Male Revision Rhinoplasty
By Paul S. Nassif, M.D., F.A.C.S.
Abstract
Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform because males usually have thick nasal skin, which is more difficult to re-support and project the nasal tip, and often have high or unrealistic expectations. The primary etiology for the need for male revision rhinoplasty is a primary rhinoplasty with aggressive lower lateral cartilage reduction that causes tip ptosis and loss of projection. The goal to an aesthetically pleasing revision rhinoplasty is to recreate adequate tip projection and an intact strong tripod complex. Following tip reconstruction, the height and width of the dorsum should be set. For male revision nasal surgery, a clear and thorough knowledge of nasal anatomy, function and surgical techniques is paramount. Having an extensive preoperative discussion including expectations, outcomes and a detailed list of potential complications with the patient can prevent physician-patient miscommunication. Prior to surgery, review the exam, previous operative summary, photos, nasal analysis sheet, problem list and plan and then proceed with the surgical treatment.
Keywords
Male revision rhinoplasty, Revision rhinoplasty, Alar batten grafts, Alar rim grafts, Structural grafting, Male rhinoplasty, Rhinoplasty
Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform. Perfecting surgery with the three dimensional nose takes years to improve and maybe master. In rhinoplasty surgery, minor rhinoplasty maneuvers that we do today may lead to significant postoperative deformities three years from now. Many of us are taught that aggressive cartilage removal is a procedure of the past. Today’s concept is “less is more”. Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafting and suturing techniques are being taught in most residencies and fellowships and at our national meetings. When primary rhinoplasties are performed, the need for a future revision rhinoplasty is becoming increasingly common. Generally, revision rhinoplasty in males are more complex than females because males may have higher or unrealistic expectations and often, thick nasal skin, which is more difficult to re-support the nasal tip than in thin nasal skin.
In male primary rhinoplasty surgery, the key to prevention of complications is pre-diagnosis of potential anatomical and functional abnormalities. For example, a patient desires a dorsal hump reduction and you identify short nasal bones, thick skin and a long middle vault. Your thorough evaluation will warn you that this patient is at risk for upper lateral cartilage subluxation from the nasal bones (inverted-V deformity) and internal valve collapse following osteotomies.
For male revision rhinoplasty patients, initially perform a detailed anatomic and functional evaluation of the nose followed by documentation of the postoperative nasal deformities that are present and sites of nasal obstruction. After the problems and potential complications are identified, create a general surgical plan while studying the preoperative photographs and prepare to use everything in your surgical armamentarium since your preoperative plans for revision nasal surgery will usually change during surgery.
Evaluation
Below is my algorithm for a revision rhinoplasty consultation. When the appointment is made, the patient is asked to bring a copy of their medical records and operative reports from their rhinoplasty surgery or surgeries, in addition to photographs of their native nose. Review the notes and photos while the prospective patient is discussing surgery with your patient care coordinator. This will give you a head start on identifying the problems assuming that a problem exists. Next, a detailed history is performed while listening very carefully to the patient’s wishes. Does he have realistic expectations? This is by far the most important detail that the astute surgeon needs to attain from the history. What is the patient unhappy with – a pinched tip or polly-beak deformity? Additionally, listen to the patient and see if negative comments are made or if the patient is seeking litigation against the prior surgeon. If this is the scenario, you may want to think twice prior to performing a revision rhinoplasty on this patient. If the male patient is not happy with the results of his surgery by you, there is a good chance that he will be saying unkind words about you in the subsequent surgeon’s office. Does he fit the SIMON profile (Single, Immature, Male, Obsessive, and Narcissistic)? If so, watch out since these patients are very difficult to please and are litiginous. During the initial five minutes of your history, the astute surgeon should know if the patient is a good candidate for revision surgery. Poor patient selection can lead to an unhappy patient and surgeon.
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Another important detail is to ascertain if the patient has nasal obstruction. The incidence of postoperative nasal obstruction following a primary rhinoplasty is approximately 10%.1 Determine if the nasal obstruction was present preoperatively. If the obstruction is a result of the surgery, a number of questions need to be answered. Did the patient have reductive rhinoplasty surgery? Have the patient point out where the obstruction is. Is it static or dynamic? Present with normal or deep inspiration? What alleviates and worsens the nasal obstruction? What are the characteristics of the nasal obstruction? Was septal surgery performed? The physical examination ensues.
