Nâng Mũi Thẩm Mỹ Nâng Cao: Nghệ Thuật, Khoa Học Và Các Kỹ Thuật Lâm Sàng Mới

922
H.A. Mayaleh
Case 1 (Fig. 65.3 )
A 33-year-old woman presented with a slight dorsal
hump, wide nasal dorsum, thick skin, and decreased
columellar-labial angle. She had a rounded, bulbous,
and under-projected nasal tip. The operative plan
was as follows: open rhinoplasty, 3-mm dorsal
reduction, 1-mm septum caudal reduction, OFF
technique, and low lateral intranasal osteotomies.
Two years post-operative, the dorsum is
straight, the nasal tip has been projected, and the
tip rotation has been enhanced.
Fig. 65.3 ( Upper ) Preoperative 33-year-old female pre-
senting with a slight dorsal hump, wide nasal dorsum,
thick skin, and decreased columellar-labial angle. ( Lower )
Two years post-operative following open rhinoplasty,
3-mm dorsal reduction, 1-mm septum caudal reduction,
OFF technique, and low lateral intranasal osteotomies.
The dorsum is straight, the nasal tip has been projected,
and the tip rotation has been enhanced

923
65 The Onlay Folded Flap (OFF) for Nasal Tip Surgery
Case 2 (Fig. 65.4 )
A 45-year-old woman presented with a short,
deviated nose, short columella, and under-projec-
tion of the nasal tip. The operative plan was open
rhinoplasty, central dorsum realignment using
external low lateral percutaneous osteotomies,
dorsal augmentation with multilayered bruised
and crushed septal cartilage grafts, and nasal tip
plasty using the OFF technique. After 18 months,
the nasal dorsum is markedly straight, augmented,
and the nasal tip is clearly projected.
Fig. 65.4 ( Upper ) 45-year-old female presented with
a short, deviated nose; short columella; and under-
projection of the nasal tip. ( Lower ) Eighteen months
after open rhinoplasty, central dorsum realignment
using external low lateral percutaneous osteotomies,
dorsal augmentation with multilayered bruised and
crushed septal cartilage grafts, and nasal tip plasty
using the OFF technique. The nasal dorsum is mark-
edly straight and augmented and the nasal tip is clearly
projected

924
H.A. Mayaleh
Case 3 (Fig. 65.5 )
A 26-year-old man presented with post-traumatic
dorsum and septum deviation, plus poor nasal tip
rotation and projection. The operative plan was as
follows: open rhinoplasty, 1-mm septum caudal
reduction, septal harvest leaving a 10-mm dorsal
and caudal L-strut, OFF technique, low lateral
intranasal osteotomies, and dorsum bruised graft.
Six months post-operative, the dorsum is mark-
edly straight and augmented. Signi fi cant nasal tip
rotation and projection has been obtained.
Fig. 65.5 ( Upper ) Preoperative 26-year-old man pre-
sented with post-traumatic dorsum and septum deviation,
plus poor nasal tip rotation and projection. ( Lower ) Six
months post-operative following open rhinoplasty, 1-mm
septum caudal reduction, septal harvest leaving a 10-mm
dorsal and caudal L-strut, OFF technique, low lateral
intranasal osteotomies, and dorsum bruised graft. The
dorsum is markedly straight and augmented and signi fi cant
nasal tip rotation and projection has been obtained

925
65 The Onlay Folded Flap (OFF) for Nasal Tip Surgery
Case 4 (Fig. 65.6 )
A 28-year-old man presented with post-traumatic
dorsum and septum deviation, excessive thick
skin, broad nose, and dorsal hump. The nasal tip
was deviated, plunging, under-projected, ill
de fi ned, and inadequately supported. The patient
had short columella, decreased columellar-labial
angle, and widened alar bases. The operative plan
was as follows: open rhinoplasty, 5-mm dorsal
reduction, 2-mm septum caudal reduction, septal
harvest leaving a 10-mm dorsal and caudal
L-strut, columellar strut, OFF technique, low lat-
eral intranasal osteotomies, and fi nally, 4-mm
alar base resections. Six months post-operative, a
reinforced, projected, symmetric, and re fi ned tri-
angular nasal tip has been obtained. A straight
dorsum, lengthened columella, increased nasola-
bial angle, and improved alar contour can be
observed.
Fig. 65.6 ( Upper ) Preoperative 28-year-old male pre-
sented with post-traumatic dorsum and septum deviation,
excessive thick skin, broad nose, and dorsal hump. The
nasal tip was deviated, plunging, under-projected, ill
de fi ned, and inadequately supported. The patient had
short columella, a decreased columellar-labial angle, and
widened alar bases. ( Lower ) Six months post-operative
following open rhinoplasty, 5-mm dorsal reduction, 2-mm
septum caudal reduction, septal harvest leaving a 10-mm
dorsal and caudal L-strut, columellar strut, OFF tech-
nique, low lateral intranasal osteotomies, and fi nally,
4-mm alar base resections. There is a reinforced, pro-
jected, symmetric, and re fi ned triangular nasal tip that has
been obtained. A straight dorsum, lengthened columella,
increased nasolabial angle, and improved alar contour can
be observed

