31 Secondary External Rhinoplasty

David W. Kim, Benjamin A. Bassichis, and Dean M. Toriumi

Surgery of the nose poses numerous unique challenges. There is incredible heterogeneity in nasal anatomy and form. The nose is a prominent three-dimensional structure, in which form is determined by material (bone and cartilage) that is awkward to reshape. Disruption of the nasal structure may lead to weakening and undesired alterations in appearance, particularly in the face of relentless postoperative scar contracture. For these reasons, primary rhinoplasty frequently results in a suboptimal outcome, with a need for revision surgery in an estimated 8 to 15% of cases.1 Revision rhinoplasty creates additional difficulties. Following primary surgery, the nasal anatomy is altered and highly variable. This compromised baseline means that traditional techniques may be of limited usefulness. Treatment must become based on diagnosing and understanding the problems caused by the previous operations and selecting the correct techniques to address them. Thus, in many ways, the study of secondary rhinoplasty is the study of the complications of primary rhinoplasty.

Patient Interview

It is imperative that the surgeon obtains as much information as possible concerning the problems that led to the patient’s visit. The typical individual seeking revision surgery is often more knowledgeable, demanding, and emotional than primary rhinoplasty patients. The patient must understand that the greater the degree of baseline damage, the more limited the possibilities for improvement. Therefore, it is critical that the surgeon instill realistic outcome expectations in these patients. Surgery should not be performed unless common expectations are reached between patient and surgeon.

During the initial consultation, old operative notes and rhinoplasty worksheets may provide useful information. However, they may be incomplete or erroneous regarding grafting material, implants, and previous surgical maneuvers. Pre- and postoperative photographs may help in determining the nature and time course of the given problems. Photographs can also reveal which problems resulted from surgery and which predated the primary surgery. These original images are valuable, as many patients may have had variant nasal anatomy that set up a predisposition to a specific postrhinoplasty deformity.

The physician should list and prioritize patient complaints and gauge how reasonable and achievable these requests are. Functional airway problems that result from anatomical disturbances are surgically correctable. Cosmetic problems should be discussed in detail with the aid of photographs and computer imaging. Each aesthetic complaint should be discussed with regard to possible etiology and prospects for repair.

Physical Examination

Cosmetic nasal analysis of the secondary nose begins with a global assessment of the deformities. Often one or two areas of deformity may be immediately noticeable to the physician. These may include an asymmetric tip, dorsal irregularities, or a narrowed base. It is important to prioritize these deformities during surgery, as surgery on each subunit of the nose affects the appearance of the others. The surgeon must modify a given structure based on the status of adjacent structures. Knowing that one aspect of the nose is particularly problematic allows the surgeon to focus on it and modify the rest of the nose around those corrections.

Analysis should continue with a systematic assessment of each view of the nose. Although analysis of the patient is done in the office setting, quality preoperative photographs allow for more detailed study at a later time. On the frontal view, symmetry and width should be assessed in each of the vertical thirds of the nose. An irregular brow-tip aesthetic line should prompt the surgeon to determine the anatomical cause. Middle vault collapse may be manifest as pinching in the middle third of the nose or as an inverted-V deformity. Previously over-resected lower lateral cartilages (LLCs) may lead to supra-alar pinching and alar retraction (revealed as excessive nostril show). Common iatrogenic tip deformities include pinching, bossae, and asymmetry.

The base view also provides information about the shape and size of the columella, alar base, nostrils, and lobule. Excessively narrowed or asymmetric nostrils, malposition of alar insertion, and the presence of visible scars are signs of complications from alar base reduction. Other stigmata of previous surgery on the base view include alar pinching, tip irregularities, alar notching or pinching, and persistent caudal septal deviation.

On the lateral view, the dorsum is assessed for a smooth profile, nasal starting point, and presence of a supratip break. An over-resected dorsum may lead to a convex appearance in the presence of a projecting tip. A low dorsum will also lead to an appearance of excessive width on the frontal view. A pollybeak may be present as the result of relative supratip excess (soft tissue or cartilaginous) or deficiency in tip projection. In the lower third, the overall projection and rotation of the nasal tip must be assessed. Using Goode’s method, the nasal tip projection as defined from the alar crease to the tip-defining point should be just over half (0.55) the length of the nose.2,3 The ideal length should be based on a nasal starting point near the superior palpebral fold and a tip-defining point determined by the ideal degree of tip rotation. One measure of rotation is the nasolabial angle, which in men should be between 90 and 95 degrees and in women between 95 and 105 degrees. In cases of relative tissue excess or deficiency at the premaxilla, this angle may not reflect the degree of rotation at the tip and infratip lobule. In these cases, use of the columellar facial angle may be more appropriate.⁴ This is the angle formed by the intersection of the columella and a vertical reference line perpendicular to the Frankfort horizontal line. A common secondary deformity occurs after excessive caudal septal resection and cephalic trim of the LLCs. In such cases, the nose is foreshortened, the nasolabial angle overly obtuse, and the ala retracted. In other cases in which the nasal base was previously inadequately supported, the tip may become ptotic, resulting in a long nose with an acute nasolabial angle. Both lateral views should be compared, as deformities may differ from side to side.⁵

The surgeon must note the thickness and sebaceous quality of the nasal skin–soft tissue envelope (SSTE). Particularly in thick-skinned individuals, previous reduction of the underlying skeletal framework may cause significant scarring in the dead space. This can cause the SSTE to be exceptionally thick and inelastic. Further structural reduction should be avoided in these patients so that subsequent additional scar formation may be prevented. In such cases, one should augment the relative deficiency of the underlying structural framework to project into the thick soft tissue envelope. An advantage of such thick SSTE is that irregularities of the underlying nasal skeleton and grafts are camouflaged.