For the physical exam, I use a detailed nasal analysis worksheet (Figure 2). Perform a detailed visual and tactile evaluation of the nose. Use an ungloved finger to palpate the nose. Examine the bony and cartilaginous skeleton, tip and skin-soft tissue envelope characteristics in frontal, oblique, lateral and base views. For the bony dorsum, examine the osteotomies, presence of open roof deformity or rocker deformity, and hump under- or over- resection. If inadequate hump reduction is in question, first examine for a deep radix and/or under-projected, ptotic nasal tip and for microgenia. Look for middle vault abnormalities such as a narrow middle vault, inverted-V deformity or under-resection of the cartilaginous dorsum (polly-beak deformity) (Figure 3). For the tip, examine tip projection, rotation, support, alar and columellar retraction, over-aggressive alar base reduction, and lower lateral crural characteristics such as over-resection, cephalically oriented or bossa formation. Over-resection of the lower lateral cartilage complex in males with a heavy sebaceous skin-soft tissue envelope can cause tip ptosis and subsequent, nasal obstruction. A deviated cartilaginous dorsum and tip can signify a deviated septum. This is only a partial list of anatomical problems that the surgeon needs to identify in nasal analysis.
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| Figure 3 Polly beak deformity (arrow) following a reductive rhinoplasty. |
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For male patients with nasal obstruction, observe him performing normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable as supra-alar, alar and/or rim collapse (slit-like nostrils) during static or dynamic states. External valve collapse (lower lateral cartilage pathology) can be evaluated with the soft end of a cotton swab while plugging the contra-lateral nostril. The cotton swab elevates the area of obstruction whether it’s the alar rim, lower lateral crura or supra-alar region. See if the nasal obstruction is alleviated by elevating the nasal tip in patients with ptosis of the nasal tip. Perform the Cottle maneuver (pulling laterally on the cheek) to check for internal valve collapse. Although this test is generally non-specific, internal nasal valve pathology caused by supra-alar pinching or a narrowed angle between the upper lateral cartilage and septum can be diagnosed. On basal view, examine the medial crura feet to identify if they are impinging into the nasal airway.
Following a thorough external nasal evaluation, the endonasal examination ensues. At minimum, perform anterior rhinoscopy with and without topical decongestion. In certain cases, nasal endoscopy and rhinomanometry may be useful. Evaluate the nasal septum for perforations, persistent deviation and for any remaining cartilaginous remnants to be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae between the lateral nasal wall and septum, nasal masses and middle turbinate abnormalities (concha bullosa).
As you are examining the patient, create a mental problem list with solutions followed by documentation on your nasal analysis sheet, such as: 1. external valve collapse secondary to over-resected lower lateral crura with a plan of open rhinoplasty with alar batten grafts using conchal cartilage, 2. internal nasal valve collapse secondary to a narrow middle vault and supra-alar pinching with moderate inspiration with a plan of bilateral spreader grafts and supra-alar batten grafts using conchal cartilage, and 3. bilateral alar retraction with a plan of bilateral conchal composite grafts. If structural grafting is necessary, decide what material may be used. A thorough knowledge of the types of autologous (septal, conchal, costal cartilage, deep temporalis fascia, and calvarium) or alloplastic grafting is needed as well as harvesting techniques.
This is only an initial plan as you are creating your algorithm. Guaranteed, it will change as you get closer to surgery. Computer morphing can be extremely useful if patients are notified that the final image is not a guarantee of results. However, despite proper notification and consent, there have been reports of lawsuits filed by patients for outcomes that are different than what was generated by the computer imager. Computer imaging can give clues to the patient’s expectations. Unrealistic expectations can be identified when a conservative image is generated by the surgeon and the patient desires a radical change. Therefore, computer imaging can be a powerful tool in evaluating patients for surgery. I can’t count the number of times that I have rejected male patients for primary and revision surgery secondary to them having unrealistic expectations only being identified by the computer morphing. An additional use for the computer image is to use it as a goal in surgery. Bring the preoperative and computer imaging photos to the operating room.
Procedure & Pearls
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| Figure 4 A residual C-shaped septal deformity with convexity to the left (arrow) is demonstrated via an open rhinoplasty approach. |
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Residual or Recurrent Caudal Deviated Septum
Many chapters have been written on correction of the caudal deviated septum. Depending on the complexity of the deviation, a closed, open or a combination of the two may be used. A caudal septum dislocated off the maxillary crest is usually approached from and endonasal approach as compared to a C- or S-shaped septal deformity (Figure 4). These deformities are best approached via an open rhinoplasty with a swinging-door approach, cartilage scoring, unilateral or bilateral spreader grafts and/or septal batten grafts to help straighten the twisted septum.