926
H.A. Mayaleh
65.3
Discussion
Nasal tip projection is essential for good nasal
aesthetics and important for the best appearance.
Various methods and many types of autogenous
implants have been described to improve it.
Autogenous onlay cartilage grafts have been used
in the nose since fi rst reported by Von Mangoldt
in 1900 [ 9 ] . The single or double onlay graft [ 10 ] ,
and the cap graft [ 11 ] , may be used to increase
nasal tip projection. Autogenous cartilaginous
hump, septal cartilage, and the cephalic portions
of the lateral crura could easily be obtained and
shaped to represent the combined domes of the
lower lateral cartilages. The conchal cartilage can
be also used; it has a high resemblance to the
shape and substance of alar cartilages. But its use
requires a donor site, which increases donor site
morbidity and lengthens the operating time [ 10 ] .
These grafts have certain potential problems
including resorption, malposition, distortion,
asymmetries, or palpability by the patient [ 12 ] .
In 1966, Anderson used a columellar cartilage
strut for nasal tip projection [ 13 ] . The disadvan-
tage of this technique is that it may cause obvious
pointing in the nasal tip. In addition, if the strut is
too long and the tension is too great, the strut may
perforate the skin of the nasal tip. In 1975, Sheen
presented his triangular nasal tip graft to increase
nasal tip projection [ 14, 15 ] . This graft can lead
to palpable and visible tip deformities and can
give the nasal tip a surgical look [ 16 ] . The trans-
domal suture [ 17 ] or alar cartilage scoring [ 18 ]
often result in a stiff, pinched, or unnatural
appearance in the nasal tip by either adding bulk
to an immature lobule or destroying natural soft
triangles. The interrupted alar techniques such as
Ponti’s butter fl y or Coldman’s classic method do
not preserve the integrity of the lobular cartilage
complex [ 19 ] .
Although arti fi cial materials, such as silicone
implants, are easy to use [ 20 ] , they are costly and
give patients the sensation of a foreign body. In
addition, they have been associated with serious
side effects such as infection and protrusion
through the skin [ 21 ] .
In 1998, Garcia-Velasco [ 22 ] described two
cartilage fl aps taken from the lateral crura and
rotated them over the original domes in one layer
to increase the length of the middle crura for
more tip projection. But the top of the fl aps does
not correspond to the horizontal position over the
domes, so these fl aps increase the risk of supratip
swelling complications.
In the last 3 years, the author has been devel-
oping the onlay folded fl ap (OFF).
The OFF technique is indicated:
For reshaping, re fi ning, and supporting the
•
nasal tip
For increasing nasal tip projection from 3 to
•
5 mm maximum, depending on fl ap fl exibility
(there is greater projection when there is less
OFF suppleness) (Fig. 65.7 )
Only in cases of primary rhinoplasty because
•
it needs intact lower lateral cartilages
Only in people with a normal or thick skin
•
It is contraindicated:
When there is insuf fi cient width in the lateral
•
crura, as using the OFF technique weakens the
lobular cartilage complex.
When the skin is thin. Care should be taken
•
when using the OFF technique because it
might lead to a very strong and noticeable tip.
Advantages of OFF technique:
The OFF technique maintains a more natural
•
appearance for the nasal tip because it simulates
the nasal domes, and its middle part follows the
interdomal segment while maintaining the con-
tinuity of the underling lobular cartilages.
The height of the OFF is decreased from front
•
to back, so its distal portion gives more tip pro-
jection because it is more elevated than its
proximal portion. In addition, the top of the
OFF (the distal portion of the OFF) corresponds
to the horizontal position over the domes, so
there is no risk of supra tip swelling.
There is no need for a cartilage graft from
•
another donor site, so we can avoid the risk of

927
65 The Onlay Folded Flap (OFF) for Nasal Tip Surgery
donor site deformity and preserve donor site
cartilage for possible surgery in the future.
The OFF is not rigid, so patients do not com-
•
plain of discomfort when touching it, unlike
cartilage grafts.
The fl ap cannot be resorbed in comparison
•
with cartilage grafts.
The OFF is more resistant to malposition
•
distortion and more stable than cartilage grafts.
The symmetry of the nasal tip is preserved.
OFF technique disadvantages:
The open approach must be used to carry out
•
this technique.
The risk of a columella scar in dark-skinned
•
people is high.
Finally, both the chin and the nose must be
taken into consideration in order to obtain a pleas-
ing and harmonious facial pro fi le [ 23 ] . Chin aug-
mentation will sometimes have to be performed
to compensate for the nasal tip projection
achieved using the OFF technique and to improve
the nose-chin relationship (Figs. 65.7 and 65.8 ).
Conclusions
The OFF technique is another alternative for
achieving tip re fi nement and projection by
remodelling the existing cephalic portions of
the alar cartilages rather than cancelling them.
It has many advantages and good post-opera-
tive results. It is effective and almost compli-
cation-free. This technique is recommended in
cases of primary rhinoplasty only in people
with a normal or thick skin for wrapping the
domes in two layers to form new, increased,
and projected domal segments and to reshape,
support, and re fi ne the nasal tip.
Fig. 65.7 OFF height: ( a ) Case 1: 4 mm. ( b ) Case 2: 3 mm. ( c ) Case 3: 3 mm. ( d ) Case 4: 3 mm. ( e ) Case 5: 3 mm. ( f )
Case 6: 5 mm

928
H.A. Mayaleh
References
1. Jang TY, Choi YS, Jung YG, Kim KT, Kim KS, Choi
JS (2007) Effect of the nasal tip surgery on asian noses
using the transdomal suture technique. Aesthetic Plast
Surg 31(2):174–178
2. Chait L, Ritz M (1991) A new approach for the
re fi nement of the very broad nasal tip. Br J Plast Surg
44(8):572–574
3. Erdo an B, Ayan M, Görgü M, Deren O (2002)
Umbrella graft of columella tip: 20 years’ experience.
Aesthetic Plast Surg 26(3):167–171
4. Sadeghi M, Saedi B, Arvin Sazegar A, Amiri M (2009)
The role of columellar struts to gain and maintain tip
projection and rotation: A randomized blinded trial.
Am J Rhinol Allergy 23(6):47–50
5. Lee KC, Kwon YS, Park JM, Kim SK, Park SH, Kim
JH (2004) Nasal tip plasty using various techniques in
rhinoplasty. Aesthetic Plast Surg 28(6):445–455
6. Jones ME, Westreich RW, Lawson W (2008)
Augmentation of nasal tip projection using the inferior
turbinate: review of technique and evaluation of long-
term success. Arch Facial Plast Surg 10(1):34–37
7. Beekhuis GJ (1982) Silastic alar-columellar prosthe-
sis in conjunction with rhinoplasty. Arch Otolaryngol
108(7):429–432
8. Abou Mayaleh H (2011) The onlay folded fl ap (OFF):
a new technique for nasal tip surgery. Aesthetic Plast
Surg 35(1):73–79
9. Von Mangoldt F (1970) Reconstruction of the saddle
nose by cartilage overlay. Plast Reconstr Surg 46(5):
498–501
10. Peck GC (1983) The onlay graft for nasal tip projec-
tion. Plast Reconstr Surg 71(1):27–39
11. Rohrich RJ, Deuber MA (2002) Nasal tip re fi nement
in primary rhinoplasty: the cephalic trim cap graft.
Aesthet Surg J 22(1):39–45
12. Foman S, Goldman IB, Neivert H, Schattner A (1951)
Management of deformities of the lower cartilaginous
vault. Arch Otolaryngol 54(5):467–472
13. Anderson JR (1966) New approach to rhinoplasty. Trans
Am Acad Ophthalmol Otolaryngol 70(2): 183–192
14. Kamer FK, Churukian MM (1984) Shield graft for the
nasal tip. Arch Otolaryngol 110(9):608–610
15. Sheen JH (1975) Achieving more nasal tip projection
by use of a small autogenous vomer or septal cartilage
graft. Plast Reconstr Surg 56(1):35–40
Fig. 65.8 ( a , c , e , g , i , k ) Preoperative. ( b , d , f , h , j , l ) Post-operative

