printed images of the predicted changes, but if they choose to do so, a printed waiver should make clear that the image is only an indication of the likely result.

It is essential to discuss with the patient realistic expectations for the intended surgery and limitations, together with potential complications. It is also important to ensure that improvement is indeed likely. A risk–benefit profile may need to be reviewed with the patient prior to consent. For a more detailed discussion see Chapter 23, section Documentation in Rhinoplasty-Photography and Computer Imaging.

Approaches

Limiting surgical tissue dissection reduces the risk of vascular compromise of the skin–soft tissue envelope; this is particularly important in revision surgery where prior dissection will have created scar tissue, making it difficult to enter ideal surgical planes. In this way, further scarring is prevented, and subsequent healing is more predictable. The skin–soft tissue envelope may be thinned and adherent to the underlying structures, particularly following multiple prior procedures and in cases where prior grafts were used over the dorsum. Careful, occasionally sharp dissection may be required to avoid buttonholing through the skin. Augmentation of specific areas is best performed in precise pockets, and limited dissection makes it easier to judge the ideal position while placing a graft. An endonasal approach with minimal soft tissue dissection is thus favored for minor deformities and is ideal for correcting minimal structural bony dorsal irregularities.

The external approach′s need for more soft tissue dissection is balanced by the unparalleled view of the nasal structural components it affords. Its main benefit, particularly in revision surgery, is in facilitating accurate diagnosis in cases where the underlying anatomy is not obvious. This is especially true in the region of the nasal tip where deformities following prior surgery cannot always be predictably anticipated. Binocular vision, bi-manual tissue handling, and the ability to precisely place and suture cartilaginous grafts, so often the key in revision procedures, are further advantages.12 The authors personally favor this approach for most reconstructive revisions, particularly where the nasal tip needs addressing. Because intercartilaginous incisions are not used, the valve area is preserved. It is important to appreciate that, whereas the major tip support mechanisms are respected in the external approach, the disruption of the skin–soft tissue envelope from the lower lateral cartilage and the division of the medial intercrural ligamentous fibrous tissue can lead to loss of some of the minor tip support mechanisms; therefore, some ptosis of the nasal tip should be anticipated in all cases. Recent refinements in incision and surgical technique have overcome some of the earlier criticisms of columellar scarring and delay in resolution of supratip skin edema, and any loss of tip projection can be countered by placement of a columellar strut to maintain support. However, with the open approach, it may be difficult to assess the supratip area and the desired tip projection due to the lack of traction of the soft tissue prior to closure of the columella incision.

Septal Considerations

Revision septal surgery may prove difficult if large areas of cartilage were excised in the original surgery, and the risk of perforation with its concomitant problems should be outlined to the patient. It is the authors’ preference to crush and replace any unused cartilage following harvesting during primary surgery. This prevents scarring following apposition of the mucoperichondrial flaps, thus facilitating easier revision surgery and harvesting if required. The risk of a septal perforation is reduced, and in any case it may provide additional support to the cartilaginous skeleton.12 In the presence of opposing tears, it is imperative to close at least one, and preferably both sides of the mucoperichondrium at the time of surgery. An interpositional graft of fascia or cartilage is also ideally placed and sutured between the flaps.

Unpredictability

The unpredictability of the findings during revision operations has already been alluded to. Soft tissue contractures and scarring may mimic underlying structural deformity, and even with meticulous planning, the surgeon must remain able to adapt or even change his or her planned techniques to suit the discovered anomaly. Provision should always be made to harvest cartilage for camouflage grafting purposes when formulating the preoperative plan to help correct such unforeseen deformities. Experience in a variety of techniques is naturally a prerequisite to undertaking this sort of procedure due the very nature of this unpredictability.