Injection
In the majority of revision rhinoplasty surgeries, an open approach is used. Infiltrate the nose with an ample amount of local with epinephrine to help hydrodissect the scar tissue from the skin-soft tissue envelope and for control of hemostasis. If a previous open rhinoplasty was performed, follow the same incision on the columella to prevent columellar skin necrosis from lack of blood supply to the tissue between the old and new incision. Once the nose has been opened, repeat the use of local to hydrodissect scar tissue from the nasal tip (Figure 5A & B) and/or mucoperichondrium from the lower lateral cartilages (Figure 6), grafts and cartilaginous dorsum. Hydrodissection will aid in dissecting scar tissue from the tip cartilage so that the surgeon will be able to identify what cartilage remains, excise the soft tissue polly-beak deformity if present and resect scar/mucoperichondrium en bloc (Figure 7) from the nasal tip to use as an onlay or camouflage graft if needed.
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| Figure 5a Scar present over the nasal tip (arrows) following previous rhinoplasty. |
Figure 5b Nasal tip revealing over-resected lateral crura (arrows) following scar tissue excision. |
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| Figure 6 Local injection used to hydrodissect mucoperichondrium from the right lower lateral cartilage (arrow). |
Figure 7 Scar excised from nasal tip following previous rhinoplasty. |
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Bony Vault
Frequent problems that occur with the bony vault are: incomplete osteotomy, rocker deformity, under- or over-resection of the nasal dorsum, dorsal depression or irregularity (callous formation) and a depressed nasal bone following osteotomy.
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| Figure 8a Lateral preoperative view of an over-resected dorsum with over-projected tip. |
Figure 8b 2 week lateral postoperative view following dorsal augmentation with crushed cartilage covered with Gore-Tex and tip de-projection. |
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Incomplete Osteotomy & Rocker Deformity
For an incomplete osteotomy or rocker deformity, the bone is usually not medialized and it may appear that the patient has an inverted-V deformity. With careful palpation and examination of the upper and middle vault of the nose and photo documentation, the rhinoplasty specialist should be able to distinguish what and where the actual problem is. If it is a bony problem, revision medial and lateral (sometimes double) osteotomies are performed. To guarantee movement of the newly fractured bone, the medial and lateral osteotomies have to connect as the medial osteotomy fades laterally and as the lateral osteotomy is curved medially beginning at the medial canthus. After this maneuver is complete, use a nasal elevator to confirm that the bone is freely mobile. With the rocker deformity, the medial and lateral osteotomies are directed towards the frontal bone without connecting which prevents the nasal bone from becoming mobilized. The goal of a perfect osteotomy is to have the lateral osteotomy start low on the frontal process of the maxilla and finish high on the nasal bone usually below the radix and for the medial osteotomy to fade laterally meeting the lateral osteotomy. In patients with low nasal bone profiles such as Asians or African-Americans, the lateral osteotomy starts and finishes low with the medial osteotomy fading laterally meeting the lateral osteotomy at the frontal process of the maxilla or on the lateral nasal bone.
Under- or Over-Resected Bony Dorsum
An under-resected nasal dorsum is usually treated with hump reduction with the use of rasps and/or rubin osteotomes and often, medial and lateral osteotomies. An over-resected nasal dorsum (Figure 8A & B) is treated with augmentation. Autologous or alloplastic implants may be used. For minimal radix and/or dorsal augmentation, my preference is to use nasal scar tissue, nasal mucoperichondrium or deep temporalis fascia (Figure 9). For moderate radix and/or dorsal augmentation, bruised septal or conchal cartilage is placed posterior to the scar tissue, mucoperichondrium or deep temporalis fascia. In my hands and in many of the revisions that I have performed from surgeries performed elsewhere, septal cartilage, conchal cartilage or rib placed on the bony dorsum either looks unnatural or eventually warps. The unnatural appearance is due to the thin skin present over the bony dorsum revealing the exact contour of the implant. For maximal dorsal augmentation, I have had good luck with the use of layered polytetraflouroethylene (Gore-Tex, W.L. Gore, Flagstaff, Arizona) (Figure 10) with or without autologous cartilage placed posterior to it. Gore-Tex may be placed utilizing guide sutures (5-0 polyglactin) with the tuberculin syringe technique. The graft usually extends from the nasofrontal angle to just short of the supratip break. The needle of the suture is straightened and placed in the hub of the syringe with the plunger withdrawn enough so that the needle is hidden in the hub (Figure 11A). The syringe is introduced into the caudal nasal dissection, followed by placement of the hub flush against the nasal skin, a few millimeters cephalad to the desired position for placement of the graft. The plunger is then depressed with the needle being expelled through the tissue (Figure 11B). The needle is grasped and pulled out and used as a guide to pull the graft into the nose (Figure 11C). After proper placement of the graft, the needle is removed and the suture may be cut at the skin level or taped to the glabellar region for a few days.
