739
f
g
h
i
j
k
l
Fig. 15.68 (continued)
Deviated Nose Correction and Dorsal Augmentation
740
Dressing After the Deviated Nose Correction
Paper tape (SteriStrips™) and dorsal splint stabilize the osteotomy segments as well as provide compression for prevention
of swelling and hematoma. The splint is removed 5–7 days after operation.
Depending on septal stability, intranasal silicone sheets are kept for 1–3 weeks to maintain the repositioned septal struc-
tures at the midline (Fig. 15.69). In most cases, the sheets are removed after the first week but can be maintained for
2–3 weeks in the presence of mucoperichondrial perforation.
If merocele is used, antibiotic ointment is applied to the surface of the material prior to insertion into the cavity. This is
maintained for 2–7 days, with systemic antibiotic administration.
a
b
c
Fig. 15.69 Intranasal splint
15 Deviated Nose Correction and Functional Rhinoplasty
741
Functional Rhinoplasty
Even in what would be considered a purely aesthetic rhinoplasty, the operator should always consider how an operation
would affect the function of nose. Functional rhinoplasty is especially important in the management of deviated nose.
Causes of Nasal Obstruction
A large number of anatomic structures are related to nasal obstruction.
Nasal obstruction can be caused by severely sunken nasal bone in a deviated nose. More commonly, nasal obstruction is
caused by the problems in the septum, turbinate, internal valve, external valve, or mucosa, and all of these structures require
a thorough examination. Pathologic causes of nasal obstruction include nasal polyp, tumor, and concha bullosa.
Causes of nasal obstruction can be classified in the following way.
Category
Causes
Structural abnormalities
Deviated septum
Valve collapse: internal valve, external valve
Turbinate problem: hypertrophied turbinate, concha bullosa, paradoxical middle turbinate
Uncinate process: prominent uncinate process or polypoid change
Mucosal problem
Allergic rhinitis
Synechiae
Intranasal mass
Nasal polyp, inverted papilloma, etc.
Discharge
Sinusitis
Nasopharyngeal problems
Nasopharyngeal mass
Paradoxical
Primary chronic atrophic rhinitis, empty nose syndrome
Drugs
Paradoxical Middle Turbinate
Unlike the normal direction of middle turbinate curvature, the paradoxical middle turbinate has an inferomedial curvature
(Fig. 15.70).
This is a rare congenital cause of nasal obstruction. Most cases of paradoxical middle turbinate are bilateral, but unilateral
cases do exist.
Fig. 15.70 Paradoxical turbinate (left
middle turbinate)
Functional Rhinoplasty
742
Diagnosis of Nasal Obstruction
Clinical Manifestation
Nasal obstruction is a very subjective clinical entity, with wide variation across individuals. Despite extremely narrow nasal
cavity, some patients do not feel any discomfort in day-to-day activity, whereas others complain of significant nasal obstruc-
tion despite a widely patent nasal airway. The correlation is very minor between the size of airway and the perceived severity
of nasal obstruction.
In most cases, the patient will complain of nasal obstruction on the side of narrow airway. However, some patients experi-
ence discomfort in the nasal cavity that is wider than the contralateral side. This is due to the nasal cycle, where the alternat-
ing mucosal congestion and decongestion occur to a greater degree in the larger cavity.
As such, the symptom of obstruction does not always equate to resistance of the airway flow. Among patients undergoing
functional septorhinoplasty, approximately 20% of patients will not find relief from obstructive symptoms.
Physical Examination
Septal deviation can be examined under direct vision through speculum or through an endoscope.
Nasal obstruction due to internal or external valve insufficiency can be position dependent (i.e., obstructive symptoms
experienced only in supine position). Either of the valves can collapse during forced inspiration, worsening inverted-V-
shaped depression. Lateral traction of cheek skin can improve symptoms of nasal obstruction, which is a positive sign of
Cottle test (Fig. 1.69). However, Cottle test also alleviates nasal obstruction due to septal or inferior turbinate problems and
is not specific to valve collapse. A more specific test would be to use a cotton swab or cerumen curette to individually lift
the internal or external valve to see if the obstruction is alleviated. This is the modified Cottle test (Fig. 1.70).
The septum, turbinate, and nasopharynx are examined using endoscopy, which can also rule out the presence of polyps
and tumor. If prompted by endoscopy, the potential for sinusitis should be evaluated with radiologic imaging.
Radiologic Examination
The nasal cavity can be examined with X-ray and CT imaging. Concha bullosa and paradoxical middle turbinate are easier
to diagnose via CT than via endoscopy.
Rhinometry
The degree of nasal obstruction can be quantified by rhinomanometry and acoustic rhinometry.
Manipulation of Inferior Turbinate
In deviated-nose correction, the inferior turbinate requires manipulation for the following reasons.
Most deviated noses contain septal deviation, which is accompanied by compensatory hypertrophy of the middle and
inferior turbinates on the concave side (Fig. 15.8). Unfortunately, the hypertrophied turbinates do not shrink spontaneously
after the correction of deviated septum.
The hypertrophied inferior turbinate not only causes nasal obstruction on its own but also prevents the septum from mov-
ing into midline or comes into direct contact with a medialized septum. This contact can also cause nasal obstruction as well
as recurrent deviation of the septum over time.
Inferior turbinate hypertrophy is divided into mucosal hypertrophy and bony hypertrophy. If epinephrine spray signifi-
cantly shrinks the size of the turbinate, the hypertrophy is due to mucosal component. Otherwise, the turbinate hypertrophy
is most likely due to bony component.
15 Deviated Nose Correction and Functional Rhinoplasty
743
Fig. 15.71 Partial turbinectomy
Treatment of Hypertrophied Turbinate
Optimal treatment of hypertrophied inferior turbinate is controversial but includes the following options.
Total/Partial Turbinectomy
Total turbinectomy or excessive turbinate resection can result in empty nose syndrome, with the myriad of symptoms such
as chronic nasal and pharyngeal dryness, sensation of too much air inspiration, paradoxical sensation of obstruction,
ozena, and neuropathic pain. Because of this complication, turbinate reductions should always be conservative.
Partial turbinectomy is a technique that can simultaneously address bone and mucosal hypertrophy (Fig. 15.71). Instead
of resecting just the anterior and posterior sections, this technique is more effective if a portion of the turbinate is removed
along the entire length. The raw surface is electrocoagulated to minimize bleeding. This technique has fallen out of favor and
has been replaced with the following techniques.
Functional Rhinoplasty
744
Lateralization of the Turbinate by Out-Fracture
Out-fracture of inferior turbinate relocates the head of inferior turbinate to a more lateral location, which increases the
cross-sectional area of the internal nasal valve. This technique is mainly employed when the bony hypertrophy contrib-
utes more to the overall bulk of the turbinate. Initially, the Joseph elevator or Freer elevator is used to push the turbinate
medially (in-fracture). Following this, the turbinate is pushed laterally to cause out-fracture, which causes complete
greenstick fracture. With this, the turbinate occupies a more lateral portion of the nasal cavity (Fig. 15.72). The advantage
of this technique is in the conservative and sparing of anatomic components. However, the most fractured turbinate head
is reported to return to its original position by 6 months, with the improvement being temporary. Because of this, the
technique should be employed in conjunction with radiofrequency channeling or microdebridement.
a
b
c
d
e
Fig. 15.72 Radiofrequency and out-fracture of inferior turbinate. (a) Application of radiofrequency (RF) coagulation to hypertrophied inferior
turbinate. (b, c) In-fracture is performed first. (d, e) Out-fracture is performed afterwards
15 Deviated Nose Correction and Functional Rhinoplasty
745
Radiofrequency Channeling
Radiofrequency channeling is used to decrease in mucosal hypertrophy by the delivery of thermal energy via the probe
inserted in the submucosa, which coagulates some of the submucosal bulk (Fig. 15.73). As such, the technique is more useful
for mucosa hypertrophy. The technique preserves the mucosa itself and only shrinks the submucosa. Because the mucosa is
intact, there is very little crust formation after the procedure, which makes for a drastic difference in the postoperative man-
agement and comfort of the patient. However, the technique is temporary, with satisfactory maintenance in the first year but
with recurrence being quite common by 3 years.
