Caution: Some of the medical photographs that you will view
in this section are graphic in nature.

Figure 1	Figure 2
Figure 3	Figure 4
Figure 5
Figure 6a Before	Figure 6b After
Figure 7a Pre-operative	Figure 7b Post-operative view following dorsal augmentation with Goretex
Figure 8a Pre-operative view	Figure 8b Post-operative view following dorsal augmentation with Goretex and crushed cartilage and tip deprojection
Figure 9a Basal View – Before	Figure 9b Basal View – After, following reconstruction
Figure 10a Basal View – Before	Figure 10b Basal View – AfterPost-operative view following bilateral lateral crural strut reconstruction.
Figure 11a Before	Figure 11b Post-operative view following tip reconstruction.
Figure 12a Before	Figure 12b After
Figure 13
Figure 14a	Figure 14b
Figure 14c	Figure 14d
Figure 14e Columellar Strut Graft	Figure 14f Shield Graft
Figure 14g Lateral Crural Strut Graft	Figure 14h Alar Batten Grafts
Figure 14i Basal View – BeforeLateral Crural Strut Reconstruction	Figure 14j Basal View – AfterLateral Crural Strut Reconstruction
Figure 15a	Figure 15b
Figure 15c	Figure 15d
Figure 16a	Figure 16b
Figure 16c Spreader Graft	Figure 16c2 Spreader Graft
Figure 16d Deep Temporalis Fascia
Figure 16e Frontal View – Before	Figure 16f Frontal View – After
Figure 16g Basal View – Before	Figure 16h Basal View – After
Figure 16i Basal View – Intra-op
Figure 17a Composite Graft taken from left ear	Figure 17b Composite Grafts
Figure 17c Graft site stitched together.	Figure 17d Full Thickness Skin Graft inserted into defect
Figure 17e Behind ear where Full Thickness Skin Graft is Taken
Figure 18a  Cephalically-oriented Lower Lateral Cartilages with collapsing ala.	Figure 18b Buckled or weak lateral alar cartilage causing external valve collapse.
Figure 18c Lower Lateral Cartilage Release with Columellar Strut	Figure 18d Repositioned Lower Lateral Cartilage with Lateral Crural Strut Grafts.

Revision rhinoplasty is performed on 5-12% of patients of patients who have undergone rhinoplasty previously. Due to the delicate nature of nose surgery, revisions are sometimes necessary to correct minor or significant imperfections that may become apparent as the nose heals. These might include pinched nostrils, a progressive nasal obstruction, scar contracture during the healing process, or the results of aggressive surgery. Sometimes the work of the best rhinoplasty surgeons needs to be revised to achieve the desired results. Without a doubt, revision rhinoplasty is the most difficult procedure that facial plastic and reconstructive surgeons perform.

Nose surgery takes years to master and methods continue to improve. Rhinoplasty techniques used just three years ago have already been replaced with more effective techniques. Rhinoplasty surgery continues to evolve. My fellowship director, J. Regan Thomas, MD, told me something that I’ll never forget – “you haven’t learned anything about rhinoplasty until you’ve performed at least a thousand procedures and followed them for many years.” This statement epitomizes the value of fellowships. Fellows gain valuable experience and learn the potential pitfalls, proper analysis, judgment, techniques, complication management and – most importantly – results through firsthand observation of a seasoned rhinoplasty surgeon. This is why I super-specialized in rhinoplasty surgery during my fellowship in Facial Plastic & Reconstructive Surgery. The training catapults new surgeons years ahead of many other surgeons who are not fortunate to have post-graduate training.

Many cosmetic surgeons are taught that aggressive cartilage removal is a procedure of the past. Today’s philosophy is “less is more.” Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafting and suturing techniques are being taught in most rhinoplasty courses and at our national meetings. It is important for any rhinoplasty surgeon to stay up to date on current techniques through continuing education.

