28 Revision Rhinoplasty

Rod J. Rohrich, Jamil Ahmad, and Ira L. Savetsky

Abstract

Rhinoplasty remains one of the most challenging operations performed by plastic surgeons. The complexity lies in the ability to have a consistent and predictable aesthetic result. The unpredictability is mainly due to the interplay of manipulated internal structures and wound healing dynamics. In addition, setting realistic expectations with the patient is essential in achieving high postoperative patient satisfaction. An open rhinoplasty approach enables an accurate and in-depth evaluation and intervention. We provide a detailed analysis and discussion on why primary rhinoplasty fails and the surgical approach to prevent these failures.

Rhinoplasty – revision rhinoplasty – open rhinoplasty – secondary rhinoplasty – spreader flaps – spreader grafts – alar contour grafts – septal extension graft – columellar strut graft

28 Revision Rhinoplasty

Key Points

A comprehensive and systematic nasofacial analysis is critical in establishing goals and formulating a precise surgical plan for aesthetic nasal surgery.
Setting realistic expectations with the patient is essential for achieving high postoperative patient satisfaction.
Using structural support and closing dead space will result in a more consistent, predictable result while minimizing primary rhinoplasty failures.
An open rhinoplasty approach enables an accurate and in-depth evaluation and intervention.

28.1 Preoperative Planning

28.1.1 Nasal History and Physical Examination

Have the patients list their top three nasal aesthetic and/or function concerns and record them precisely.
Note any prior nasal trauma and operations including rhinoplasty, septal reconstruction/septoplasty, and sinus surgery and, when possible, prior operative reports should be reviewed.
An internal nasal examination should include assessment of the septum, turbinates, and internal and external valves.
Palpate the nose to assess the length of the nasal bones and strength of the lower lateral cartilages.

28.1.2 Nasofacial Proportions and Systematic Nasal Analysis: “10–7–5” Nasal Analysis (Table 28.1)

The front view evaluation should include 10 key areas: Facial proportions, skin type/skin thickness, symmetry/nasal deviation, bony vault width, midvault asymmetry, dorsal aesthetic lines, tip shape/tip-defining points, alar rims/base, infratip lobular projection, and periapical hypoplasia/upper lip length.

**Table 28.1** Evidence-based nasal analysis: The 10–7-5 method
Nasal view	Analysis
Frontal
1. Facial proportions	Height (thirds), width (fifths), symmetry
2. Skin type/quality	Fitzpatrick type, thin or thick, sebaceous
3. Symmetry/nasal deviation	Midline, dorsal deviation, C-„, reverse C-„, or S-shaped deviation
4. Dorsal aesthetic lines	Straight, symmetric or asymmetric, well- or ill-defined, narrow or wide
5. Bony vault	Narrow or wide, asymmetric, short or long nasal bones
6. Midvault	Narrow or wide, collapse, inverted-V, saddle deformity
7. Nasal tip	Ideal/bulbous/boxy/pinched, supratip, tip-defining points, infratip lobule
8. Alar rims	Gull-shaped, facets, notching, retraction
9. Alar base	Width
10. Upper lip	Long or short, dynamic depressor septi, upper lip crease
Lateral
1. Nasofrontal angle and radix	Acute or obtuse, high or low radix, prominent or low nasion
2. Nasal length, dorsum and supratip	Length: long or short Dorsum: smooth, hump, scooped out Supratip: break, fullness, pollybeak, overprojected or underprojected
3. Tip projection	Overprojected or underprojected
4. Tip rotation	Overrotated or underrotated
5. Alar–columellar relationship	Hanging or retracted ala, hanging or retracted columella Maxillary or soft tissue deficiency
6. Periapical hypoplasia	Maxillary or soft tissue deficiency
7. Lip–chin relationship	Normal, overprojected or underprojected chin
Basal
1. Nasal projection	Overprojected or underprojected, well- or ill-defined tip-defining points, columellar-to-lobule ratio
2. Nostril	Symmetry, long/narrow or short/wide nostril, nostril–tip ratio, concave or convex ala
3. Columella	Caudal septal deviation, flaring of medial crura
4. Alar base	Width
5. Alar flaring

The profile view includes 7 areas: Radix height and position, dorsal convexity, nasal length, tip projection, tip rotation, alar–columellar relationship, and chin projection.
Use the base view to assess 5 areas: Nasal projection, nostril shape/symmetry, columella symmetry/width, alar base width, and alar rim flaring.

28.2 Operative Steps

We have shown the safety of ignoring prior incisions in the columella and basing the new scar location based on where the surgeon feels is ideal (Unger et al. 2013.).
The nose should be approached using an open technique as described in Chapter 15 Open Rhinoplasty Finesse. It is critical that dissection remains deep to the scar tissue.
See Video 28.1.

28.2.1 Nasal Dorsum and Midvault

Deformities of the nasal dorsum are commonly found in revision rhinoplasty and can not only lead to irregularities and disruption of the dorsal aesthetic lines but also lead to compromise of the internal nasal valve.
Inadequate support can lead to midvault collapse resulting in an aesthetically displeasing inverted-V deformity. Maximal control with a graduated approach of the dorsum is critical.
Use of the senior author’s “4Rs” component dorsal hump reduction is recommended when addressing this area: (1) Release the upper lateral cartilages from the septum, (2) incrementally Resect the septum proper, (3) Rasp the bony dorsum, and (4) Restore the dorsal aesthetic lines. Deformities of the nasal dorsum are commonly found and can lead to irregularities and disruption of the dorsal aesthetic lines (Fig. 28.1).
When sufficient upper lateral cartilage volume is present, restoration of the dorsal aesthetic lines is predictably achieved by using the senior author’s four-step approach for autospreader grafts: (1) pull-twist-turn, (2) horizontal mattress sutures, (3) percutaneous osteotomies, and (4) simple interrupted sutures.
Spreader grafts should be used selectively when additional midvault infrastructure is needed (Fig. 28.2a–c).
External nasal valve compromise is also commonly encountered in revision rhinoplasty. This area is particularly prone to late changes due to wound contraction and scarring of the soft triangles and the lack of structural support in this region.
Alar collapse due to misplaced alar grafts causing obstruction is commonly encountered.
Removal of obstructing alar grafts and replacement with appropriate structural support will open the external nasal valve and restore air flow.
Proper and routine placement of extended alar contour grafts in primary rhinoplasty is advocated as it helps to prevent external nasal valve collapse secondarily.