The operator must take care not to allow the thermal energy to reach the mucosa layer, which requires accurate inser-
tion of the probe in the submucosa. Blanching of the mucosa should prompt the cessation of radiofrequency activation.
To avoid injury to the mucosa and bony tissue, the radiofrequency delivery should be on the conservative side.
As an alternative to coagulation radiofrequency (400 °C), coblation delivers a lower temperature (60–70 °C) without any
thermal injury.
Submucosal Resection (Turbinoplasty)
Submucosal resection maximally preserves the turbinate mucosa while resecting the hypertrophied bony part. This is per-
haps the technique that yields the most optimal, long-term outcome for bony hypertrophy.
Upon injection of local anesthetic and packing for vasoconstriction, a small incision is applied through the mucosa at the
turbinate head. From the incision, the mucosa is dissected using Freer elevator. The hypertrophied turbinate bone is resected.
Redundant mucosa can be excised, but enough should be left behind to allow adequate covering of the turbinate bone. The
bony resection should be as conservative as possible.
The microdebrider is a cylindrical instrument that is used for bony resection. The end of the instrument contains a recip-
rocating blade that cuts the tissue, with underlying suction that evacuates the cut tissue. The microdebrider allows quick and
easy removal of the hypertrophied submucosal tissue as well as bony tissue. This method of reducing hypertrophied turbinate
is associated with the most effective long-term result.
Hypertrophied middle turbinate can be out-fractured and partially removed using the methods described above.
Fig. 15.73 Insertion of
radiofrequency probe in the
inferior turbinate submucosa
Functional Rhinoplasty
746
Treatment of Concha Bullosa
A concha bullosa is a pneumatization of the middle turbinate (Fig. 15.74). This is a very common anatomic variation,
observed in up to 50% of the population. Most instances of concha bullosa are not associated with a sinus problem.
Occasionally, a large concha bullosa may cause the turbinate to bulge sufficiently to block the sinus drainage, causing recur-
rent sinus infection. A big concha bullosa within a turbinate is often associated with deviation of the nasal septum towards
the opposite side of the nasal cavity, which could be a cause of nasal obstruction.
Concha bullosa is best diagnosed with a CT scan. While the turbinates normally show up with a medium intensity on CT
scan, concha bullosa appears as a pocket of air (low intensity) within the turbinate tissue.
Endoscopic surgical treatment of the conchal bullosa ranges from minimal excision of medial or lateral lamella to crush-
ing of concha to total resection of middle turbinate.
a
b
Fig. 15.74 Concha bullosa (right middle turbinate)
15 Deviated Nose Correction and Functional Rhinoplasty
747
a
b
c
Fig. 15.75 Internal valve narrowing on the right from scar contracture
Correction of Internal Valve Collapse
Internal nasal valve is the specific slit-like segment between the septum and the caudal margin of upper lateral cartilage.
Insufficiency of this valve can be static or dynamic. Static insufficiency can be caused by high septal deviation, mucosal scarring,
and upper lateral cartilage collapse (Fig. 15.75). Dynamic insufficiency is caused by forced inspiration, during which the valve
cannot withstand the negative pressure and collapses. The causes of internal valve insufficiency are discussed in Chap. 1.
Several techniques are available to correct incompetence of internal nasal valve.
Functional Rhinoplasty
748
Flare Sutures
Flaring splay suture is a horizontal mattress suture placed in the ULC. The suture suspends the upper lateral cartilages and
widens the internal nasal valve. By itself, the technique does not produce reliable result and is used as an adjunct to other
techniques (Fig. 15.76).
Fig. 15.76 Flare suture
15 Deviated Nose Correction and Functional Rhinoplasty
749
Fig. 15.77 Batten graft for correction of internal valve insufficiency
Batten Graft
The batten graft used for internal valve competency can be prepared from septal cartilage, auricular cartilage, and costal
cartilage. The graft is prepared in a long elliptical shape, 8–10 mm by 15.20 mm, and placed in the scroll area. The concave
surface of graft is oriented medially towards the airway while the convex side is oriented laterally to allow maximal lateral-
ization of the collapsed portion of lateral nasal wall (Fig. 15.77).
Functional Rhinoplasty
750
Spreader Graft
Spreader graft is the most frequently used technique for internal valve competency.
Described by Sheen in 1984, this technique is used to correct the inverted-V deformity and internal valve collapse by
widening the narrow valve area. Graft is a long, thin piece of cartilage that is inserted between the dorsal septum and upper
lateral cartilage. It acts as a spacer to push the upper lateral cartilages outward and to widen the angle between the septum
and upper lateral cartilage, thus increasing the nasal airway cross section. The graft is inserted after the upper lateral cartilage
is detached from the dorsal septum (Fig. 15.78). The graft must be placed from the osseocartilaginous junction to the septal
angle. Usually, multiple pieces of graft are not necessary. The small change in cross-sectional area brought on by a single
spreader graft is often enough to increase the patency of the valve.
The graft ends should be prepared to a beveled edge to minimize palpable step-off. Grafts are fixed with double-horizon-
tal-mattress suture using 5-0 PDS. The preferred graft material is septal cartilage, although auricular cartilage and rib car-
tilage are acceptable in a pinch. Irradiated homologous costal cartilage can also be used but is not as reliable as autologous
grafts.
Spreader graft is easier to place through open rhinoplasty incision but can be placed through a closed approach. For closed
approach, a small incision is placed in the roof of the intercartilaginous junction. Using a D-knife or septal elevator, the dis-
section is carried between the dorsal septum and upper lateral cartilage down to the nasal bone. The height of tunnel is made
similar to or slightly higher than that of the spreader graft. The dissection is performed with the index finger of nondominant
hand on the dorsum to palpate the tip of the elevator. Dissection and tunnel formation are carried slightly cephalad to the
caudal margin of nasal bone. The graft is inserted into the tunnel without any fixation. The incision is closed with absorbable
suture.
a
b
c
d
Fig. 15.78 Spreader graft (septal cartilage) for right-sided internal valve insufficiency
15 Deviated Nose Correction and Functional Rhinoplasty
751
Splay Graft
Splay graft is used only when the lower lateral cartilage is severely collapsed, most commonly using auricular cartilage
(Fig. 15.79). The method flares and widens the upper lateral cartilage. The graft is placed deep to both upper lateral cartilages
and acts as a spring to elevate the upper lateral cartilages, which corrects middle-vault collapse and widens the internal valve.
The graft should be long enough to span from the end of a pyriform aperture to the end of the other pyriform aperture.
Upon dissecting and elevating the mucoperichondrium from the overlying upper lateral cartilages, the graft is inserted in
the space created between the mucoperichondrium and upper lateral cartilage. Preexisting collapse or deficiency of dorsal
septum can be augmented by using a thicker splay graft. If the dorsum is not high, the added thickness of splay graft can
result in dorsal hump. Because of this, the dorsal septum should be lowered first before placement of the splay graft.