Revision rhinoplasty may be necessary when the primary rhinoplasty surgeon failed to pre-diagnose potential anatomical and functional abnormalities of the nose that will affect the results of surgery. For example, if the patient desires a hump reduction, the surgeon should identify short nasal bones and a narrow middle vault. This evaluation warns the surgeon that the patient is at risk for upper lateral cartilage subluxation from the nasal bones (inverted V deformity) (Figure 1) and internal valve collapse. In revision nasal surgery, the previous surgeon missed these potential anatomical abnormalities and the revision rhinoplasty surgeon must correct the complication. We always perform a detailed anatomic and functional evaluation of the nose followed by a diagnosis of the post-operative nasal deformities and/or nasal obstruction. The incidence of post-operative nasal obstruction is approximately 10%1. After the problems and potential complications are identified, we create a surgical plan while studying the preoperative photographs. We prepare to use everything in our surgical armamentarium since we must always prepare for the unexpected when performing surgery.

Consultation

Revision rhinoplasty accounts for about 60% of my practice. When I meet with a potential patient for the consultation, I am trying to determine if I can help based on the patient’s desires and their existing nose. When the appointment is made, the patient is asked to bring a copy of his/her medical records and operative reports from previous rhinoplasty surgery or surgeries, in addition to photographs of the nose prior to surgery. If email is an option, we have patients send photos and comments to us before the consultation. Initially, I’ll review the patient’s notes and photos while he or she is discussing surgery with my patient care coordinator. Next, I perform a detailed history while listening very carefully to the patient’s desires. I will interpret from our conversation if the patient has realistic expectations. This is by far one of the most important details that I need to attain from a patient’s history. What is the cause of the dissatisfaction – a pinched tip (Figures 2–4) or Polly beak deformity (under-resection of the hump just behind the tip) (Figures 5 and 6a – Before; 6b – After)? My goal is to determine if the patient is a good candidate for revision rhinoplasty surgery.

Another important detail I must ascertain is whether or not the patient has a nasal obstruction preoperatively. If the obstruction is a result of the previous nasal surgery, a number of questions need to be answered. Did the patient have reductive rhinoplasty surgery? I will have the patient point out the location of the obstruction. 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? With these important questions answered I am now ready to perform the physical examination.

Physical Examination

For the physical exam, I use a detailed nasal analysis worksheet. I will perform a detailed visual and tactile evaluation of the nose. For the bony dorsum, I will examine the osteotomies, presence of open roof deformity or rocker deformity, and hump under- or over- resection (Figures 7a – Before; 7b – After; 8a – Before; 8b – After). Then I will examine the middle part of the nose, called the middle vault. I will look for middle vault abnormalities such as a narrow middle vault, inverted V deformity or under-resection of the caudal cartilaginous dorsum (Polly beak deformity). For the tip, I will examine tip projection, rotation, support, alar and columellar retraction, over aggressive Weir incisions, and lower lateral crural characteristics such as over-resection, cephalically oriented or bossae formation (Figures 9a- Before; 9b- After; 10a – Before; 10b – After). Over-resection of the lower lateral cartilage complex in patients with a heavy sebaceous skin-soft tissue envelope can cause tip ptosis and nasal obstruction (Figures 11a – Before; 11b – After; 12a – Before; 12b – After). This problem often occurs in Hispanic, Asian, Middle Eastern and African-American patients. A deviated cartilaginous dorsum and tip can signify a deviated septum. This is only a partial list of anatomical problems that I need to identify in the nasal analysis.

For patients with nasal obstruction, I’ll observe the patient performing normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable as supra-alar, alar and/or rim collapse or 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. I will see if the nasal obstruction is alleviated by elevating the nasal tip in patients with ptosis of the nasal tip. I will 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, I’ll examine the medial crura to identify if they are impinging into the nasal airway. Following a thorough external nasal evaluation, I will examine the inside of the patient’s nose with a nasal speculum and check the nasal septum for perforations, persistent deviation (Figure 13) and for any remaining cartilaginous remnants to be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae (scar bands) between the lateral nasal wall and septum, nasal masses and middle turbinate abnormalities (concha bullosa).

As I’m examining the nose, I will create a mental list with solutions followed by documentation on the nasal analysis sheet, such as:

1. External valve collapse secondary to over-resected lower lateral crura with a plan of open rhinoplasty with lateral crural strut grafts ( Figures 14a, b, c, d, e, f, g, h, i – Before; j – After ) using conchal (ear) cartilage ( Figure 15a, b, c, d ). Figure 15d shows a post-operative photo of the ear and ear scar after cartilage has been removed.