929
65 The Onlay Folded Flap (OFF) for Nasal Tip Surgery
16. Sheen JH (1993) A 20-year retrospective. Plast
Reconstr Surg 91(1):48–63
17. McCollough ET, English JL (1985) A new twist in
nasal tip surgery: an alternative to the Goldman tip for
wide or bulbous lobule. Arch Otolaryngol 111(8):
524–529
18. Lipsett EM (1959) A new approach to surgery of the
lower cartilaginous vault. Arch Otolaryngol 70(1):
42–47
19. Micheli-Pellegrini V, Ponti L, Ponti G, Guidarelli P
(1996) Interrupted and continuous strip technique for
tip surgery during traditional rhinoplasty. Facial Plast
Surg 12(4):347–355
20. Hong-Ryul J, Tae-Bin W (2009) Nasal tip augmenta-
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Head Neck Surg 140(4):526–530
21. Papadopulos A, Harada C (1987) Compound implant
to project the nasal tip. Aesthetic Plast Surg 11(3):
181–185
22. Garcia-Velasco J, Vidal JT, Garcia-Casas S (1998)
Increasing the length of the middle crura for better tip
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Surg 22(4):253–258
23. Millard DR (1965) Adjuncts in augmentation mento-
plasty and corrective rhinoplasty. Plast Reconstr Surg
36:48–461

Part VII
Complications

933
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_66, © Springer-Verlag Berlin Heidelberg 2013
66
66.1
Introduction
Rhinoplasty is still considered one of the most
dif fi cult cosmetic operative procedures performed
today. Technological advances in materials and
surgical techniques have simpli fi ed and reduced
complications in many aesthetic procedures. But
rhinoplasty continues to present challenges to the
aesthetic surgeon and patient alike. The nose, at
the center of the human face, is plain for all to see
and critique. The successful rhinoplasty must pro-
duce a pleasing result to the eye and still maintain
proper function. Unfortunately, “pleasing to the
eye” can be dif fi cult to de fi ne. What is pleasing to
the surgeon’s eye may not be to the patient. Even
more importantly, it may not be pleasing to the
patient’s friends. Aesthetics combines an artistic
judgment in fl uenced by current trends, fashion,
and cultural and ethnic preferences. It is, thus,
highly subjective. It is imperative that the preop-
erative consultation involves a frank and honest
discussion of the goals of surgery as well as the
limitations. Only then will the doctor and patient
have similar expectations for the result.
Rhinoplasty requires a three-dimensional mani-
pulation of various tissues often performed with
limited access. Results in rhinoplasty can be
dependent on the doctor’s surgical skill as well
as variations in the patient’s skin thickness, sub-
cutaneous tissue, cartilage, bone, and mucous
membranes. Previous surgery may have dramati-
cally altered the patients’ response to additional
surgical interventions. The surgeon must develop
an effective method to reliably and predictably
alter and sculpture the elements of the nose.
Typically, a graduated or systematic process
should be developed to produce the desired result
based on the existing anatomy of the patient.
Typically, the least amount of manipulation that
can produce the desired result is utilized. There
is no standard rhinoplasty operation because the
underlying anatomy of each patient is unique.
Therefore, the surgeon must develop the ability to
not only analyze the anatomic relationships of
the nasal structures but also develop techniques
to adequately alter these structures for each
patient’s anatomy. No single incision, approach,
or manipulation of the tissues can be used in
every case. Through years of experience and
meticulous record keeping, the surgeon can
develop predictable and reliable results which
will minimize the need for revision surgery. The
fi nal result of surgery is a combination of the
surgical manipulation of the tissues as well as
the healing responses of multiple different tissue
types. Few other cosmetic procedures involve
the healing of bone, cartilage, skin, muscle, and
soft tissue. This is further complicated because
the fi nal result is often not visualized until years
after the procedure is performed. A result that
Complications of Rhinoplasty
Brian C. Harsha
B. C. Harsha , DDS, M.D.
Coastal Facial Aesthetic & Laser Surgery ,
708 21st Avenue North , Myrtle Beach,
SC 29577-7400 , USA
e-mail: bharsha@sc.rr.com

934
B.C. Harsha
looks perfect 1 week postoperatively may appear
overly operated several years later.
The literature reports an incidence of postop-
erative rhinoplasty complications ranging from
5% to 28% [ 1– 4 ] . Minor irregularities may only
be appreciated by the surgeon and not require
reoperation. On the other hand, perfectly accept-
able results in the eyes of the surgeon may be
viewed as a failure to the patient.
Many factors may in fl uence the fi nal outcome
in rhinoplasty. Skin thickness can be both a bless-
ing and a curse. Patients with thick skin can
undergo extensive alterations to the underlying
cartilaginous and bony structures without fear of
the appearance of minor irregularities. Unfortu-
nately, the thicker skin will not redrape as well,
and it may not be possible to produce a re fi ned
nose. Conversely, thin skin can easily display the
surgeons’ skill for manipulation of the underly-
ing tissues. Unfortunately, minor irregularities
in the shape and symmetry of the underlying tis-
sues will also be easily visible. Patients over the
age of 40 have their own unique anatomical con-
siderations. The elderly patient’s skin becomes
in creasingly inelastic and therefore less able to
redrape properly postsurgically. The cartilage
may be calci fi ed, and the bones of the nose and
septum tend to be more brittle. Finally, a decrease
in vascularity of the tissues may also affect the
surgical outcome.
Generally, complications in rhinoplasty can be
divided into three categories. Complications can
occur intraoperatively, early postoperatively, or
manifest themselves in the late postoperative
period. Intraoperative complications can be a
result of errors in technique or judgment. These
include injuries to the soft tissue, cartilage, or
bone. Early postoperative complications can
include hemorrhage, hematoma, infection, perios-
titis, edema, ecchymosis, skin problems, and sep-
tal perforations. Many of these complications in
rhinoplasty can be avoided by meticulous atten-
tion to detail during the operative procedure. This
is perhaps most important at the end of the opera-
tive procedure. A fi nal check of the surgical result
prior to suturing and splinting is mandatory. The
bony and cartilaginous dorsum should be inspected
for small spicules of bone or cartilage and minor
irregularities. Rubbing a moistened fi nger over
the dorsum can help identify any areas that need
fi nal adjustment. The skin envelope is examined
to make sure no small pieces of debris remain that
could contribute to infection or visible irregulari-
ties. Wound edges are then gently approximated
to provide ideal healing. Taping and splinting are
utilized to stabilize and maintain surgical manip-
ulations.
Late complications generally involve abnor-
malities of the nasal tip, cartilaginous vault, and
bony vault. They usually involve either over- or
underresection or asymmetrical resection of the
involved tissues. These complications may occur
because of a failure to understand the conse-
quences of surgical manipulation of the tissues or
as a result of the idiosyncrasies of the various
anatomical tissues’ healing.
66.2
Intraoperative Complications
Rhinoplasty involves the delicate manipulation
of soft tissue, cartilage, and bone. It is possible
during the operative procedure to produce unin-
tended results to any of these tissues.
66.2.1 Soft Tissue Injuries
It is possible to produce a laceration of the skin
during the undermining process. The skin is thin
and adherent to the underlying cartilage in the
dome region. Previous surgery may also alter the
quality of skin and eliminate natural planes of dis-
section. If a perforation of the skin envelope
occurs, it must be repaired in a meticulous fashion.
Eversion of the wound edges is especially impor-
tant. Additional procedures such as dermabrasion
or laser resurfacing may be necessary down the
road to produce an acceptable result. Proper utili-
zation of the surgeon’s nondominant hand to
ensure the dissection forces are applied in the
proper orientation can minimize this complication
(Figs. 66.1 and 66.2 ).
Cautery burns or tears to the mucoperichon-
drial fl aps may also occur. The need for cautery
can be minimized by maintaining the proper
surgical plane. Dissection along the plane closest
to the cartilage and bone will produce the least