The graft is sutured to the dorsal septum first, and the upper lateral cartilages are sutured to the splay graft.
Fig. 15.79 Splay graft
Functional Rhinoplasty
752
Correction of External Valve Collapse
The external valve occupies a greater volume of space compared to the internal valve. The borders of external valve are
internal nasal valve superiorly, septum and columella medially, alar cartilage and fibrofatty tissue laterally, and nostril open-
ing caudally.
In Caucasian patients with thin skin and anteroposterior orientation of the nostril, excessive resection of cartilage during
tip plasty can easily lead to external valve collapse. This dynamic collapse of external valve is less common in Asians.
However, the same problem can be observed in Asian patients who have thin skin and weak lower lateral cartilages.
External valve collapse is worse during forced inspiration. According to Bernoulli’s principle, the airflow speeds up and
decreases pressure with decreased cross-sectional area. In the narrow area of external valve, airflow velocity increases and a
relatively negative pressure is generated. If the airflow is increased in incompetent external nasal valve, the negative internal
pressure is lowered in relation to the outer extranasal pressure, resulting in the valve collapse. This effect is exacerbated by
forced inspiration (Fig. 1.65).
Nonsurgical Treatment
For nonsurgical treatment, many patients use external nasal dilators (e.g., nasal strip with elastic recoil) or intranasal stents
to expand the lateral nasal wall and improve airflow (Fig. 15.80).
Fig. 15.80 External nasal dilator
15 Deviated Nose Correction and Functional Rhinoplasty
753
Fig. 15.81 Alar rim graft
Surgical Treatment
Permanent treatment for external nasal valve collapse is primarily surgical.
The choice of operative technique will vary according to the cause of valve collapse, but there are certain basic principles
to be observed. First, deviated caudal septum should be repositioned to midline. Second, a cartilage graft is used as a stent
for the external valve. This stent will need to support the weakness in the lateral nasal wall (i.e., alar rim, lateral crura of
lower lateral cartilages, and soft-tissue area between lateral crura and upper lateral cartilages). If needed, flaring suture can
be placed along with the graft.
A variety of structural cartilage grafts have been introduced to support the weakened lateral nasal wall of external valve
region. They are alar rim graft, lateral crural onlay graft, lateral crural strut graft, and alar batten graft.
The alar rim graft may be the simplest solution for weak alar rim (Fig. 15.81). Grafts are taken from the septum or ear
auricle. Alar rim graft is usually placed through a marginal incision as a part of the rhinoplasty. It can also be placed through
an external incision in the alar-facial groove. By itself, alar rim graft is rarely strong enough to completely correct external
valve collapse but provides additional strength to alar rim when performed with other procedures (Fig. 15.82).
The alar batten graft is also commonly used. Batten grafts reinforce the nasal sidewall and prevent collapse during inspira-
tion. The grafts are placed into precisely positioned pockets or sutured to the point of maximal lateral wall collapse. The
batten graft used for external valve insufficiency should be placed at the level of or caudal to the lateral crura (Fig. 15.83).
Batten graft is not a technically challenging procedure, but it adds volume to the lateral nasal wall and can worsen nasal
obstruction. Because of this, batten graft should be avoided in a nose with very narrow vestibules. There is a controversy on
whether the posterior end of graft should reach the pyriform aperture, but the author finds that the batten graft is functionally
effective when it reaches the pyriform aperture. The graft pocket is created in the deep tissue away from the external skin. If
the pocket is too close to the skin, the soft tissue is displaced towards the airway, and the graft can become visible through
the skin.
Lateral crural onlay graft or lateral crural strut graft are employed when the weakness of lateral nasal wall is due to weak
lateral crura of lower lateral cartilages.
Functional Rhinoplasty
754
a
b
c
d
e
f
g
h
i
j
Fig. 15.82 Alar rim graft for external valve collapse. (a) This patient has congenitally weak alar rim. (b, c) Forced inspiration leads to collapse of
alar rim, especially on the left side. (d–g) Alar rim graft is used to strengthen and stent open the weak alar rim. (h–j) At 10 months after operation,
the external valve no longer collapses during forced inspiration
15 Deviated Nose Correction and Functional Rhinoplasty
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Fig. 15.83 Batten graft for external valve insufficiency
Functional Rhinoplasty
756
Further Reading
1. Deroee AF, Younes AA, Friedman O. External nasal valve collapse repair: the limited alar-facial stab approach. Laryngoscope. 2011;121:474–9.
2. Toriumi DM, Josen J, Weinberger M, Tardy ME Jr. Use of alar batten grafts for correction of nasal valve collapse. Arch Otolaryngol Head Neck
Surg. 1997;123(8):802–8.
3. Jameson JJ, Perry AD, Ritter EF. High septal osteotomy in rhinoplasty for the deviated nose. Ann Plast Surg. 2006;56(1):40–5.
4. Jang YJ, Wang JH, Lee B-J. Classification of the deviated nose and its treatment. Arch Otolaryngol Head Neck Surg. 2008;134(3):311–5.
5. Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated nose: optimizing results using a simplified classification and algorithmic
approach. Plast Reconstr Surg. 2002;110(6):1509–23.
6. Teixeira J, Certal V, Chang ET, et al. Nasal Septal deviations: a systematic review of classification systems. Plast Surg Int. 2016:1–8.
7. Jang YJ, Yeo NK, Wang JH. Cutting and suture technique of the caudal septal cartilage for the management of caudal septal deviation. Arch
Otolaryngol Head Neck Surg. 2009;135(12):1256–60.
8. Constantine FC, Ahmad J, Geissler P, Rohrich RJ. Simplifying the management of caudal septal deviation in rhinoplasty. Plast Reconstr Surg.
2014;134(3):379e–88e.
9. Mau T, Mau ST, Kim DW. Cadaveric and engineering analysis of the septal L-strut. Laryngoscope. 2007;117:1902–6.
10. Howard BK, Rohrich RJ. Understanding the nasal airway: principles and practice. Plast Reconstr Surg. 2002;109:1128–46.
11. Guyuron B, Behmand RA. Caudal nasal deviation. Plast Reconstr Surg. 2003;111:2449–57. discussion 2458
12. Guyuron B, Uzzo CD, Scull H. A practical classification of septonasal deviation and an effective guide to septal surgery. Plast Reconstr Surg.
1999;104:2202–9. discussion 2210
13. Stallman JS, Lobo JN, Som PM. The incidence of concha bullosa and its relationship to nasal septal deviation and paranasal sinus disease. Am
J Neuroradiol. 2004;25(9):1613–8.
14. Hatipoğlu HG, Cetin MA, Yüksel E. Concha bullosa types: their relationship with sinusitis, ostiomeatal and frontal recess disease. Diagn Interv
Radiol. 2005;11(3):145–9.
15. Mehta R, Kaluskar SK. Endoscopic turbinoplasty of concha bullosa: long term results. Indian J Otolaryngol Head Neck Surg. 2013;65(Suppl
2):251–4.
16. Guyuron B, Michelow BJ, Englebardt C. Upper lateral splay graft. Plast Reconstr Surg. 1998;102(6):2169–77.
17. Jang YJ, Wang JH, Sinha V, et al. Percutaneous root osteotomy for correction of the deviated nose. Am J Rhinol. 2007;21(4):515–9.
18. Fischer H, Gubisch W. Nasal valves--importance and surgical procedures. Facial Plast Surg. 2006;22(4):266–80.
19. Byrne PJ, Walsh WE, Hilger PA. The use of “inside-out” lateral osteotomies to improve outcome in rhinoplasty. Arch Facial Plast Surg.