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| Figure 9 Deep temporalis fascia used for augmentation or to cover cartilage grafts. |
Figure 10 2 mm thick polytetraflouroethylene (Gore-Tex) used for dorsal augmentation. |
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| Figure 11a The needle of the suture is straightened and placed in the hub of the syringe with the plunger withdrawn enough so that the needle is hidden in the hub. |
Figure 11b Tuberculin syringe inserted into nose with needle exiting dorsal nasal skin.. |
Figure 11c Gore-Tex being inserted into nasal dorsum with guide suture. |
Dorsal Bony Sidewall Depression & Dorsal Bony Irregularities (Callous Formation)
Dorsal sidewall depressions can be corrected with placement of soft tissue and/or bruised cartilage. Dorsal irregularities such as callous formation, which may form as late as eight months following rhinoplasty, usually form on the medial osteotomy line. Treatment for callous formation is rasping.
Depressed Nasal Bone
A depressed nasal bone or segment may occur following osteotomies. This may occur immediately or many months following a rhinoplasty. In most instances, scar tissue, mucoperichondrium or deep temporalis fascia with or without bruised septal or conchal cartilage is placed posterior to the soft tissue.
Middle Vault
Problems seen in the middle vault are under- or over-resection of the cartilaginous dorsum, narrow or subluxation of the upper lateral cartilage(s).
Under- or Over-Resection of the Cartilaginous Dorsum
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| Figure 12 Left spreader graft (arrow) harvested from septal cartilage and secured to septum. |
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A polly-beak deformity (Figure 3) is usually due to under-resection of the cartilaginous dorsum or a build up of scar tissue, especially in the region of the supra-tip. Meticulous removal of the scar tissue and/or reduction of the cartilaginous dorsum will correct this common problem in revision rhinoplasty. A saddle nose deformity may be caused by over-resection of the cartilaginous dorsum or an overaggressive septoplasty. Autologous cartilage is usually well-tolerated in this region secondary to thick nasal skin. Soft tissue may also be used if minimal augmentation is needed or to cover the cartilaginous implant. If autologous tissue is not available, polytetraflouroethylene (Gore-Tex) may be used.
Narrow Middle Vault (Inverted-V Deformity)
Patients with the triad of short nasal bones, thick skin and a long middle vault are at risk for an inverted-V deformity (Figure 1) following rhinoplasty. Subluxation or collapse of the upper lateral cartilage(s) can be treated with an onlay graft or spreader graft(s). My preference is to use a spreader graft especially in the case of a narrow internal nasal valve. The spreader graft may be placed via an open (Figure 12) or endonasal approach. The endonasal approach for spreader graft placement is more technically challenging. Spreader grafts may be carved from septal (my preference), conchal or rib cartilage. In patients with thin skin, deep temporalis fascia is placed over the spreader grafts to soften their appearance. Bruised cartilage, soft tissue or a combination of the two may be used as an onlay graft.
Tip Surgery
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| Figure 13 Male patient with a “pinched” tip with bossa formation. |
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| Figure 14 Over-resected nasal tip with minimal to no lateral crura present lateral to the dome (arrows). |
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Revision nasal tip surgery is the most difficult aspect of the procedure. In order to achieve your goals, you need to balance the functional and cosmetic portions of the nose. For example, if a patient has nasal obstruction secondary to collapse of the external nasal valve from over-resection of the lateral crura and the patient likes the “pinched” look (Figure 13), how do you place alar batten grafts without relieving the “pinched” look? On a similar note, a patient has nasal obstruction, complains of a bulbous tip and desires a smaller tip. With your exam, you notice that he has over-resection of the lateral crura and the “pinched” look, makes the central nasal tip appear bulbous. Obviously to correct this, you need to build up the alar sidewalls to make the central nasal tip “flow” into the alar sidewall. This maneuver will efface the step-off between the tip and ala, creating a harmonious tip/ala complex. Unfortunately, you have to notify the patient that you are going to make the nose wider but more aesthetically pleasing. This is an art in itself. Prior to commencing surgery, the rhinoplasty revisionist needs to possess the aesthetic and functional prowess to balance the nose, make it look better (even though it is bigger) and correct the breathing. It is an incredible balancing act to make the patient happy and the nose functional.
Alar Collapse
The most common nasal tip complication that I see in my practice is an over-resected tip. The non-ethnic patients have the typical appearance of a “pinched” nose with loss of tip projection. Intraoperatively, narrow (4 -5 mm) lower lateral crura (Figure 14) are identified in the majority of cases. To correct this problem, alar batten grafts are carved from septal or auricular cartilage. Auricular cartilage (Figure 15) is the preferred autologous tissue since it is convex in nature and replicates the native nasal tip cartilage much better than septal cartilage. Rigid septal cartilage, if present, needs to be carved to create a convex structure. This can be performed, but often lacks the desired convexity. Auricular cartilage harvesting from the concha cavum and cymba may be approached from the anterior (Figure 16 A & B) or posterior surface.