935
66 Complications of Rhinoplasty
hemorrhage. Tears of the mucoperichondrial fl aps
can be minimized by meticulous technique.
Previously operated or traumatized noses may
make some tears unavoidable. Small, unilateral
tears will usually heal by themselves. Bilateral
tears of the same area are usually best repaired.
Rarely, visual disturbances or even blindness
have been reported during the injection of local
anesthesia or augmentation materials [ 5 ] . Aspi-
ration to ensure nonvascular injections is always
advisable.
66.2.2 Bone and Cartilage Injuries
The upper lateral cartilages attach to the under-
neath surfaces of the nasal bones. Overly aggres-
sive manipulation or rasping of the cartilages can
result in an avulsion of this attachment. Collapse
of the middle third of the nasal vault can occur if
the upper lateral cartilages are not properly sup-
ported. Proper orientation of the Rubin osteotome
is important intraoperatively to ensure the proper
amount of bony hump removal (Fig. 66.3 ). It is
also important that the osteotomies of the nasal
bones are performed properly. The lateral osteot-
omies of the nasal bone should be performed low
enough on the face to avoid producing a step
deformity above the nasofacial groove. The
medial nasal osteotomy can sometime fracture in
such a manner as to produce a “rocker” defor-
mity. If the nasal bone fractures higher up in the
Fig. 66.1 ( a ) The thin skin of the nasal tip has been perforated. ( b ) Six weeks postoperatively, the scar is minimal
Fig. 66.2 The surgeon’s nondominant hand is important
to feel the proper orientation of the dissection to prevent
button holing of the skin
Fig. 66.3 Proper orientation of the Rubin osteotome is
essential. The tendency is for the osteotome to dive too
deep into the nasal bones

936
B.C. Harsha
thicker portion of the nasofrontal junction, a ful-
crum might exist. When the lower portion of the
nasal bone is displaced medially to close the open
roof, the superior portion will rock laterally. This
can be recti fi ed by performing an additional
medial nasal osteotomy in a more caudal direc-
tion. Care must be taken when performing nasal
osteotomies to minimize the chance of injuries to
the nasolacrimal apparatus [ 6 ] .
66.3
Early Postoperative
Complications
66.3.1 Hemorrhage
Hemorrhage or epistaxis usually occurs during
the fi rst 48 h or at 10–14 days postoperatively.
Preoperatively, patients must be screened for any
medications that may interfere with normal clot-
ting or make the patient prone to bleeding post-
operatively. Aspirin and salicylates are generally
discontinued 10–14 days prior to surgery. Patients
should be speci fi cally asked about herbal medi-
cations as they often do not consider these as
“real medicine.” Rhinoplasty patients should
generally be normotensive pre- and postopera-
tively. Bleeding may be encountered from raw
edges of the cartilaginous incisions. Bleeding is
most likely to occur at the trans fi xion incision or
anterior septal mucosal incisions. Proper closure
of these incisions at the time of surgery will mini-
mize this complication. Surgery performed in the
correct surgical plane will also lessen the inci-
dence of hemorrhage. The patient is also informed
to minimize physical activity in the early postop-
erative period. Exertion, bending over, or valsalva
maneuvers are discouraged.
The second most common time for postopera-
tive bleeding occurs from the 10th to the 14th
day. This is most likely the result of separation of
the maturing clot from the incision. If the bleed-
ing occurs from the anterior nose, the exact point
should be identi fi ed and treated under direct
vision. Severe bleeding may require anterior and
posterior nasal packs. Persistent bleeding may
rarely require hospitalization and treatment in the
operating room.
66.3.2 Hematoma
Bleeding underneath the skin fl ap may cause dis-
placement and distortion of the nasal tissues.
Thick amounts of clotted blood underneath the
skin can produce excessive scar tissue and dis-
ruption of the normal healing mechanisms.
Hematomas of the dorsal skin can also be pro-
duced during removal of the cast. Great care
should be taken to adequately loosen any plaster
or tape from the skin prior to its removal. Mild
soap or orange solvent applied to cotton applica-
tors can be used to soften plaster and Steri-Strips.
Septal hematomas can lead to nasal obstruction
and septal perforations, if not treated promptly.
Patients undergoing submucous resection or
other septal procedures typically have a light
nasal packing placed to aid in hemostasis
(Fig. 66.4 ). Careful inspection of these areas for
a hematoma is mandatory. A mattress or quilting
type of suture can be performed on the septum to
Fig. 66.4 Light septal packs are typically utilized when a
septoplasty is performed