2003;5:251–5.
20. Soni RS, Choudhry OJ, Lui JK, et al. Postoperative cerebrospinal fluid leak after septoplasty: a potential complication of occult anterior skull
base encephalocele. Allergy Rhinol (Providence). 2013;4:e41–4.
21. Thakar A, Lal P, Verma R. Delayed cerebrospinal fluid leak following septoplasty. Ann Otol Rhinol Laryngol. 2009;118(9):636–8.
22. Onerci TM, Ayhan K, Ogretmenoglu O. Two consecutive cases of cerebrospinal fluid rhinorrhea after septoplasty operation. Am J Otolaryngol.
2004;25:354–6.
23. Passali D, Loglisci M, Politi L, Passali GC, Kern E. Managing turbinate hypertrophy: coblation vs. radiofrequency treatment. Eur Arch
Otorhinolaryngol. 2016;273(6):1449–53.
24. Hegazy HM, ElBadawey MR, Behery A. Inferior turbinate reduction; coblation versus microdebrider - a prospective, randomised study.
Rhinology. 2014;52(4):306–14.
25. Acevedo JL, Camacho M, Brietzke SE. Radiofrequency ablation turbinoplasty versus microdebrider-assisted turbinoplasty: a systematic
review and meta-analysis. Otolaryngol Head Neck Surg. 2015;153(6):951–6.
26. Chen YL, Tan CT, Huang HM. Long-term efficacy of microdebrider-assisted inferior turbinoplasty with lateralization for hypertrophic inferior
turbinates in patients with perennial allergic rhinitis. Laryngoscope. 2008;118(7):1270–4.
27. Moss WJ, Lemieux AJ, Alexander TH. Is inferior turbinate lateralization effective? Plast Reconstr Surg. 2015;136(5):710e–1e.
28. Rohrich RJ, Krueger JK, Adams WP, et al. Rationale for submucous resection of hypertrophied inferior turbinates in rhinoplasty: an evolution.
Plast Reconstr Surg. 2001;108:536–444.
29. Motamedi KK, Stephan SJ, Ries WR. Innovations in nasal valve surgery. Curr Opin Otolaryngol Head Neck Surg. 2016;24(1):31–6.
30. Park SS. The flaring suture to augment the repair of the dysfunctional nasal valve. Plast Reconstr Surg. 1998;101:1120–2.
31. Kang JM, Nam ME, Dhong HJ, et al. Modified mattress suturing technique for correcting the septal high dorsal deviation around the keystone
area. Am J Rhinol Allergy. 2012;26(3):227–32.
32. Ballert JA, Park SS. Functional rhinoplasty: treatment of the dysfunctional nasal sidewall. Facial Plast Surg. 2006;22(1):49–54.
15 Deviated Nose Correction and Functional Rhinoplasty
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© Springer Nature Singapore Pte Ltd. 2018
M. K. SUH, Atlas of Asian Rhinoplasty,
Secondary Rhinoplasty
16
General Considerations
Compared to other fields of aesthetic surgery, aesthetic rhinoplasty consists of a wide variety of operative techniques as well
as implant materials and graft types. As such, the wide spectrum of outcomes can be observed, depending on the skill and
experience of a surgeon.
The nose occupies the central real estate of the face, and the soft tissue is relatively thinner, which does not mask minor
irregularities of the underlying skeletal framework. The postoperative appearance continues to change for 1–2 years after an
intervention. In Asian rhinoplasty, the high frequency of implant use results in complications.
For these reasons, rhinoplasty is associated with higher frequency of revision, compared to other type of aesthetic surgery.
In addition to complications, subjective patient dissatisfaction is also higher for rhinoplasty, which also contributes to higher
rates of revision.
Revision rate is reported at 8–15% after primary rhinoplasty. This revision rate decreases with operative experience and
improvements in technique, but there is a baseline rate of complication and patient dissatisfaction that even the most experi-
enced rhinoplasty surgeon will accept as a fact of life.
Secondary rhinoplasty is a lot more demanding than primary rhinoplasty because of the alteration in the nasal anatomy,
preponderance of soft-tissue problems, and abundance of scar tissues. The amount of donor cartilage is limited, and patients
often have psychological hang-ups from prior rhinoplasty experience.
Through a detailed interview and nasal examination, the operator must come to understand the material problem of the
nose as well as wishes and expectation on the part of the patient. Prior to the revisional operation, the patient must also come
to understand and let go of unrealistic aspects of the expectation. The patient and the operator must come to an agreement on
realistic operative goals and the potential for further complications at the time of giving surgical consent.
To obtain a satisfactory operative outcome, the rhinoplasty surgeon must perform the operation that is based on scientific
principles. The operator must have thorough understanding of the normal anatomy and its variations, proper skills for nasal
examination, surgical techniques, wound-healing process, and long-term changes following an operation.
Rhinoplasty is a science but also an art. Many patients seek secondary rhinoplasty for a subjective dissatisfaction. To
address such subjectivity or to identify the unrealistic expectations of patients, the rhinoplasty surgeon must have a keen
artistic appreciation for the nose. Although the scientific aspect is what determines the success of a rhinoplasty operation, the
artistic aspect of rhinoplasty cannot be ignored. The artistic appreciation is based on the harmony between the nose and
remainder of face, changes in the aging nose, and ethnic standards, and it is a skill that a rhinoplasty surgeon must also aim
to build over the course of his/her career.
Consultation and Nasal Examination
Patient Interview
The importance of adequate communication between patient and surgeon cannot be emphasized enough. A complete inter-
view will thoroughly identify and explore the wishes and expectations of a patient and build a strong rapport between the
operator and patient that could decrease problems in the postoperative period. Above all, the most important aspect of the
758
communication before a secondary operation is to come to an unequivocal understanding of the goals and limitations of the
proposed operation and to screen those patients who are not appropriate candidates for the operation.
Patients who are considering secondary rhinoplasty tend to have preoperative consultations with several surgeons and
research various operative methods via the Internet. As such, these patients usually have a good understanding and insight
into the state of their nose or the problem. At the same time, patients can also present with wrong information and can often
have an exaggerated perception regarding the outcome of operation. If a patient demonstrates psychological issues or expec-
tations not based on physical reality, the rhinoplasty surgeon has the right and duty to preserve his/her own psychological
well-being, by avoiding the operation in such patients.
Listening is an important skill. Without truly listening to the patient, the operator cannot discover the exact thing the
patient wishes to obtain through a repeat operation. A simple operative solution based purely on the medical perspective is
highly likely to result in a dissatisfied patient. Beyond the simple medical and surgical history, the operator must explore and
obtain answers to what about the prior operation the patient finds unreasonable or dissatisfactory. Through this process, the
surgeon will get a sense of the patient’s character and preference as well as whether the expectation is realistic.
Psychological evaluation is a highly important aspect of preoperative evaluation. Among patients who elect to undergo
repeated rhinoplasty operation, there are a select subgroup of patients who suffer from an underlying psychiatric disorder.
There are no published data on the frequency of psychiatric disorder in the rhinoplasty population, but most rhinoplasty
surgeons will agree that it is not a rare occurrence. Among various disorders, body dysmorphic disorder is especially com-
mon. A patient with this mental disorder will often perceive and believe that a certain portion of their body is disfigured or
deformed, despite the reality of having normal anatomy or a usual variation thereof.
A rhinoplasty surgeon is not a psychiatrist and should not be practicing the diagnosis and treatment of psychiatric disor-
ders. The surgeon, however, should be able to delineate whether a patient presenting for rhinoplasty has an underlying psy-
chiatric disorder that warrants a consultation from a psychiatrist.
