Revision Rhinoplasty

Revision rhinoplasty/ anatomical fundamentals of revision rhinoplasty

The number of revision rhinoplasties is increasing consistantly as the demand for rhinoplasties is rising. The complete comprehension of the complex anatomy of the nose in combination with operative measures that consider the longterm consequences of surgical steps are requirements for the understanding, why complications occur.

In publications revision rates of 5-18% are described. The amount of complications is base upon the kind of patient selection, the qualification and experience of the rhinoplastic surgeon and the initial diagnosis. Of the patients that wish for a revision rhinoplasty or a corrective procedure, approximately 50% have one deformity, 30% two deformities and 20% three or more problematic areas of the nose.

A majority of the patients with wishes for revision has problems with the lower third of their nose, as well as the tip of the nose. The most common problems are:

• tip assymetry
• prominent tip/ supratip
• large nostrils in comparison with smaller upper third of the nose/ bridge of the nose
• ventilation disorders
• deviated septum

Problems (open roof, bony irregularities) in the upper third of the nose for example develop because of the following reasons:

Difficulty &treatment:

• see-through skin on the bridge of the nose: Inset of tissue transplant to thicken the skin or diced gartilage grafts (mashed cartilage from the ear)
• insufficient surgical sectioning/mobilisation of the nasal bones: application of power tools (drill, ultrasound drill), to precicely cut through the nasal bones
• very broad septum/ high deviated septum: straightening of nasal septum deviation

Problems in the middle third of the nose (polly beak deformity, too tight inner nasal valves or collapse of collapse of them, saddle back nose) develop for example through:

Difficulty &treatment:

• inadequate resection of the septum: reinforcement of the septum through stitch-on application of cartilage grafts
• scaring, over-resection of the lateral nasal cartilage: cautious preparation, inset of spreader grafts and flaps, if necessary titanic breathe implants
• instable nasal septum, over-resection of the hump: buildup and stabilizing with concha cartilage (grafted from the ear) or rib cartilage

Problems in the lower third of the nose (drooping or broad tip of the nose, hanging columella) develop through:

Difficulty &treatment:

• scaring: cautious release and removal of the scars
• weak cartilage: reinforcement through small, individually tailored cartilage grafts (so called tip shields, columella shields, tip grafts…)
• nasal septum too long: shortening of the nasal septum

Psychological aspects of the revision rhinoplasty

The revision rhinoplasty has grown into a specialty within septorhinoplasty. The rhinoplasty surgeon doesn’t only have to be able to handle scarred, previously operated on tissue, take functional and aesthetical aspect into consideration, but also has to know the particular psychological situation of the patient and his/her family.

Patients are traumatised after a failed previous operation and understandably enough overly sensitive. As a physician you have to be prepared not only to carry out the specific surgical aspects of the operation but also to offer the psychological support after the revision procedure. The time of waiting for the swelling to go down and the revelation of the final result, may take up to 3 years and it should be clearly communicated, what the patient has to expect once again and approximately at what time.

All the more it is imperatively important to raise realistic expectations in the affected patient. The computer simulation is a compulsory necessary tool, to achieve this goal. Digital morphin (computer simulation) helps to achieve the understanding between aesthetical wishes of the patient and realisticaly achievable surgical possibilities.

Revision of ventilation disorders

A thorough examination of the patient stand at the beginning of every diagnostic procedure of a ventilation disorder:

• medical history (chronic abuse of nasal sprays? allergies? chronic sinusitis? rhinitis?)
• anterior rhinoscopy
• endoscopic examination of the nose

subsequent investigations according to the initial situation:

• rhinomanometry
• nasal provocation test
• prick test to varify inhalative allergies and food allergies
• epicutane test to varify contact allergies
• CT or DVT for imaging of the complex structures of the paranasal sinuses and the nasal septum respectively after trauma

Functional aspects of revision rhinoplasty contains nasal septum deviation, collapse of the inner nasal valve, nasal conchae hyperplasia (enlargement), nasal septum perforation and adhesions of the nasal mucosae (synechia). In the last 20 years the increasing use of spreader grafts (small cartilaginous splints, preferably from the nasal septum, are being set in between nasal septum and lateral nasal cartilage after removal of the nasal hump) to open the tight nasal valve has improves the operation method and functional outcome.

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