937
66 Complications of Rhinoplasty
close dead space and lessen the chances of hema-
toma formation.
66.3.3 Infection
Infection after rhinoplasty is generally much
less common than might be anticipated.
Rhinoplasty is generally performed after a nasal
prep but is considered an unsterile operation.
Antibiotics are typically utilized in the periop-
erative period. Typically, a broad-spectrum
cephalosporin can be used for antibiotic pro-
phylaxis. Small localized abscesses can occur
along the incision lines or in areas where surgi-
cal debris has collected. These can be treated
with incision and drainage along with the appro-
priate antibiotics. Typically, these infections are
a result of Staphylococcus aureus or in rare
instances, a Pseudomonas infection. A minor
low-grade infection may occur along the osteot-
omy sites as a result of bone dust left behind.
Pain, swelling, and erythema may be present.
Initial treatment consists of antibiotic therapy.
If the infection persist, drainage of the area and
removal of any debris or sequestrum may be
necessary. Infections may be more common
when
utilizing
synthetic
graft
materials.
Generally, the open approach to rhinoplasty is
recommended when placing nonautogenous
materials. Patients who have undergone multi-
ple previous procedures may also be more sus-
ceptible to infection as a result of a decrease in
blood supply to the tissues.
Toxic shock syndrome has been reported in
cases of nasal packing [ 7 ] . Necrotizing perior-
bital cellulitis has also been reported [ 8 ] . The
close proximity of the cavernous sinus makes
basal meningitis possible, although fortunately a
rare occurrence [ 9 ] .
66.3.4 Edema and Ecchymosis
Swelling following rhinoplasty is an expected
result and therefore not a true complication.
However, there is a great variation in the amount
of swelling among patients. Some surgeons believe
the utilization of perioperative glucocorticoid
steroids is bene fi cial in the reduction of edema.
De fi nitive clinical studies have yet to be pro-
duced. For most patients, it takes 6–12 months
before most of the swelling in the nasal tip and
nasal dorsum have resolved and the fi nal result is
visualized. Small changes in the nasal tip may be
seen as late as 2 years postoperatively. If the
occurrence of a super tip prominence is felt to be
persistent swelling, injection of steroids into the
pollybeak may be helpful.
Patients who undergo lateral osteotomies are
at risk of periorbital ecchymosis. This may last
for 2–4 weeks after surgery. The use of a smaller
unguarded osteotome may lower the occurrence
of this complication [ 10, 11 ] .
66.3.5 Skin Abnormalities
Minor skin reactions to the tape and splint may
result in skin in fl ammation. Patients with oily
skin may develop pustules. These generally
resolve once the offending agent is removed.
Occasionally, new spider veins or telangiectasias
may develop. Excessive use of steroid injections
to resolve postoperative edema may make this
occurrence more common.
Skin necrosis may occur over the nasal dor-
sum or the nasal tip. Overly aggressive thinning
of the nasal tip or excessive use of the cautery can
cause this complication. Necrosis of the skin of
the dorsum is most likely a result of excessive
pressure from the splint. If open rhinoplasty is
performed simultaneously with excessive nasal
lobule narrowing, vascular compromise of the
nasal tip skin is possible. Weir procedures should
be delayed to a secondary surgery if this is a
concern.
Poor scars from the external approach are also
possible. Generally, the transcolumellar incision
heals with an imperceptible scar. Occasionally, as
a result of inadequate reapproximation or poor
healing, a more obvious scar may develop. Great
care should be taken not to infringe on the soft
tissue facets of the nasal rim when any marginal
rim incision is made. Soft tissue notching can
result (Fig. 66.5 ).

938
B.C. Harsha
66.3.6 Septal Perforations
Septal hematomas that are not properly drained
may lead to septal perforations. Other causes of
perforations include infection, pressure necrosis,
and symmetrical septal mucosal tears. Small per-
forations may heal suf fi ciently by wound contrac-
ture. It is important to keep the area clean with
hydrogen peroxide and antibiotic ointment. Larger
perforations can be extremely dif fi cult to close and
may require the elevation of large septal fl aps.
66.4
Late Complications
66.4.1 Nasal Tip
The nasal tip may be the area that requires the
most revision in rhinoplasty surgery. Compli-
cations may result from over- or underreduction
of the tip as well as asymmetrical resection.
Rhinoplasty is a compromise, and the most con-
servative surgery that accomplishes the desired
result is typically the best. To produce an attrac-
tive tip, it is usually essential to understand and
maintain the support mechanisms of the nasal tip.
Support mechanisms have generally been divided
into two categories, major and minor. Major sup-
port mechanisms generally include (1) the medial
and lateral crura, (2) the medial crural footplate
attachment to the caudal margin of the septal
cartilage, and (3) the attachment of the upper lat-
eral cartilage to the lower lateral cartilage. There
are also several minor nasal tip support mecha-
nisms: (1) the connective tissue between the
domes of the lower lateral cartilages, (2) the car-
tilaginous septal dorsum, (3) the connective tis-
sue complex from the lateral crura to the pyriform
aperture, (4) the attachment of the lower lateral
cartilages to the overlying skin, (5) the nasal
spine, and (6) the membranous septum. Failure to
preserve or reconstitute the tip support mecha-
nism may lead to loss of vital tip support.
66.4.2 Over Reduction of the Nasal Tip
Over resection of the lateral crus is perhaps the
most common problem seen after rhinoplasty
[ 12 ] . Overreduction of the lateral crus may lead
to the predictable changes of alar retraction,
pinching, bossing, and tip asymmetry. Not only
does overly aggressive nasal tip surgery results in
an increase in postoperative complications, it can
also lead to functional disorders of the nose as
well [ 13 ] . Many complications of nasal tip sur-
gery arise from the operator’s desire to accom-
plish more than what is possible with the nasal tip
tissues. Thick oily skin with sebaceous glands
can lead to overzealous resection of the cartilagi-
nous tip elements in an effort to produce
re fi nement. If too many of the tip-supporting
mechanisms are interrupted during the surgical
procedure and not reconstituted, the tip may set-
tle postoperatively. In these cases, many of the
major and minor tip support mechanisms should
be maintained and consideration made toward
augmenting tip support.
Surgical repair of the overly resected tip may
require autogenous cartilage grafts to replace
missing tissue. In some cases, it may appear that
adequate lateral crura remained but that second-
ary scar contracture overpowered the rim carti-
lage. Generally, it is wise to leave it at least
6–9 mm of the lateral crus behind. Thin-skinned
individuals who possess large fi rm and thick
alar cartilages may undergo buckling of these
cartilages months or even years after the initial
operation. It is important to take a conservative
Fig. 66.5 Notching of the left nostril is produced by
encroachment of the marginal rim incision on the soft tri-
angle of the nostril