Functional problems such as nasal obstruction should be elucidated and recorded.
During the consultation, the surgeon should avoid criticizing or judging the surgeon who had performed the previous
rhinoplasty operation or the operative outcome thereof because it could well be that the previous operator ends up being a
colleague or the surgeon himself/herself. It is difficult for a patient to be able to respect a physician who speaks poorly of
another, and it is not rare for a patient to be withholding a significant amount of information for one reason or another. The
patient may not divulge the complete history of rhinoplasty operations or may be mistaken about the type of operation that
they had undergone. The history that a patient gives should help guide the consultation and medical decision-making process,
but is not to be taken as an absolute recollection of the past.
The use of photographs and simulation program can be helpful in communicating to the patient, but should not be used
as a guarantee. Also, the simulated postoperative appearance should not be printed and given to the patient for a number of
reasons.
Nasal Examination
For the reasons mentioned above, the history regarding previous surgery should be taken as a reference and not as an abso-
lute. For secondary rhinoplasty, a thorough and careful examination is especially important as it can identify information
regarding prior operation.
As it is with primary rhinoplasty, it is important to examine the nose in the context of whole face. A patient’s perception
of “abnormality” may be not only due to the nose itself but also from the disharmony between the nose and remainder of
face. In addition, the desired outcome following the secondary rhinoplasty may not be harmonious with the face. It is espe-
cially important to examine protrusion of the forehead, chin, and mouth. In addition, the face should be examined for inter-
medial canthal distance, facial width and height, and facial asymmetry.
16 Secondary Rhinoplasty
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Skin
Thick tip skin is a factor for unfavorable outcome following tip plasty and contributes to less than ideal outcomes for second-
ary rhinoplasty as well. Because of this, the operator must explain the limitations caused by thick skin and adjust the patient’s
expectation accordingly. In contrast, thin skin can increase the likelihood of dorsal implant visibility. As such, dorsal implants
should not be recommended in patients with thin dorsal skin. In such patients, the dorsum should be augmented with tempo-
ral fascia, mastoid fascia, perichondrium of costal cartilage, dermal autograft, or dermal allograft.
With dorsal implant, the redness in skin is caused by increased soft-tissue tension (Fig. 16.1). This is caused by excessive
implant height or placement of the implant above the periosteum. In such cases, the implant pocket should be converted into
subperiosteal plane. The height of implant can be decreased with or without placement of temporal fascia. However, this may
not result in complete resolution of the problem, which will require implant removal and dorsal augmentation using autolo-
gous soft tissue, such as dermofat graft.
Skin thinning and implant visibility are managed by decreasing implant height or by implant removal with dermofat graft.
However, the telangiectasia will not improve or can become worse. In such cases, the skin redness and telangiectasia should
be managed with vascular laser treatment (585 nm).
For severe redness, the implant is removed first, and the subsequent augmentation delayed for 2–6 months to allow for the
nose to heal.
Fig. 16.1 Dorsal skin redness caused by implant
General Considerations
760
External Nasal Framework
The nasal framework is examined from the radix to the nasal tip. Most Asians prefer a moderate radix height (Fig. 16.2).
Excessively high radix from dorsal augmentation is a frequent cause of revision rhinoplasty. Female patients prefer a slightly
curved dorsal profile, but male patients prefer a straight dorsal line.
For a patient with dorsal implant, the nose should be examined for implant width, visibility through the skin, and any
depression between implant tip and tip onlay graft.
In the absence of an implant, the dorsum should be evaluated for irregularity, inverted-V deformity, and internal valve
function. The nasal bone should be evaluated for post-osteotomy step deformity and bony asymmetry.
The supratip area should be evaluated for any depression or bulging. Unlike Caucasians, a definite supratip break appears
unnatural in Asians and is a cause for complaint.
a
b
Fig. 16.2 In this patient, the dorsal implant resulted in excessive radix augmentation, which makes the nose appear highly unnatural with the
“operated appearance” and aggressive countenance
16 Secondary Rhinoplasty
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Nasal Tip
The nasal tip should be evaluated for height, volume, and ratios.
Augmentation of low dorsum does not represent the entirety of Asian rhinoplasty, and nasal tip aesthetic is also extremely
important for Asian patients. Across Asian countries, the incidence of secondary rhinoplasty operations is increasing for
unpleasing nasal tip. It is not an exaggeration to state that the completeness of an operation is determined by the state of nasal
tip. In the author’s practice, low nasal tip is the most common cause of revisional surgery, followed by bulbous tip, asym-
metric tip, and pinched tip.
The complaint of “low nasal tip” or “tip bulbosity” should be interpreted in the context of the factors which influence a
patient’s perception of the nasal tip. For example, a patient complaining of bulbous nasal tip may in fact have a pinched tip.
In such a patient, the nasal tip does not have a whole lot of volume, but the supratip volume is significantly larger compared
to the infratip-alar rim. It is the discrepancy in the tip-lobule-ala ratio that gives the perception of bulbous nasal tip.
For rigid tip, the cause should be delineated among fixed-type columellar strut graft, septal extension graft, or L-shaped
implant.
Columella and Alar Base
Important metrics for aesthetically pleasing nose include nasolabial angle, columella projection/retraction, and width of alar
base.
Among Asian patients, cephalic rotation of tip and large nasolabial angle are not welcome. For superstitious reasons,
excessive nostril show is shunned. The alar should be evaluated for hanging ala, thick ala, and thin ala. For ala-columella
relationship, hanging or retraction should be distinguished between true hanging and pseudohanging.
Causes of columella deviation should be delineated between lower lateral crura and caudal septal deviation.
Functional Examination
Using nasal speculum, endoscopy, plain X-ray, and/or CT imaging, functional abnormalities are evaluated, such as septal
deviation, septal perforation, turbinate hypertrophy or atrophy, mucosal synechiae, and sinus problem. A patient may or may
not be cognizant of a functional problem, but all abnormalities should be documented and communicated to the patient prior
to an operation.
The nose should also be evaluated for internal and external valve insufficiency. Examination of valve function is described
in Chap. 1.
Timing of the Secondary Rhinoplasty
Generally, the timing of secondary rhinoplasty is at least a year after the last rhinoplasty operation. The rationale for this is
the resolution of postoperative edema and relative completion of scar tissue remodeling. However, the wait should be longer
(1.5–2 years) for history of infection or multiple operations.
While it is generally a wiser move to wait for the full duration of a year, early revision is possible in the following
situations:
1. Implant exchange or correction of implant deviation without tip surgery.
2. Impending exposure of implant through tip skin or vestibular mucosa.
3. The presence of functional problem.
General Considerations
762
4. Significant deformation that interferes with social activity.
5. In the early postoperative period (<2 weeks), the patient may have more to benefit by undergoing an immediate revision
for a clear and significant problem, compared to waiting a whole year for the problem to worsen. In such cases, the sur-
geon must communicate fully and the patient understand the need for such an early revision. The patient must also accept
the fact that the operative outcome will be less than ideal and may further require another operation down the road.
How to Choose the Incision and Approach
A simple revision can be performed via closed approach. The closed approach is associated with decreased edema with quick
recovery. Closed approach can be considered in the following situations:
1. Implant exchange
2. Osteotomy
3. Conservative tip revisional surgery, including tip onlay/shield graft
Incisions used for closed approach include inframarginal incision, intercartilaginous incision, and intracartilaginous
incision.