The SSTE may have been overly thinned, damaged, or devascularized during prior surgery. The presence of acquired cutaneous telangiectasias, purple or blue discoloration of the nasal skin with cold temperature, and visible irregularities are signs of such a condition. In these patients, the dissection of the SSTE of the underlying structural framework must be precise and deliberate, as extensive soft tissue elevation will increase the risk of ischemia and wound breakdown. Although patients with thin skin may not have injury to the SSTE, it is important to remember that there is added risk of contour irregularities becoming visible or palpable. Care must therefore be taken to ensure that all existing bony and cartilaginous structures, grafts, and implants are precisely positioned and smoothly contoured. The benefit of thin skin is that general contour changes made at the time of surgery will translate into similar final contours postoperatively, requiring less of a compromise on what one would consider an ideal aesthetic outcome.⁶

It is crucial to obtain an assessment of the patient’s nasal airflow, which should be undertaken prior to and after decongestion of the nasal mucosa. The surgeon must note the external stigmata of an obstructed nose or one that is prone to develop postoperative problems. These characteristics include thin SSTE, a narrow or collapsed middle vault, short nasal bones, supra-alar pinching, a prominent supra-alar crease, narrow nostrils, and thin lateral nasal walls. Intranasal exam may reveal a narrow internal valve angle, internal recurvature of the lateral crura, dynamic lateral wall collapse, septal deviation, inferior turbinate hypertrophy, mucosal synechiae, or shortage of lining from prior excision. Assessment of dynamic function should be performed by observing the lateral wall of the nose with inhalation. Obvious collapse indicates lateral wall weakness. Significant improvement of breathing by supporting the lateral wall with a small instrument may predict airway improvement with placement of a supporting graft to the lateral wall. All of these factors must be considered in formulating a surgical plan that will restore or preserve a functional airway.

Palpation of the nose is important to determine the shape, position, and strength of the nasal structure. Dorsal irregularities may not be visible beneath a thick SSTE and may require digital palpation to be detected. An attempt should be made to trace the LLCs to assess position and stability. The resistance and recoil of the nasal tip to digital pressure will provide information of tip support. Finally, palpation of the caudal nasal septum will help to determine the position and integrity of the caudal septal strut.⁷

General Considerations

Patients who seek revision rhinoplasty may come with any number of problems. Small asymmetries, malposition, and irregularities may occur as the result of errors of omission or technique. These problems are generally straightforward and easily corrected. Significant asymmetries, functional obstruction, and gross deformities are more likely to result from errors of judgment. In such cases, the primary surgeon may have been overly aggressive in excisional or reductive maneuvers or failed to resupport destabilized structures. These problems may not become apparent for years and may therefore escape the awareness of the original surgeon.

There are several categories of complications, each of which results from different types of surgical errors. Identification, diagnosis, and correction of these problems depend on a thorough understanding of the surgical pitfalls and postoperative processes. The various groups of complications are listed in Table 31.1.

A common problem is one of subtle asymmetry or malposition of structures, grafts, or implants secondary to technical errors. In thin-skinned patients, imprecise graft placement or uneven excision of cartilage may lead to cosmetic imperfections. Asymmetric skeletal modifications can lead to nasal pyramid imperfections. These complications are typically minor and are readily correctable. An exception to this is the case of alloplastic implants that become infected and have begun to extrude. Though such a problem can be easily corrected by removing the implant, if left untreated, the infection can become serious and lead to permanent damage to the nose. Additionally, these implants may lead to a contractile process of the skin envelope, making it difficult to re-expand the area of desired augmentation. Failure to reapproximate the columellar incision exactly and appropriately can result in a visible scar. Even after an appropriate and technically sound operation, the forces of scar contracture, mechanical trauma, and edema may result in an imperfect outcome.

Errors of omission result in variable degrees of postoperative problems, depending on the severity and nature of the original problem. This type of error, often committed by an inexperienced or overly conservative surgeon, may be evident in preoperative photographs. Common examples include the twisted nose, asymmetric middle vault, and various tip deformities. These problems are readily corrected with the proper techniques.

A third class of error involves failure to resupport destabilized structures. Many maneuvers in primary rhinoplasty require disassembling the various support structures of the nose. Left unsupported, these destabilized areas become more susceptible to the forces of scar contracture, gravity, and facial mimetic function. The most common problems of this type include failure to stabilize the nasal tip at the base after compromising tip support mechanisms, failure to resupport the upper lateral cartilages onto the dorsal nasal septum after cartilaginous hump removal, and failure to support the lateral nasal wall in patients with a lateral wall deficiency. Correction of such problems usually requires structural grafting techniques to restore strength to the nasal framework.

A more problematic type of error is one of excessive reduction and excision. Excessive caudal septal resection, lateral crural cephalic trim, dorsal hump reduction, alar cartilage division, and alar base reduction may result in an assortment of cosmetic and functional sequelae. The type and severity of deformity resulting from over-reduction of the underlying nasal structure partially depend on the quality of the SSTE. Many of these problems are challenging to repair, as there is a deficiency of tissue that may not be able to be replaced. This is particularly true when a portion of the internal lining of the nose has been excised.

Table 31.1 Complications and Errors

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