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| Figure 15 Convex auricular cartilage used for tip reconstruction. |
Figure 16a Auricular cartilage harvested from the anterior approach. |
Figure 16b Anterior surface of the ear following incision closure and coapting sutures placed through the concha cavum and cymba (arrow). |
After the auricular cartilage is harvested, alar batten grafts are carved to the appropriate size. Often, the grafts are 5 – 6 mm wide and 10 to 18 millimeters in length. In most cases, the grafts are placed just lateral to the dome and are placed on the anterior surface of the existing cartilaginous remnant and secured with 5-0 chromic horizontal mattress sutures through the existing cartilage and vestibular tissue (Figure 17). The lateral extent of the graft usually extends just medial to the pyriform aperture. These grafts are also helpful in enlarging the airway when lateral osteotomies have collapsed the pyriform aperture and caused airway obstruction. In some cases, the grafts are placed on the caudal or cephalad aspect of the over-resected crura. This depends on where the collapse is identified. If the alar rim and alar (where the existing lower lateral cartilage is) is collapsing, the alar batten graft is placed on the caudal aspect of the native cartilage and alar rim (Figure 18 A & B). In this scenario, a rim incision, not a marginal incision, is the preferred incision. This combined alar rim/alar batten graft will serve to support the alar rim and the ala. In some situations, separate alar rim and alar batten grafts are placed. The rim grafts can be fixated to the vestibular tissue caudal to the preexisting remnant as long as sufficient vestibular tissue is present. If present, mild alar retraction may be corrected with these grafts. If vestibular tissue is not sufficient following the rim incisions or when a marginal incision is made, alar rim grafts can be placed into a small pocket made in the lateral alar soft tissue extending to the nasal base. The graft (averaging 15 mm in length and 2 mm in width) is inserted into this pocket and extends the entire length of the ala just short of the dome (Figure 19). In open rhinoplasty, the grafts have to be gently lifted over and placed caudal to the dome so that the graft is only supporting the alar rim.
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| Figure 17 Conchal cartilage alar batten grafts (arrows) secured to the native lower lateral cartilages. |
Figure 18a Combined conchal cartilage alar batten/rim grafts secured to the caudal edge of the native lower lateral cartilages and vestibular tissue, especially on the left (arrow). An infra-tip lobule graft is also in place (arrowhead). |
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Figure 18b Alar batten/rim grafts and an infra-tip lobule graft covered with deep temporalis fascia (arrow). |
Figure 19 Scar excised from nasal tip following previous rhinoplasty. |
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| Figure 20a Conchal cartilage alar batten grafts (arrows) are placed over the skin immediately prior to placement via an endonasal approach. |
Figure 20b Following placement of alar batten grafts. |
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In the closed rhinoplasty approach, the region of collapse is identified, marked with a surgical marker and measured. Often, the cartilage to be used for grafting is placed over the skin immediately after marking (Figure 20A), making an imprint on the cartilage graft. Following a partial rim or marginal incision and sharp dissection of a precise pocket slightly larger than the graft, the graft is then placed into the pocket (Figure 20B).
In some instances, alar collapse occurs in the presence of adequate lower lateral cartilage size. The lateral aspect of the lateral crura may impinge into the airway following placement of tip sutures and/or due to a weak, concave lateral crura. When this occurs, sub-cartilaginous lateral crural strut grafts are placed. The vestibular tissue attached to the posterior surface of the lower lateral cartilage is infiltrated with local, followed by the creation of a sub-cartilaginous pocket. Struts, measuring 5 mm in width and approximately 1 centimeter in length, are placed in the pocket and sutured to the native lower lateral cartilage with 5-0 chromic horizontal mattress sutures. Lateral crural strut grafts will lateralize and support the lateral crura and open the external nasal valve.