939
66 Complications of Rhinoplasty
approach when performing the cephalic resec-
tion of the lower lateral cartilage. Knuckling or
bossae formation may also occur when inter-
rupted strip techniques are utilized in thin-
skinned individuals. Nasal tip onlay grafts and
supportive columellar struts may improve pro-
jection in minor cases.
If severe alar retraction occurs or the ala col-
lapses on inspiration, it may be repaired with the
use of alar batten grafts [ 14 ] . Severe cases may
require auricular composite grafts [ 15 ] . Composite
grafts can replace the missing volume and pro-
vided support to hold the nostril rim in a more
anatomic position. Nasal obstruction may also
occur if there is prolapse of the upper or lower
lateral cartilages into the nasal valve region.
Collapse of the upper lateral cartilage is usually
treated with the placement of a spreader graft
secured between the dorsal septum and the upper
lateral cartilages.
66.4.3 Underresection of the Nasal Tip
Underreduction of the nasal tip structures is usu-
ally a result of inadequate attempts to produce
nasal re fi nement [ 16 ] . Inadequate reduction of
the tip structures is preferable, however, to overly
aggressive treatment. Inadequate reduction rarely
causes functional disorders that overly aggressive
surgery may cause. Furthermore, because addi-
tional tip re fi nement is required, these complica-
tions are generally easier to correct than those
associated with overly aggressive treatment.
Repair of these complications usually requires
exposure and delivery of the lower lateral carti-
lage. The repair is performed with the most con-
servative procedure that will produce the desired
result. If possible, complete strip techniques are
preferable (Fig. 66.6 ). Complete strip techniques
have the following advantages: (1) preservation
of tip support and projection, (2) resistance to
rotation, (3) resistance to tip retrodisplacement,
(4) prevention of alar retraction, (5) symmetrical
healing, and (6) safety and predictability [ 17 ] .
Interrupted strip techniques are generally reserved
for patients who require maximal tip rotation,
re fi nement, or decrease projection and who have
thick skin.
Underreduction of the nasal tip may be a result
of inadequate volume reduction. This is usually
caused by an inadequate or unequal re fi nement of
Fig. 66.6 ( a ) Preoperative.
( b ) Postoperative after a
complete strip technique.
Adequate tip rotation and
re fi nement was obtained

940
B.C. Harsha
the alar cartilages. This may be caused by leaving
alar cartilages behind that remain too broad.
Correction would involve re fi nement of the alar
cartilages through a delivery approach result-
ing in narrowing of the residual alar cartilage re -
mnants.
Underresection of the nasal tip may also result
in a boxy tip. In this case, the initial procedure
has failed to attenuate the broad arch and spring
of the alar cartilage. Again, it is best to perform a
stepwise correction of these deformities. The
most conservative procedure that produces the
desired effect is employed. Interdomal suturing,
transdomal suturing, or strip interruption tech-
niques may be necessary to weaken the spring of
the lower lateral cartilage.
Underresection of an overly projected tip may
also require additional correction. If the nasal tip
remains overprojected after the initial surgery,
repair may involve intentional disruption of the
tip support mechanisms. This may allow poste-
rior retrodisplacement of the tip. Again, a gradu-
ated approach can be utilized until the proper
amount of retrodisplacement is performed.
Retrodisplacement can be encouraged by (1)
complete trans fi xion incision, (2) interruption and
Fig. 66.7 ( a ) Preoperative.
( b ) Postoperative following
an interrupted strip technique
utilized for maximal tip
retrodisplacement. The lateral
crura were divided, a portion
excised and then
reconstituted

941
66 Complications of Rhinoplasty
repair of the medial crura, (3) interruption and re -
pair of the lateral crura, and (4) dissection and
reduction of the anterior nasal spine (Fig. 66.7 ).
Inadequate nasal tip reduction may also result
in failure to rotate the nasal tip. Loss of tip sup-
port can lead to tip ptosis and the appearance of
an elongated nose. Failure to adequately rotate
the tip will require additional surgical procedures
to produce tip rotation. Procedures that pro-
duced tip rotation include shortening of the cau-
dal septum, columellar struts, augmentation of
the nasal labial angle, or resection of a triangular
piece of cartilaginous septum through a high
trans fi xion incision.
Finally, an excessively wide alar fl air may
exist postoperatively. This is most common fol-
lowing intentional reduction of an overprojected
tip. Correction includes alar base reduction. The
shape of the nostril width is reduced by excision
of a portion of the nostril fl oor and sill.
66.4.4 Cartilaginous Vault
Over reduction of the cartilaginous vault can
result in a saddle deformity of the nasal dorsum
and produce a poor supratip relationship. Careful
evaluation during the initial surgery may lessen
the chances of this deformity. If the surgeon notes
excessive cartilage has been removed during the
operative procedure, it is best to replace a portion
of the excised cartilage as an onlay graft. If revi-
sion surgery is required, autogenous cartilage can
be used for the repair of larger defects. Small
defects may be corrected with alloplastic materi-
als if they can be placed in a surgically sterile
pocket. It is important to leave an adequate strut
of cartilaginous septum in order to prevent the
postoperative collapse of the nasal vault. If sub-
mucous resection of the cartilaginous septum is
necessary, the surgeon must also allow for dorsal
hump resection. An adequate L-shaped strut of
cartilage, usually at least 1 cm, must remain for
nasal support after both procedures.
Underreduction of the cartilaginous vault may
produce a persistent dorsal hump or a pollybeak
deformity [ 18 ] . Again, careful evaluation of the
nasal tip as it relates to the cartilaginous and bony
dorsum at the time of the original surgery can
minimize these problems. Occasionally, polly-
beak deformities may develop over time, if the tip
becomes more ptotic postoperatively. It is impor-
tant to maintain adequate tip support mechanisms
during the surgical procedure to prevent postop-
erative loss of tip projection. Typically, the nasal
tip will settle slightly postoperatively, so the sur-
geon must ensure adequate cartilaginous hump
removal during the initial procedure (Fig. 66.8 ).
The pollybeak deformity may also be relative to
overresection of the bony dorsum. Treatment of
the pollybeak deformity is dependent on the
actual cause. If the pollybeak deformity is a result
of inadequate cartilaginous hump removal, then
additional hump resection may be necessary. If
the pollybeak deformity is a result of tip ptosis,
the insertion of a columellar strut may be
bene fi cial. If the bony hump was overresected,
then augmentation to the bony dorsum may be
Fig. 66.8 A slight pollybeak remains as a result of inad-
equate reduction of the dorsal cartilage