An open approach with transcolumellar incision and inframarginal incision is needed for more complicated operations:
1. Deviated bony and cartilage framework
2. Asymmetric nasal tip and columella
3. Contracted nose
4. Moderate-to-severe mid-vault collapse
5. Revisional surgery requiring complex structural graft
Open approach provides complete exposure of the operation field and allows accurate assessment of the nasal deformity.
Through the approach, the surgeon can place a more precise suture and graft placement as well as tissue manipulation.
However, the approach leads to prolonged edema with increased operative time and recovery time.
The surgeon should arrive at the appropriate approach by evaluating the anatomy, clinical problem, and prior operation
detail for each individual patient.
The columellar incision is the same for a primary open rhinoplasty. An inverted-V incision is placed at the narrowest por-
tion of columella or along the preexisting incision scar.
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Implant-Related Complications
The complication rate for silicone implant is reported at 2.2–3.6%, with similar rates reported for e-PTFE implants. However,
the frequency of implant-related complication is bound to differ widely, depending on surgeon experience and technique.
Rhinoplasty surgeon must understand the imperfect nature of implants and must adopt operative techniques which mini-
mize implant-related complications. When these complications do occur, the surgeon must be equipped to manage them.
Implant-related complications are associated with peculiar characteristics of each implant material, but the most common
causes are from the use of inappropriately sized implants or the use of L-shaped implants.
Movable Implant
A silicone or e-PTFE implant placed within subperiosteal pocket does not move or moves very little. If the implant pocket is
created in the wrong place, the implant can easily become dislocated from the desired position. Such an implant can be
manipulated with minor touch (e.g., putting on makeup), which can be an extreme source of psychological distress to the
patient (Fig. 16.3).
Causes of Movable Implant
Weakness or tear in the periosteum of nasal bone can allow the implant to mobile. However, most instances of movable
implant are caused by placing the implant within a supraperiosteal pocket.
Correction
Movable implants are addressed by converting the implant pocket from supraperiosteal plane to subperiosteal plane. A torn
periosteum can be responsible for implant migration. If the range of implant movement is minor, it is necessary to reassure
the patient that the minimal amount of movement does not require an operative intervention. If the implant movement is
significant, then the implant can be placed deep to the posterior capsule, but elevating the posterior capsule without tearing
is a difficult task. Compared to silicone implants, e-PTFE implants tend to have increased adhesion to nasal bone and under-
lying cartilage, with tissue ingrowth lowering the risk of implant migration. As such, the surgeon could consider exchanging
a silicone implant to an e-PTFE implant.
a
b
Fig. 16.3 Movable silicone implant
Implant-Related Complications
764
Deviated Implant
Most cases of implant deviation are due to improper pocket creation. If the pocket dissection is performed via closed
approach from the right nasal cavity, it is easy for the pocket to deviate towards the left at the level of radix. To avoid this
issue, the pocket should be created using a symmetric approach through bilateral inframarginal incisions.
On the one hand, a large pocket allows too much freedom in implant mobility. On the other hand, a pocket of exact size
is more likely to be deviated or off midline. Thus, the pocket should be slightly larger than the implant to allow a snug fit that
allows the implant to be positioned without allowing too large of movement afterwards.
If the nasal dorsum provides an irregular foundation, the irregularity should be addressed with rasping. Otherwise, the
bottom surface of the implant should be carved to compensate for the irregularity in the dorsal surface (Fig. 16.4).
a
b
Fig. 16.4 Deviated silicone implant. (a) A patient with deviated silicone implant. (b) Facial CT image demonstrates deviated nasal bone (asym-
metric nasal bony slope)
16 Secondary Rhinoplasty
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Correction
Unilateral Capsulotomy
A deviated silicone implant can be addressed with unilateral longitudinal lateral capsulotomy. In this technique, the capsule
is opened longitudinally on the side that is away from the direction of implant deviation, which opens up additional space
that is contiguous with the capsule. The deviated implant is then manually set in midline and stabilized with compressive
dressing (Fig. 16.5). The capsulotomy should be made as close to the floor of lateral margin as possible.
This technique is a simple, easy technique but does not allow for implant exchange. Additionally, the technique is inap-
propriate for a patient who has experienced multiple episodes of implant deviation and for movable implant.
a
b
c
d
Fig. 16.5 Unilateral capsulotomy for the correction of deviated silicone implant. (a) This patient has a deviated silicone implant. (b) Preoperative
photograph showing the planned design for capsulotomy along the left lateral margin of capsule. (c) D-knife is used for the capsulotomy. (d)
Through the closed approach, the D-knife is inserted into the implant pocket, and the capsule is incised from within the lumen
Implant-Related Complications
766
New Pocket Formation Under the Posterior Capsule
After removing the deviated implant, a new pocket is created deep to the preexisting posterior capsule. The implant is then
inserted into the newly created pocket. This is the more surefire method of correcting deviated implant, with low rates of
recurrent deviation (Fig. 16.6).
Because e-PTFE implants do not induce capsule formation, correction of implant deviation is relatively easier. A dissec-
tion is performed to create space for the deviated implant. The elevator is used to detach the implant from the nasal bone and
upper lateral cartilage. The freed implant is then set into the proper midline orientation. Depending on the situation, the old
implant can be exchanged with a new one.
a
b
Fig. 16.6 Correction of deviated silicone implant. (a) In this patient, the silicone implant is deviated to the right side. The implant was removed,
and a new implant was placed in a pocket created under the posterior capsule. (b) Postoperative photograph demonstrates symmetric dorsum
16 Secondary Rhinoplasty
767
Color Change of Dorsal Skin
The most common color change due to dorsal implant is dorsal skin redness. Other types of skin change include translucency
and reflective changes (Fig. 16.7). The color change of dorsal skin is caused by the pressure, tension, and skin thinning from
the implant.
Fig. 16.7 Redness of dorsal skin from silicone implant
Implant-Related Complications
768
Correction
The definitive correction of skin color change is to replace the implant with either dermal or dermofat graft (Fig. 16.8).
In the sacrococcygeal area, the dermis is thicker than anywhere else in the body. In addition, the subdermal fat layer is
relatively dense. These anatomic properties of the sacrococcygeal soft tissue create for an excellent source of dermofat graft.
Harvest and implantation technique for dermofat graft is described in detail in Chap. 7.
Because of the resorption, the postoperative outcome is less predictable for dermofat graft. However, the graft allows for
a naturally appearing dorsal augmentation in patients with thin skin. It also permits immediate or early augmentation in a
previously infected nose and is able to correct implant-related color change.
A method which undergoes less of resorption than dermofat graft with greater augmentation is vertically oriented folded
dermal graft technique. This technique is also described in Chap. 7.
a
b
c
Fig. 16.8 Correction of implant-related skin redness. (a) In this patient, the dorsal and nasal tip skin redness developed after dorsal augmentation
using Gore-Tex® implant. (b) The implant was removed (above), and the dorsum was augmented using dermofat graft (below). (c) At 6 months
after operation, the skin redness has resolved completely
16 Secondary Rhinoplasty
769
After removing a silicone implant, a dermofat or dermal graft should not be placed into the empty capsule. Instead, the
graft should be placed in a space between the anterior capsule and the dorsal skin (Fig. 16.9). After removing an e-PTFE
implant, there will be no capsule. In this case, a graft can be placed in the pocket that was previously occupied by the e-PTFE
implant.
Although dermofat or dermal graft will significantly improve dorsal skin redness, the patient should understand that
implant removal and graft placement do not always lead to complete resolution of the redness (Fig. 16.10).
Solid autogenous tissue (e.g., cartilage graft) does not improve dorsal skin redness.