Alar Rim Collapse
Alar rim collapse is generally seen in patients that have had previous aggressive nasal tip surgery (Figure 21 A – D), rhinoplasty with undiagnosed weak alar rims (Figure 22) or pre-existing vertically oriented lower lateral cartilages (parenthesis deformity) (Figure 23 A & B) that became worse following lower lateral cartilage reduction and tip suturing or over-aggressive lower lateral cartilage reduction. In the presence of the parenthesis deformity, releasing the lower lateral cartilages from its lateral vestibular attachments (Figure 24) and repositioning the cartilage from a vertical to caudal position with rim grafts (Figure 25) will correct this problem. Alar rim collapse may be diagnosed alone or often, in conjunction with alar collapse. If alar rim collapse, which may cause nasal obstruction and/or an unattractive appearance, is present as the only abnormality, alar rim grafts are placed. Alar rim grafts may be carved from septal or auricular cartilage. Auricular cartilage is the preferred autologous tissue secondary to the cartilage being naturally curved and soft. If rim incisions are combined with an open rhinoplasty, rim grafts can be fixated to the vestibular tissue caudal and posterior to the lower lateral cartilage as long as sufficient vestibular tissue is present (Figure 25). Another approach to place rim grafts in open rhinoplasty is to use an eleven blade to make a stab incision into the lateral caudal alar margin (caudal to the marginal incision) followed by dissection with small scissors. A small pocket is made which will hold the alar rim in place. The grafts are long and thin, averaging 15 millimeters in length and 2 millimeters in width. The alar rim graft is placed in the pocket and extends the entire length of the alar to the region of the soft tissue triangle (Figure 19). Customizing the appearance of the medial end of the alar rim graft is often necessary to balance the alar rim. When the skin flap is redraped, the alar rim graft needs to be “pulled down” into the correct position under the alar rim. If a closed approach is used, alar rim grafts may be placed via a rim incision and sutured to the vestibular tissue with 5-0 chromic or slid into a small pocket via a small rim incision after careful sharp dissection is performed through the alar rim.
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| Figure 21a A. Base view demonstrating alar rim collapse (big arrows) and bossa formation (small arrows) following two previous rhinoplasties. |
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Figure 21b One year postoperative basal view following open rhino-plasty with bilateral alar/rim grafts, repair of bossa and scar tissue covering the domes. |
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Figure 21c Frontal view before surgery. |
Figure 21d Frontal view after surgery. |
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| Figure 22 22. Basal view revealing weak alar rims (arrows) prior to primary rhinoplasty. |
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Figure 23a Close-up frontal view of vertically-oriented lower lateral cartilages (arrows) (Parenthesis deformity). |
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Figure 23b Basal view. |
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| Figure 24 Basal view of released lower lateral cartilages (arrows) from its lateral vestibular attachments. |
Figure 25 Basal view of repositioned lower lateral cartilages with rim grafts. |
Poor Tip Projection
To maintain an aesthetically balanced nasal profile with a pleasing supratip break, tip projection must be maintained or augmented. Some degree of tip projection is lost in the majority of rhinoplasties. Releasing the lower and medial lateral cartilages from the adherent vestibular tissue (Figure 26) with placement of a columellar strut may be all that is needed verses structural grafting to increase tip projection. Numerous grafts may modify tip projection such as a basic columellar strut (Figure 27), shield tip graft, bruised onlay domal graft or a combination of any of these grafts. In the majority of my primary and revision rhinoplasties in males, a columellar strut is placed. This graft sets the foundation for tip projection as the nasal tip is rebuilt. Columellar struts may be carved from septal cartilage (my preference), auricular cartilage or rib cartilage. If the patient has had a septoplasty in the past, palpation of the septum may help determine if any significant cartilage remains. In many instances, cartilage is present along the dorsal septum. In addition to the endonasal approach, dorsal septal cartilage may be harvested from the open approach by elevating the middle vault mucoperichondrium from the septum following release of the caudal end of the upper lateral cartilage. Dorsal septum maybe harvested without loss of dorsal support as long as at least one centimeter of septum is preserved. If the septal cartilage harvested is short, two segments may be sutured to one another towards their distal ends (Figure 28).
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| Figure 26 26. Released lower and medial lateral cartilages (arrows) from the adherent vestibular tissue to aid in increasing tip projection. |
Figure 27 Columellar strut (large arrow) carved from septal cartilage placed in a pocket between the medial crura (small arrows). |
Figure 28 Two short segments of septal cartilage sutured to one another towards their distal ends creating a columellar strut. |
A columellar strut may be created with auricular cartilage by suturing a double-layered segment with the concave sides facing one another (Figure 29). In addition to adding tip projection, a shield graft will add length to the infratip lobule and create the proper domal highlights. Shield grafts made from auricular cartilage (Figure 30) are usually less rigid than septal grafts but either will be suffice. If the graft extends a moderate amount above the native tip, a domal support or CAP graft is usually placed behind the shield graft to prevent “bending” of the graft. Additionally, rim grafts may be added to create a balanced alar-dome contour. Bruised onlay domal or CAP grafts from cartilage may be used to increase tip projection. Once all grafts are sutured into place, either thinned scar tissue removed from the tip or supratip, mucoperichondrium or deep temporalis fascia is placed over the tip complex (Figure 31) to prevent skin shrink-wrappage with eventual visibility of the grafts through the skin.