942
B.C. Harsha
necessary. Finally, occasionally, the pollybeak
deformity may be a result of excessive scar for-
mation. If the dead space of the supratip area is
not stabilized by proper splinting, then postoper-
ative fl uid accumulation may occur, resulting in
excessive fi brosis and scarring. The subcutane-
ous injection of triamcinolone may be helpful in
these cases.
Cartilaginous vault abnormalities may also
arise from the upper lateral cartilages. If there is
inadequate support of the upper lateral cartilages
after dorsal hump removal, they may collapse
and produce an inverted-V deformity [ 19 ] . The
nasal mucoperichondrium can provide signi fi cant
support to the upper lateral cartilages and may
help decrease the risk of collapse of the upper lat-
eral cartilages after hump excision. It is also pos-
sible to produce abnormalities of the upper lateral
cartilages by dislocating them from the undersur-
face of the nasal bones. It is important to remem-
ber the relationship of the caudal nasal bones
and the underlying upper lateral cartilages.
Ex cessive use of a bony rasp can accidentally
avulse and disarticulate the cartilage. This will
produce a visual step-off depression requiring
camou fl age.
66.4.5 The Bony Vault
Underreduction of the bony vault results in a con-
tinued dorsal hump deformity postoperatively.
Typically, a stronger dorsal pro fi le is preferable
to an overreduced nasal pro fi le. If additional sur-
gery is required, it is much easier to correct the
underreduction, than repair an overreduction.
Depending on the amount of additional reduction
required, simple rasping of the dorsal hump may
be suf fi cient in lowering the hump to its desired
position. If a more extensive removal is required,
then lateral osteotomies may be required to prop-
erly narrow the nose and prevent an open roof
deformity.
Over reduction of the bony dorsum will result
in a saddle deformity (Fig. 66.9 ). The overreduc-
tion may also involve the cartilaginous portion of
the nasal dorsum as well. Surgical correction
requires onlay grafting with autogenous cartilage.
If autogenous material is not available, synthetic
material can be used cautiously [ 20 ] . It is impor-
tant to prepare a precise pocket in the nasal dor-
sum when correcting these deformities. An overly
large pocket will invite shifting and displacement
of the graft material. The pocket should be devel-
oped to allow for the thickest possible soft tissue
covering over the graft. This will lessen the likeli-
hood of smaller irregularities being visible through
the dorsal skin.
There may also be asymmetrical abnormali-
ties of the bony vault. Uneven osteotomies,
asymmetrical hump removal, rocker deformities,
and persistent bony ridges may become apparent
postoperatively. During surgery if the bony hump
is removed with an osteotome, it should be
inspected to ensure an even amount of bone
removal. Rocker deformities may occur if the
Fig. 66.9 A saddle deformity has occurred as a result of
excessive loss of the bony and cartilaginous dorsum

943
66 Complications of Rhinoplasty
lateral nasal osteotomies are taken too high into
the thick frontal bone. The open roof deformity
results from the failure to close the space between
the lateral nasal bones after hump removal.
A cross section of the nose will appear as a trap-
ezoid instead of the more natural triangular
con fi guration. Correction of this deformity
requires closing the space between the lateral
nasal bones. If the nasal dorsum has been overre-
duced in addition to the open roof deformity, an
autogenous graft might also be necessary. If
there has been minimal hump removal, then
medial osteotomies may be needed to fully mobi-
lize the nasal bones. This will allow medial dis-
placement of the nasal bones to close the open
roof deformity.
Persistent nasal deviations may remain post-
operatively in patients. Correction of the deviated
nose presents a dif fi cult challenge. There is usu-
ally a functional problem as well as an aesthetic
concern. Abnormalities in the nasal septum are
usually a major component of the deviation and
must be adequately addressed [ 21 ] . The nasal
bone will usually require mobilization through
asymmetric osteotomies.
Abnormalities of the soft tissue envelope may
also occur. Rhinoplasty should be performed in
the proper tissue planes. Performing dissection in
too super fi cial a plane can damage the vascular
supply to the overlying skin of the nose. It also
produces a bloodier surgical fi eld, which is more
dif fi cult to operate in. If the soft tissue envelope
is damaged, it is impossible to fully repair. If the
scar retraction is severe, it can lead to a complica-
tion known as the cruci fi ed tip. There may be loss
of vestibular skin and heavy scarring of the cuta-
neous tissue, producing an amorphous tip with
severe contraction and retraction. Repair of this
deformity can be extremely dif fi cult and may
require multiple full-thickness grafts to replace
missing tissue [ 22 ] . The residual blood supply is
usually compromised, and healing will be pro-
longed and less predictable than normal.
Rarely, entrapment of the nasal mucosa can
result in the formation of mucous cyst (Fig. 66.10 )
[ 23 ] . The formation of foreign body-type reactions
has also been reported [ 24 ] . These types of cystic
formations are generally treated by excision.
Complications in cosmetic surgery can be par-
ticularly distressing to the patient. Generally
healthy patients have decided to undergo a surgi-
cal treatment so that an aesthetic improvement
might occur. Complications can adversely affect
the surgical outcome. Typically, complications
that arise from overly aggressive surgery are
more dif fi cult to treat than those caused by too
conservative a procedure. Because rhinoplasty
involves the healing dynamics of different tissue
types, there will always be an element of unpre-
dictability. It is the surgeon’s responsibility to
limit this unpredictability as much as possible.
By carefully evaluating the patient preoperatively,
a graduated systematic approach can be devel-
oped. In cosmetic surgery, the ultimate goal is to
make the patient happy. This may be accom-
plished by either producing the results the patient
desires or educating them as to why these results
are not possible. Each rhinoplasty will have its
own set of goals. The surgeon must decide
Fig. 66.10 A small dorsal nasal cyst developed along the
superior aspect of the right lateral osteotomy. The lesion
was excised