If a patient will only permit the use of implant, an implant of lower height can be used to decrease the tension in the skin.
The implant can be placed deep to the posterior capsule, to keep more soft tissue between implant and dorsal skin. Also, the
implant can be covered with deep temporal fascia, which will help with decreasing the skin redness and implant visibility
through thin skin (Fig. 16.11). Acellular dermal matrix can be used to cover the implant, in lieu of fascia (Fig. 16.12). In a
recent study, the author has reported on how the use of this technique leads to formation of a thin, fine capsule, which
decreases the risks of capsular contracture.
Fig. 16.9 Dermofat or dermal graft should be placed between the anterior capsule and dorsal skin
Implant-Related Complications
770
a
b
c
d
Fig. 16.10 Correction of implant-related skin redness. (a, b) This patient has a history of five rhinoplasty operations and presented with dorsal
skin redness. The implant (Gore-Tex®) was removed and replaced with a dermofat graft. The tip was revised using conchal cartilage. (c, d) After
1 year, the dorsal skin is markedly improved, but slight skin redness remains in the dorsum and tip
16 Secondary Rhinoplasty
771
a
b
c
d
e
f
Fig. 16.11 Temporal fascia coverage to improve conspicuous implant contour. (a, b) Preoperative photograph reveals visible implant contour.
The columella is hanging. (c, d) The preexisting implant was removed (not shown). A new silicone implant was carved and covered with deep
temporal fascia. The tip was revised using columellar strut graft (septal cartilage) (not shown). (e, f) At 6 months, the implant contour is no longer
conspicuous, and the hanging columella is improved
Implant-Related Complications
772
a
b
c
d
e
Fig. 16.12 Dermal allograft
coverage of silicone implant.
(a) Preoperative photographs
demonstrate redness of dorsal
skin and conspicuous implant
contour. (b) Dermal allograft
(above) (MegaDerm®, L&C
Bio, Seoul, Korea) and new
implant (below); size of the
ADM is 0.7mm_5cm_1.2 cm.
(c, d) The dermal allograft is
rehydrated and covers the new
implant. (e) At 5 months after
the operation, dorsal skin
redness and implant conspicu-
ousness are improved
16 Secondary Rhinoplasty
773
Implant Showing Through Thinned Dorsal Skin
Implant visibility occurs in patients with thin dorsal skin and can also be caused by excessively tall implant. This problem
can be corrected using the same set of techniques used for skin redness.
This problem cannot be addressed by exchanging a silicone implant with an e-PTFE implant. In fact, the e-PTFE does not
form a capsule and adheres to the skin envelope, which makes it more likely for the implant contour to be conspicuous
through the skin. As such, e-PTFE implants should be avoided in patients with thin skin (Fig. 16.13).
a
b
Fig. 16.13 In this patient, the Gore-Tex® implant has conspicuous margins and contour
Implant-Related Complications
774
The “Operated-Look” Implant
The unnatural, operated look of a dorsal implant can be caused by excessive height of the radix and/or dorsum, dorsal skin
redness, implant visibility through thin dorsal skin, and conspicuous implant margins. In most cases, the “operated” nose will
likely consist of more than one of these features.
A radix height that may appear natural in a Caucasian nose will appear extremely out of place in an Asian nose. As such
radix augmentation should carefully balance out the need for augmentation versus the preservation of ethnic identity. The
exchange of high implant with a lower implant can drastically improve the unnatural appearance of the nose.
The dorsal skin redness and implant visibility can be addressed with the method discussed in previous sections.
Conspicuous Implant Margins
Conspicuous implant margins have five variations (Fig. 16.14):
Type I: Implant with excessive width
Type II: Implant of inadequate width
Type III: Abrupt transition between dorsal surface and sidewall of implant
Type IV: Thinned dorsal skin
Type V: Capsular contracture
16 Secondary Rhinoplasty
775
Fig. 16.14 Five types of visible implant
margins. (a) Type I (implant with excessive
width). (b) Type II (implant of inadequate
width). (c) Type III (abrupt transition
between dorsal surface and sidewall of
implant). (d) Type IV (dorsal skin atrophy).
(e) Type V (capsular contracture)
Implant-Related Complications
776
a
b
c
d
e
Fig. 16.14 (continued)
16 Secondary Rhinoplasty
777
Correction of Conspicuous Implant Margins
The problems of implant width (types I and II) are corrected by exchanging the implant with a more appropriately sized
implant. Abrupt transition in the implant sidewall (type III) should be addressed by exchanging the implant with an aestheti-
cally carved implant.
For implant margin visibility due to thinned dorsal skin (type IV), the most sound method of correction will involve
replacing the implant with dermofat graft. If an implant must be used, the implant can be covered with temporal fascia or der-
mal allograft. In this case, it can be helpful to insert additional temporal fascia or dermal allograft along the implant margin
on both sides (Fig. 16.15). Temporal fascia graft can also be used to mask the visible margin of e-PTFE implant (Fig. 16.16).
a
d
b
c
e
f
Fig. 16.15 Correction of visible implant margins.
(a–c) This patient with conspicuous implant margins
underwent implant removal and placement of new
implant covered with dermal allograft. (d–f) After
11 years, the implant margins remain much less
conspicuous
Implant-Related Complications
778
a
b
c
Fig. 16.16 Correction
of conspicuous implant
margins using
temporal fascia graft.
(a) In this patient, the
conspicuous margins
are due to a Gore-Tex®
implant. (b) Deep
temporal fascia graft is
placed along both
margins of the implant.
(c) At 3 years, the
conspicuous margins
are difficult to observe
Capsular contracture surrounding the implant margins can pull in the dorsal skin along the implant margins, which causes
the implant contour to become visible (type V). This problem requires the following solutions.
First, the visible implant contour can be camouflaged by the injection of fat or filler along the implant margins (Fig. 16.17).
The injection should be placed between the skin and the capsule. Microfat graft injection undergoes high amount of resorp-
tion, which requires 2–3 repeated injections. Temporal fascia graft undergoes lesser degree of resorption, compared with fat
injection.
Second, the capsule can be opened bilaterally along the lateral margins, and the silicone implant is exchanged with an
e-PTFE implant wrapped in temporal fascia, which does not lead to capsule formation. Otherwise, the implant can be
exchanged with dermal or dermofat graft after capsulectomy (Fig. 16.18).
16 Secondary Rhinoplasty
779
Fig. 16.17 Fat injection along the margins of implant
a
b
Fig. 16.18 Conspicuous implant margin due to capsular contracture. (a) Preoperative photograph shows the conspicuous implant margins due to
capsular contracture. The patient underwent capsulectomy and exchange of silicone implant with dermofat graft (not shown). (b) After 9 months,
the dorsum appears very natural
Implant-Related Complications
780
Which Implant Looks More Natural?
Traditionally, e-PTFE implants are considered to cause less skin thinning and appear natural, compared to silicone implants.
However, this is no longer believed among experienced surgeons.
Unlike silicone implants, e-PTFE implants do not leave a capsule. Instead, the material adheres to the dorsal skin, which
can cause significant visibility of implant contour in a thin skin. Also, the e-PTFE does not necessarily remove dorsal skin
redness (Fig. 16.19). As such, the author disagrees with the suggestion that e-PTFE implant should be used for dorsal aug-
mentation in patients with thin dorsal skin. With thin dorsal skin, the capsule formation from silicone implant can be useful,
provided that the silicone is covered with fascia or dermal allograft.
Implant-related complications are dependent on the size of implant and the thickness of dorsal skin, and the type of
implant material plays a very minor role in the development of these complications.