Grafting

It is generally agreed that autologous grafts are the preferred material for rhinoplasty surgery. Septal and auricular cartilages are the most often used options. Prior surgery may limit the amount of such cartilage, but costal cartilage can provide a limitless source of grafting material. The sixth to eighth rib region is ideally harvested to obtain a long segment for dorsal reconstruction, but smaller individual grafts can be taken via a small submammary crease incision. Multiple grafts can be harvested from the cartilaginous rib segment, although warping of the implant is a definite risk, albeit minimized by ensuring the cartilage is systematically concentrically carved from the central portion of the rib rather than the peripheral areas.13,14

Alloplastic materials risk infection and possible extrusion and are thus generally inadvisable, particularly in young patients where the lifetime risk of such complications is higher. Such risks should be discussed with the patient preoperatively prior to entertaining their use. Harvested temporalis fascia can be used as a valuable soft tissue cover to camouflage minor irregularities. It is also usefully employed in patients with very thin skin where even the tiniest imperfections over the dorsum may be visible. It can further be effective as an additional cover over cartilaginous grafts placed in the dorsal and tip regions, helping to efface the edges. Alternative alloplastic options include the use of a porcine collagen matrix, which may be resorbable (Surgisis, Cook, West Lafayette, Indiana), and the cross-linked, more permanent matrix (Permacol, Tissue Science Laboratories Inc., Andover, Massachusetts). Reports of use of the acellular donated human dermis (Alloderm, Life Cell Corp., Branch-burg, New Jersey) appear to be favorable,15 but there are no extensive long-term follow-up data available. It is also no longer available in parts of Europe, including the United Kingdom. Such materials are normally available as a flat sheet of tissue that comes in varying thicknesses, depending on the requirement. Rolling the implant to form a more solid structure that can be used to augment the dorsum has been advocated, but this risks long-term absorption, thereby leaving a residual defect; thus, the use of these materials is advocated for covering grafts only. Multiple revision surgeries can cause significant thinning of the dorsal skin; hence, such soft tissue cover can prove of great importance. Other commonly used, more solid implants are silicone (Silastic), expanded polytetrafluoroethylene (e-PTFE; Gore-Tex, WL Gore and Associates, Flagstaff, Arizona),16 and porous polyethylene (Medpore, Porex Surgical, Newnan, Georgia). The former two are easily removable in the presence of complications. Porous polyethylene promotes significant tissue ingrowth that may be advantageous but has the distinct disadvantage of potentially causing major soft tissue damage if removal proves necessary. Irradiated autogenous rib cartilage has also been advocated, but risks associated with it include long-term absorption and the possibility of warping.

Skin–Soft Tissue Envelope Deformities

Disturbance of the skin and subcutaneous tissues during primary surgery may lead to postoperative scarring, turning a shorter term good cosmetic postrhinoplasty result into a suboptimal one with time.

It is easy to neglect evaluation of the skin–soft tissue envelope when other, more marked deformities may be visible. This is done at the surgeon′s peril, however, as deformities are not always correctable and thus must be identified in the preoperative assessment. Accurate documentation and marking of specific irregularities are critical, as perioperative injection of local anesthesia may mask such deformities. Dissection in correct surgical planes, during both primary and revision rhinoplasty, prevents postoperative scarring and differential thickness of the soft tissues. Circumspect resection of such irregularities during revision rhinoplasty may be required, but caution is advised, as skin–soft tissue envelope changes are largely permanent, and correction can prove troublesome. Of particular concern are the erythematous changes over the dorsum that can occur in up to 10% of patients after revision rhinoplasty. Patients with rosacea are particularly prone to such changes. Correction may require treatment with a laser or intense pulsed light (IPL). Patients with the extremes of very thin and very thick skin types are equally problematic. The thin skin in revision surgery is often fragile and risks perforation while trying to raise it off the underlying structures. It is prone to redness postoperatively, and minor irregularities are easily seen through it. Underlay soft tissue camouflage grafts are often required. Thicker skin has the converse problem of hiding any underlying change to the structure. Patients with very thick skin may be disappointed by the lack of definition of the nasal contour postoperatively and should thus be appropriately counseled beforehand to temper expectations. The underlying soft tissue can be gently trimmed by judicious plucking of the subdermal area using multitoothed Brown-Adson forceps, removing only what easily comes away ( Fig. 25.4 ). Sharp dissection using scissors in the region is best avoided, as it risks damage to the subdermal plexus. The use of postoperative steroid (triamcinolone) injections to reduce the risk of soft tissue pollybeak formation is discussed later in this chapter.

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