"The main difference between a primary and a secondary procedure is that cartilage for grafting is less readily available in the latter," he says. "You don't want to close the tissues under tension or dissect widely, but instead, minimize the incisions and trauma to those already compromised tissues."
Another misconception held by some surgeons is that secondary rhinoplasty is better performed using an open technique because the better visualization afforded by open surgery is particularly useful for the relatively more complicated secondary cases. Such thinking is backward, however, because it violates the rules for all other surgical operations, Dr. Constantian says."In secondary rhinoplasty, where there is already damage from scarring, the aim should be to limit the dissection and avoid closing the skin under tension. In these more complicated cases, a closed technique should be used," he says. "Often, surgeons who see a very badly damaged secondary nose with abnormal tissues try to do too much, which will commonly result in further tissue trauma and loss. You cannot risk tissue loss, and it would be wiser to approach such cases with an endonasal technique.
"My recent data shows that secondary patients who have undergone open rhinoplasty have more numerous and more severe deformities than those who were previously treated endonasally. These findings should make us all re-examine our assumptions," he says.
Dr. Constantian says he performs only closed rhinoplasty, but that surgeons who do both could consider the open technique for the simplest cases.
SELECT PATIENTS WISELY Another of Dr. Constantian's principles involves wise patient selection. Careful patient screening is a rule that applies to all cosmetic procedures, but surgeons should be aware that patients with body dysmorphic disorder (BDD) may be disproportionately over-represented within the population seeking rhinoplasty, particularly among those who present to surgeons specializing in nasal surgery, he says.
The explanation for this phenomenon is that across all cultures of patients with BDD, the nose is the feature of greatest concern, and patients with BDD are likely to be dissatisfied with prior outcomes and seek out surgeons with particular expertise for secondary procedures.
Dr. Constantian advises that it is important to eliminate the extreme patients who have delusions about a nonexistent problem. Patients with BDD represent a broad spectrum, however, and within this group there are suitable surgical candidates who can be identified by applying judicious criteria.
"I will accept patients for surgery if they complain of a problem I think I can fix, I anticipate they will be cooperative with postoperative management, and they seem to understand there is an inherent margin of error in surgery and will be able to tolerate a complication or imperfect result if those events occur," he says.