2. Internal nasal valve collapse secondary to a narrowed middle vault and supra-alar pinching with moderate inspiration with a plan of bilateral spreader grafts (Figures 16a, b, c, c2) and supra-alar batten grafts using conchal cartilage.

3. Bilateral alar retraction with a plan of bilateral conchal composite grafts (See Next Section). If structural grafting is necessary, I will discuss with the patient what material may be used, such as remaining septal, ear cartilage or alloplastic grafts (Goretex, Porcine skin or Alloderm). If a blanket of tissue is needed to cover the structural grafting, such as a shield graft, or to add a thin layer of dorsal augmentation, deep temporalis fascia (Figure 16d) is an excellent tissue that is easily harvested from a small incision made in the hairline.  If ear cartilage is needed, a well-hidden incision is made inside the ear or on the back of the ear with minimal to no post-operative deformities. Before and after photos of frontal views (Figures 16e- Before; 16f – After) and basal views (Figures 16g – Before; 16i – Intra-op; 16h – After) show complete internal and external valve reconstruction using bilateral spreader grafts and bilateral lateral strut grafts.

Composite grafts are a combination of skin and cartilage taken from the ear (Figure 17A) . This graft (Figure 17B) is then added to the inside of the patient’s nose to help correct retracted or notched ala. In simpler terms, the nostrils may pull up following rhinoplasty surgery, which will reveal the nostril openings and show too much of the columella. This is a common finding in secondary or revision rhinoplasty surgery. Once the graft is taken from the ear, either the defect (area where the skin/cartilage has been removed) is stitched together (Figure 17C), or in some cases a piece of skin (Full Thickness Skin Graft) is taken from behind the ear and then placed in the defect (Figure 17D) where the composite graft was removed. This usually heals with minimal to no visible scar (Figure 17E). The grafts are inserted into the nostril and with time, they will heal and become part of the ala/nostril. Occasionally, the grafts can become swollen up to approximately 3 months and there is a small risk that the graft will not survive for one reason or another.

Prior to undergoing revision rhinoplasty, the orientation of the lower lateral cartilage has to be examined to determine if it is cephalically or vertically positioned (Figure 18A). This is often called a parenthesis deformity. The tip cartilage is directed towards the inside corner of the eye instead of the more natural position towards the outer corner of the eye. This malpositioning does not give enough support for the ala, which can cause buckling or pinching of the ala (Figure 18B) that may lead to nasal obstruction. If tip cartilage is removed in rhinoplasty surgery with a parenthesis deformity, the tip will lose its natural contour and the nostrils will probably collapse and cause nasal obstruction. To prevent these problems, the tip cartilage has to be released (Figure 18C) and then repositioned (Figure 18D) to a more horizontal position and reinforced with lateral crural strut grafts.

This is only my initial plan as I am creating an individual’s algorithm for surgery. It will change as we get closer to the rhinoplasty surgery. Photo imaging is usually performed, which can be extremely useful if it is understood that the final image is NOT A GUARANTEE of results. Occasionally, I can identify if a patient has unrealistic expectations when a conservative image is generated by me and he or she desires a radical change. If this is the case, I will discuss this issue with the patient and explain why the change may be considered unrealistic. If we decide to move forward, I will use the computer image as a goal in surgery. Oftentimes, patients will bring photos (models, movie stars, etc.) of what they feel their nose should look like. My goal is to take the patient’s existing nose and make a moderate – or sometimes significant – difference in the appearance and function of the nose, creating an aesthetically pleasing, natural nose.

After Surgery

Following surgery, the majority of patients have minimal pain. Incisions inside the nose must be cleaned twice a day. Patients will be instructed to spray salt water (saline) into the nose with a spray bottle and a baby bulb syringe. The cast and the stitches will be removed in one week (assuming that open revision rhinoplasty was performed). For the second week, the nose will be taped. Following the second week, if needed, I will instruct the patient on how to tape his or her nose nightly to help reduce the swelling. The most important attribute that the patient can possess following revision rhinoplasty is PATIENCE. It may well take one year for the swelling to completely resolve. I can promise you that I will do the best job possible to improve the health and appearance of your nose.

1Beekhuis GJ: Nasal obstruction after rhinoplasty: Etiology, and techniques for correction. Laryngoscope 86:540, 1976.

Read more about revision rhinoplasty

Read Revision Rhinoplasty FAQ’s answered by Dr. Nassif

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