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| Figure 29 An auricular cartilage columellar strut created by suturing a double-layered segment with the concave sides facing one another. |
Figure 30 Shield graft (arrow) made from auricular cartilage will add tip projection and lengthen the nose. |
Figure 31 Mucoperichondrium (arrow) placed over the shield graft to prevent visibility of the graft through the skin. |
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| Figure 32 Tongue-in-groove suture placed through septum and medial crural ligament (arrow) with 5-0 nylon to increase tip projection. |
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Tip Ptosis
Violation of any of the major or minor nasal tip support mechanisms will eventually lead to tip ptosis. Tip ptosis can occur in conjunction with poor tip projection, especially in male patients with thick skin and a previous over-aggressive reductive tip rhinoplasty. In the majority of male revision rhinoplasties, tip ptosis is a common finding secondary to aggressive reduction of the lateral crura. Reconstruction of the lateral crura with alar batten grafts and with placement of a columellar strut will restore tip integrity and will rotate the nose upward and add tip projection. Refinement of tip rotation may be achieved with plumping grafts, tongue-in-groove suture from the medial crura or medial crural ligament to the septum (Figure 32), and spanning sutures through the cephalad lateral crura to the upper lateral cartilages.
Over-Rotated Nasal Tip
Over-rotation of the nasal tip is not a frequent problem in male revision rhinoplasty since males with thick skin may have tip ptosis following aggressive rhinoplasty. Over-aggressive resection of the anterior septal angle, caudal septum or aggressive lateral crural reduction in male patients with thin nasal skin may cause alar retraction and an over-rotated tip, especially at the infra-tip lobule. A retracted columella may be present in the case of an aggressive caudal septum reduction. For infra-tip over-rotation, a shield or a bruised infra-tip lobule graft (Figure 33) covered with soft tissue may be used. For severe over-rotated tips in the presence of a retracted columella, a septal extension graft (Figure 34) or a combination of an onlay vertical columellar graft spanning the length of the medial crura and a infra-tip graft placed caudal to the columellar onlay graft covered with soft tissue. Soft tissue in the form of scar tissue, mucoperichondrium (Figure 35) or deep temporalis fascia will also augment the retracted nasal tip.
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| Figure 33 An overhead view of a conchal cartilage infra-tip graft (small arrow), scar tissue (arrowhead) to cover the infra-tip graft and bilateral alar batten grafts (large arrows) in a tertiary rhinoplasty. |
Figure 34 A septal extension graft (small arrow) is used to lengthen a retracted columella and short nose secondary to over-aggressive caudal septal excision. The upper (arrowheads) and lower lateral cartilages (large arrows) are retracted away from the septum. |
Figure 35 Mucoperichondrium (small arrow) is used to lengthen the infra-tip. Alar batten grafts (large arrows) were used to reconstruct the lower lateral crura. |
Alar Retraction
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| Figure 36 On basal view, large bilateral concha cymba composite grafts (arrows) are used to lengthen bilateral retracted ala. |
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Alar retraction may occur in male patients with thin skin when alar scar contracture forms secondary to over-aggressive lower lateral cartilage excision. Mild alar retraction may be corrected by placement of alar rim grafts that are placed caudal with or without overlap to the native lower lateral cartilages (Figure 25). To best correct alar retraction with this technique, alar rim incisions are needed to expose vestibular tissue caudal to the lower lateral cartilage. For moderate to severe alar retraction, concha cymba auricular composite grafts (Figure 36) are the gold standard.
Conclusion
Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform because males usually have thick nasal skin, which is more difficult to re-support and project the nasal tip, and often have high or unrealistic expectations. The primary etiology for the need for male revision rhinoplasty is a primary rhinoplasty with aggressive lower lateral cartilage reduction that causes tip ptosis and loss of projection. Many male patients will try and convince you to be aggressive with their surgery since they think that the results will be better. Do not get lured into this misguided game. Stay the course and perform a conservative rhinoplasty. Conservative rhinoplasty techniques are the mainstay in preventing the need for a revision.
If you decide to undertake the task of performing male revision nasal surgery, a clear and thorough knowledge of nasal anatomy, function and surgical techniques is paramount. Having an extensive preoperative discussion including expectations, outcomes and a detailed list of potential complications with the patient can prevent physician-patient miscommunication. Prior to surgery, review the exam, previous operative summary, photos, nasal analysis sheet, problem list and plan and then proceed with the surgical treatment.
Do not feel pressured to embark on surgery that is beyond your capabilities. First, do no harm! Know your limitations. Do not be afraid to refer your patient to your colleague that specializes in revision rhinoplasty for a second opinion or to perform the actual surgery. The patient will think the world of you for being honest with them and sending them elsewhere.