The naturalness of an implanted nose is determined by the following factors:
1. Height of implant: Excessive height contributes to unnatural appearance of the dorsum.
2. Dorsal skin thickness: The implant may become visible or its contours become apparent through a thin dorsal skin. This
is true whether the skin is naturally thin or has atrophied from excessive implant height.
3. Skin tension: Dorsal augmentation and tip lengthening can place a great amount of tension through the dorsal soft tissue,
which can lead to redness and thinning of the skin.
4. Pocket plane: Abundance of soft tissue tends to mask the implant beneath the skin. As such, the implant pocket should be
created in the subperiosteal pocket. To supplement the soft-tissue volume, the space between the implant and dorsal skin
can be bolstered with dermal allograft.
5. Aesthetically meticulous carving of implant: The implant should be carved such that the transition is gradual between the
sidewall and the base.
a
b
Fig. 16.19 In this patient with thin dorsal skin, the adhesion between e-PTFE implant and subcutaneous tissue is readily visible
16 Secondary Rhinoplasty
781
Implant Exposure Through Skin/Mucosa
Implant exposure through tip skin or vestibular skin/mucosa is reported at a rate between 0.5 and 10%. In clinical experience,
this complication is extremely rare unless the implant used was either an L-shaped implant or a long implant that is extended
into the nasal tip.
When the complications do occur, the implants are usually exposed through tip, columella, or vestibular skin/mucosa
(Fig. 16.20). Patients with implant exposure through vestibular skin/mucosa are not aware of the problem for a long time.
When they do present, the patients most likely already suffer from infection and contracture.
a
b
c
Fig. 16.20 Exposed silicone implant
Implant-Related Complications
782
Causes
A properly sized implant will have its distal end at a location more cephalic than the domes of lower lateral cartilages.
Implant exposure is usually due to inappropriately long implant that extends into the nasal tip. This is especially the case for
L-shaped implant, which is associated with extremely high rates of thinning and rupture of tip skin and should not be used
under any circumstances.
If the distal end of implant is hard or has an acute angle, the implant tip can dig through the scroll area and become
exposed to the nasal cavity (Fig. 16.21).
At times, the implant exposure can be caused by inflammation in the soft tissue.
Even with a short I-shaped silicone implant, an implant with slippery bottom side can slide caudally and expose through
the nasal tip skin (Fig. 16.22). A silicone implant with textured surface is useful in minimizing migration and deviation. If
implant migration is a concern, the implant can be sutured unto the upper lateral cartilages. Compared to silicone implants,
e-PTFE implants are less likely to migrate.
Fig. 16.21 Implant exposure through the
intercartilaginous area
16 Secondary Rhinoplasty
783
a
b
c
d
Fig. 16.22 This patient had undergone silicone implant placement 10 days prior. She is at risk of impending exposure through the tip skin due to
caudal slipping of the implant
Implant-Related Complications
784
Symptoms
Symptoms that precede implant exposure through the tip skin are conspicuous and readily apparent to the patient. In addition
to the palpable hardness of the tip, the skin can become pale or turn red, with or without pain and tenderness. In advanced
state, the implant end can be observed as skin bulging (Fig. 16.23), and it is only a matter of time before the implant actually
extrudes through the skin.
a
b
Fig. 16.23 Impending extrusion of implant through the tip skin
16 Secondary Rhinoplasty
785
Correction
If the skin or mucosa has yet to rupture, the correction is not difficult. After implant removal, the tip skin will have a dimpling
deformity due to thinning of dermal and subcutaneous layer (Fig. 16.24). The use of onlay graft to re-project the nasal tip
will result in visible graft through the thinned skin. Because of this, dermal graft should be used to bolster the area of thinned
skin (Fig. 16.25). If a new implant is used, the distal end should not be allowed to reach into the nasal tip.
If the implant has already ruptured through the tip skin or the vestibular mucosa, the implant is carefully removed. The
ruptured skin or mucosa needs to be repaired (Fig. 16.26). If primary repair is not an option, the defect is allowed to heal by
secondary intention, followed by secondary operation at a later time.
The repaired tip skin will be contracted, depressed, and with an ugly retracted scar. To minimize the contracture and
retracted deformity, the atrophied soft tissue of the tip should be supported by dermofat or dermal graft. The graft is not a
definite correction of the ruptured tip. Rather, it serves as a temporary space filler to prevent ugly sequelae. Despite the soft-
tissue graft, depression deformity can still develop down the road, which must be communicated to the patient well ahead of
time.
After implant removal, various authors have reported immediate dorsal augmentation using autogenous tissues such as
dermofat or cartilage graft. This decreases the stress associated with staged operations, decreases the risk of contracture, and
can be relatively safe in the absence of infection. However, this option should be exercised with caution in patients with
infected implant cavity. If dorsal augmentation is to be performed with an implant, the secondary operation should be
delayed for 3–4 months after the removal of exposed implant.
a
b
c
Fig. 16.24 Tip dimpling deformity after implant removal. (a, b) In this patient, the long silicone implant is deviated and is at risk of rupture
through the thin tip skin. (c) Intraoperative photograph shows dimpling deformity after implant removal
Implant-Related Complications
786
a
c
b
d
Fig. 16.25 Tip skin padding with dermal allograft. (a, b) The nasal tip skin is atrophied from the pressure of a long silicone implant. The implant
was replaced with a shorter implant, and the tip skin was padded with dermal allograft. (c, d) At 5 months, the tip does not have any dimpling
deformity nor visible cartilage graft
a
b
Fig. 16.26 Repair of implant exposure. (a) Implant exposure through tip skin. (b) The implant was removed, and the ruptured skin was padded
with dermal graft and closed primarily
16 Secondary Rhinoplasty
787
Late Spontaneous Hematoma
A sudden accumulation of blood in the implant capsule can occur several months to several years after a dorsal augmenta-
tion. Clinically, this presents as a sudden onset of nasal edema and bruising (Fig. 16.27). Aspiration of the subcutaneous mass
will reveal dark blood, which distinguishes the presentation from an infection.
a
b
Fig. 16.27 Late spontaneous hematoma. (a) Sudden swelling and
bruise around the nasal dorsum is a typical presentation for late
spontaneous hematoma. (b) Aspiration demonstrates the
subcutaneous flocculation to be dark liquefied hematoma, which is
distinguishable from local infection
Implant-Related Complications
788
Causes
The etiology is not well known, but a plausible explanation is the erosion of inner surface of capsule. The calcified deposit
on the implant surface may scratch the inner surface of capsule. If a hole was created in the implant for fixation suture,
ingrowth of capsule tissue into the implant hole can be torn and bleed after a sudden traction of the implant. However, spon-
taneous hematoma can be observed outside of these situations.
Treatment
The accumulated blood is aspirated with a syringe. Compression dressing is helpful. At times, patients may require desmo-
pressin or steroid. In most cases, conservative management is adequate, but repeated hematoma formation can be addressed
by exchanging the silicone implant with e-PTFE implant or autogenous tissue.
Calcification
Over time, silicone implant induces deposition of lipid or calcium on implant surface, resulting in calcification. This usually
occurs on the dorsal surface of silicone implant but can also occur all around the implant. The calcifications can be palpated
as small humps (Fig. 16.28). Focal calcifications are believed to be present in 50% of implants which have been implanted
for more than 9 years.
b
a
Fig. 16.28 Calcification on the implant. (a) In this patient, the dorsum is noticeable for irregular texture and a hump. (b) Removal of implant
identifies calcification of the silicone surface as the cause
16 Secondary Rhinoplasty