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In revision rhinoplasty, one 30-year veteran surgeon advises restraint

Article-In revision rhinoplasty, one 30-year veteran surgeon advises restraint

Key iconKey Points

  • Revision rhinoplasty can be a problematic procedure
  • One 30-year veteran surgeon shares his preferences, tools, sequence and tips for successful outcomes

33-year-old female patient, who had two prior rhinoplasties, shown before (far left and near right) and 3 years and 5 months after (near left and far right) correction with revisional surgery using cartilage grafts including super-crushed auricular cartilage in the tip and corrective septal surgery.
In any rhinoplasty operation, the first surgeon has the best opportunity to obtain optimal results. The second surgeon must be prepared to deal with a myriad of potential anatomic deficits, many of which can only be assessed intraoperatively. In over 30 years of experience in performing rhinoplasty, I've learned that there are more than a few pitfalls to revision rhinoplasty procedures. At the same time, I've developed a variety of practices and techniques that, in the appropriate situations, have helped to keep me out of trouble. Certainly, every revision procedure starts with the goal of correcting existing problems but also carries the danger of creating new ones. A few of the principles that I have found useful are outlined here.

AUTOLOGOUS PREFERRED If augmentation is indicated, use autologous tissue whenever possible. In exploring the internal structures of the nose, you frequently find that patients who have been operated on previously have little or no septal cartilage remaining. Although septal cartilage is always my first choice for augmentation purposes, when it is not an option I will consider alar cartilage.

If I have to remove the cephalic portion of the lower lateral cartilage, I'll often use it to augment small defects. Or I can usually obtain enough cartilage from one or both ears, even in a major reconstructive procedure, to avoid having to look elsewhere. I do not harvest rib cartilage, although I have used irradiated rib cartilage (which is difficult to obtain today). It is a good product if used properly but requires special techniques to prevent warping.

If I were going to use alloplastic materials, Gortex® would be my first choice. It can be used along the nasal dorsum. Sometimes, if there has been too much cartilage removed and I need to stiffen the lateral crura, I will place a small piece of Gortex®. I do not like alloplastic materials in either the lobule of the nose or the columella. The majority of alloplastic materials placed in these highly movable parts of the nose have a tendency to extrude.

TOOLS AND SEQUENCE In a revision rhinoplasty requiring minimum hump removal, use a fine rasp rather than an osteotome to reset the bridge. First, one should be very careful not to take too much off the dorsum initially. I don't make my final adjustments to the dorsum until after I have finished with the tip.

Second, if you take off any hump, it is essential to perform an osteotomy in order to avoid creating a plateau or an "open roof" deformity. However, in a revision rhinoplasty, you have no way of knowing if osteotomies have previously been performed. If you use an osteotome for hump removal, it can dive into an old medial osteotomy fracture — precisely where you don't want it. So when you are doing revisions, or working on a traumatized nose that has had breaks in the bone, it is much safer to use a fine rasp to reset the bridge.

You'll hear it said that you should never rasp a nose after you've done an osteotomy. In general, that's true. But if you use a sharp fine-toothed rasp, and if you use your fingers to firmly press the nasal bones right against the nasal septum and secure those bones, then you can gently rasp the edge. This becomes important at times if, after an osteotomy, there is a bit of prominence in the radix nasi. You can go back and safely smooth the edges, as long as you hold the bones in position against the septum.

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