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| Figure 37 A-D |
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| Figure 37 E-H |
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| Frontal view of a Hispanic patient (A) before and (B) 3 months after revision rhinoplasty and chin implant. An open rhinoplasty was performed with findings of: thick skin envelope with supra-tip scar, silicone columellar strut, minimal projection, tip ptosis, poor tip support, over-resected lower lateral cartilage with external valve collapse, retracted columella, narrow middle vault with internal valve collapse, deep radix, deviated septum and microgenia. Procedures performed were: septoplasty for cartilage graft harvesting and for correction of deviated septum, ear cartilage harvest, excision of supra-tip scar tissue, removal of silicone columellar strut, placement of a radix graft, bilateral spreader grafts, columellar strut, bilateral alar batten grafts, plumping grafts, shield graft and chin implant. Oblique view (C) before and (D) after surgery. Lateral view (E) before and (F) after surgery. Base view (G) before and (H) after surgery. Notice the improvement in tip projection and natural nasal appearance. |
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| Figure 38a Frontal view of a Hispanic patient before surgery. |
Figure 38b Frontal view of a Hispanic patient after surgery. |
Figure 38c Oblique view after surgery. |
Figure 38d Oblique view after surgery. |
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| Figure 38e Lateral view before surgery. |
Figure 38f Lateral view after surgery. |
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| 1 year after revision rhinoplasty and septoplasty. An open rhinoplasty was performed with findings of: over-resected lower lateral cartilage, open roof deformity, over-active depressor septi muscle, deviated septum, poor tip support and severe tip ptosis. Procedures performed were: septoplasty for cartilage graft harvesting and for correction of deviated septum, undermining of existing lateral crura cartilage from vestibular tissue, rasp rhinion for irregularities, depressor septi muscle excision, bilateral medial and lateral osteotomies, 3 mm lateral crural overlay with sub-vestibular lateral crural strut grafts, placement of a columellar strut and plumping grafts, low medial crural to high septal tongue-in-groove suture, inter-domal suture with permanent suture and deep temporalis fascia placement over nasal tip. | ||||||
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| Figure 39 A-D |
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| Figure 39 E-H |
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| Figure 39 I-L |
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| Frontal view of a Hispanic patient (A) before and (B) 2 months after fourth revision rhinoplasty with ear cartilage graft and chin implant. The patient complained of nasal obstruction, unacceptable cosmetic appearance and a small chin following 3 aggressive rhinoplasties. The patient urged the surgeon to keep removing more nasal tip cartilage with each surgery. Patient presents for revision rhinoplasty to improve his breathing and nasal asymmetry. An open rhinoplasty was performed with findings of: a narrow right middle vault with internal valve compromise, over-resected lower lateral cartilage (medial and intermediate cartilage present, no lateral crural) (C & D) with external valve collapse on right with alar rim collapse and poor tip projection. Procedures performed were: right conchal cartilage and composite graft harvest, removal of tip scar tissue, right spreader graft, 5 mm right alar batten graft, 2 right alar rim grafts, right supra-alar bruised onlay graft, bruised onlay dome graft, left conchal composite graft and large chin implant. (C) Over-resected lower lateral cartilages encased with scar (arrows) and (D) following scar removal (arrows). Close-up frontal view (E) before and (F) after surgery. Oblique view (G) before and (H) after surgery. Lateral view (I) before and (J) after surgery. Base view (K) before and (L) after surgery. The right alar rim is more symmetric with the left despite the right rim irregularity that may smooth out with more healing or need to be revised in the future. |
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| Figure 40 A-B |
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| Figure 40 C-F |
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| Figure 40 G-J |
| Frontal view of a patient (A) before and (B) 6 months after fifth revision rhinoplasty with ear cartilage graft and deep temporalis fascia harvest. The patient complained of nasal obstruction and unacceptable cosmetic appearance following 4 rhinoplasties. The patient gave a history of poor nasal tip skin healing with the last 2 surgeries with associated tip irregularities. An open rhinoplasty was performed with findings of: a narrow left middle vault with internal valve compromise, no lower lateral cartilage identified with external valve collapse, small silicone dorsal implant, atrophic central and left nasal tip skin with soft tissue depression and adhered scar/cartilage graft to right nasal tip. Procedures performed were: conchal cartilage graft harvest, removal of silicone dorsal implant with adequate dorsal height after implant removal, right spreader graft, bilateral alar batten grafts, bruised conchal cartilage onlay graft covered with deep temporalis fascia to left nasal tip, and columellar strut placement. Close-up frontal view (C) before and (D) after surgery. Oblique view (E) before and (F) after surgery. Lateral view (G) before and (H) after surgery. Base view (I) before revealing the left tip depression and (J) after surgery showing a moderate improvement.
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View a video of this procedure.
References
1. Beekhuis GJ. Nasal obstruction after rhinoplasty: Etiology, and techniques for correction. Laryngoscope 1976;86:540