Special Challenges of Revision Rhinoplasty
The nationally reported revision rate for primary rhinoplasty ranges from 8 to 15%.1-8 Sadly, there will likely never be a shortage of patients requiring revision rhinoplasty. Experienced revision surgeons consistently achieve a high level of satisfaction among their patients. Still, complications can occur despite technically well-performed surgery. All surgeons have complications.
Revision surgery is different from primary surgery. Often the tissue planes have been obliterated, precious tissue has been overresected or asymmetrically resected, and healing forces have distorted weak or weakened cartilages.
The elasticity and quality of the skin-soft tissue envelope is a critical limiting factor in revision surgery and must be factored into the surgical plan. In addition, the revision surgeon must undertake a careful analysis of the existing cartilage and bony structure. This requires analysis of the existing structure and a mental reconstruction
Figure 18-3 Nasal endoscopy may be performed with either a rigid or flexible telescope, which allows improved diagnosis in the evaluation of nasal obstruction.
Having the opportunity in my practice to examine a large number of revision rhinoplasty patients from across the country and around the world, I have observed a wide range of problems. A detailed listing of problems encountered in the revision patient is found elsewhere in this text. Here, I have selected problems encountered in my revision practice that I feel warrant highlighting, either because they are problems that I encounter frequently or because they illustrate specific surgical techniques that may be particularly useful in your armamentarium, if they are not already there.
Overresection of Lateral Crura
Overresection of the lateral crus is perhaps the most common problem I see in my revision rhinoplasty practice. Overresection of the lateral crus leads to the predictable changes of alar retraction, pinching, bossae, and tip asymmetry (Fig. 18-4). Excision of vestibular mucosa in primary rhinoplasty also may contribute to scar contracture with alar retraction.
It is important to note here that I have also found, in a significant number of revision cases, that the amount of lateral crus that remained appeared ample. It appears that in these cases, the scar contracture caused by healing overpowered the remnant cartilage. It has become clear to me that if the tip cartilages are soft and weak, and if the scar contracture is profound, undesirable changes can occur.
In some cases, this situation can be anticipated. In an anatomic study of the alar base, Becker et al. recognized that in a normal patient population, 20% of patients had a thin alar rim24. This anatomic variation must be recognized, and cephalic resection should probably be avoided in these patients to minimize the risk of alar retraction or external nasal valve collapse.21 However, these changes are not always predictable and are not always avoidable.
Figure 18-4 Overresection of the nasal tip cartilages in this patient resulted in predictable, unfavorable changes. Reconstruction included bilateral alar batten grafts, a columellar strut, and a tip graft to provide some increased length. (A,B,C) Preoperative and (D,E,F) 2 year postoperative photos.
Understanding that the healing forces are not completely predictable, it is important to take a conservative approach when undertaking cephalic resection. Risk cannot be eliminated but can be reduced in this manner.