944
B.C. Harsha
whether tip projection is to be reduced, main-
tained, or enhanced. In addition, the surgeon must
decide whether it is advisable to alter the tip vol-
ume, rotation, or symmetry. Similar goals have to
be established for the treatment of the cartilagi-
nous and bony dorsum. Once the goals are estab-
lished, the surgeon must decide which incisions
will be utilized. These must provide adequate
access to allow predictable modi fi cation of the
nasal structures. Typically, years of experience
are required to thoroughly understand and master
re fi nement of the nasal tip. The fi nal result is not
visualized for many months or years after the
procedure. Through the use of long-term follow-
up and careful examination of patients, the sur-
geon will gain a better understanding of the
consequences of surgical manipulation. The use
of standardized pre- and postsurgical photographs
along with objective analysis of the results will
ultimately speed this process.
References
1. Rees TD (1980) Postoperative considerations and
complications. In: Rees TD (ed) Aesthetic plastic sur-
gery. Saunders, Philadelphia
2. Becker DG (2002) Complications in rhinoplasty. In:
Papel I (ed) Facial plastic and reconstructive surgery,
2nd edn. Thieme, New York
3. Webster
RC
(1975)
Revisional
rhinoplasty.
Otolaryngol Clin North Am 8(3):753–782
4. Busca GP, Amasio ME, Satoris A (1990) Compli-
cations of rhinoplasty. Acta Otorhinolaryngol Ital
10(31):1–37
5. Khawaja HA, Shiffman MA, Hernandez-Perez E,
Hernandez-Perez E (2010) Complications of fat trans-
fer. In: Shiffman MA, Di Giuseppe A (eds) Body con-
touring: art, science, and clinical practice. Springer,
Berlin, pp 617–625
6. Goldan O, Georgiou I, Haik J, Tessona A, Winkler E
(2008) Lacrimal fi stula 10 years after closed rhino-
plasty: case report. Aesthetic Plast Surg 32(1):153–154
7. Jacobson A, Kasworm E (1986) Toxic shock syndrome
after nasal surgery. Case reports and analysis of risk
factors. Arch Otolaryngol Head Neck Surg 112(3):
329–332
8. Moscona R, Ullmann Y, Peled I (1991) Necrotizing
periorbital cellulitis following septorhinoplasty.
Aesthetic Plast Surg 15(2):187–190
9. Holt GR, Garner ET, McLarey D (1987) Postoperative
sequelae and complications of rhinoplasty. Otolaryngol
Clin North Am 20(4):853–876
10. Tardy ME, Denneny JC (1984) Micro-osteotomes in
rhinoplasty. Facial Plast Surg 1(2):137–145
11. Erisir F, Tahamiler R (2009) Lateral osteotomies in
rhinoplasty: a safer and less traumatic method. Aesthet
Surg J 29(4):335–337
12. Becker DG, Becker SS (2006) Reducing complica-
tions in rhinoplasty. Otolaryngol Clin North Am
39(3):475–492
13. Thomas JR, Tardy ME Jr (1986) Complications of
rhinoplasty. Ear Nose Throat J 65(1):19–34
14. Toriumi DM, Josen J, Weinberger MS, Tardy ME Jr
(1997) Use of alar batten grafts for correction of nasal
valve collapse. Arch Otolaryngol Head Neck Surg
123(8):802–808
15. Tardy ME Jr, Toriumi DM (1989) Alar retraction:
composite graft correction. Facial Plast Surg 6(2):
101–107
16. Stucker FJ, Bryarly RC, Shockley WW (1984) The
failed rhinoplasty. In: Gates GA (ed) Current therapy
in otolaryngology head and neck surgery 1984–1985.
Decker, Philadelphia, pp 129–134
17. Hewell TS, Tardy ME (1984) Nasal tip re fi nement.
Facial Plast Surg 2:87–124
18. Kamer FM, McQuown SA (1988) Revision rhino-
plasty. Arch Otolaryngol Head Neck Surg 114(3):
257–266
19. Toriumi DM (1995) Management of the middle nasal
vault. Oper Tech Plast Reconstr Surg 2:16–30
20. Turgun M, Acarturk TO, Ozturk S, Sengezer M (2008)
Aesthetic and functional restoration using dorsal sad-
dle Medpor implant in secondary rhinoplasty. Ann
Plast Surg 69(6):600–603
21. Stucker FJ (1982) Management of the scoliotic nose.
Laryngoscope 92(2):128–134
22. Tardy ME, Cheng EY, Jenstrom V (1987) Misadventures
in nasal tip surgery. Otolaryngol Clin North Am
20(4):797–823
23. Harley EH, Erdman JP (1990) Dorsal nasal cyst for-
mation. Arch Otolaryngol Head Neck Surg 116(1):
105–106
24. Chang DY, Jin HR (2008) Foreign body inclusion cyst
of the nasal radix after augmentation rhinoplasty.
J Korean Med Sci 23(6):1109–1112

Part VIII
Revision Rhinoplasty

947
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_67, © Springer-Verlag Berlin Heidelberg 2013
67
67.1 Introduction
Patients seeking revision rhinoplasty have numer-
ous functional and cosmetic concerns. Revision
rhinoplasty has been studied in several articles
[ 1– 4 ] that report an incidence of 5–15%. However,
most of these studies considered only the per-
spective of the evaluating surgeon and not the
patient’s concerns. The goal of this chapter is to
systematically present the most common reasons
why patients seek revision rhinoplasty [ 5 ] .
Although objective quantitative measures and
expert technique are important to the outcome,
the subjective qualitative evaluation by the patient
ultimately determines patient satisfaction and a
successful outcome in aesthetic facial plastic sur-
gery. To optimize patient satisfaction from revi-
sion rhinoplasty, the surgeon must be keenly
aware of the functional and cosmetic de fi ciencies
that the patient considers most problematic.
Multiple studies [ 1, 2, 6, 7 ] identify and evalu-
ate objective “deformities” from the perspective of
the surgeon and subsequently discuss revision
techniques speci fi c to the recognized deformity.
These articles [ 1, 2, 6, 7 ] delineate the most com-
mon aesthetic abnormalities in multiply revised
noses to be pollybeak, depressed tip, tip contour
irregularity/asymmetry, tip bossae, overrotated tip,
acute nasolabial angle, dorsal irregularity, dorsal
saddle, open roof deformity, crooked nose, midna-
sal asymmetry, residual hump, retracted ala,
retracted columella, hanging columella, wide base,
and implant adjustment (Table 67.1 ). Although
these analyses are important, they are all retro-
spective, objective in nature, and reported from
the surgeon’s viewpoint. Thus, these studies may
not re fl ect the patient’s primary reasons for pur-
suing revision rhinoplasty.
Other authors have researched the subjective
concerns of patients after revision rhinoplasty
using popularized outcome tools. Guyuron and
Bokhar [ 8 ] assessed general patient satisfaction
after revision rhinoplasty using global assess-
ment of three broad categories: satisfaction,
breathing, and appearance. Most et al. [ 9 ] and
Alsarraf [ 10 ] designed the Rhinoplasty Outcomes
Evaluation, a validated 6-question graded instru-
ment that taps into the physical, mental, emo-
tional, and social domains of patients after
rhinoplasty surgery. Although this outcome tool
was initially widely used for primary rhino-
plasties, Hellings and Nolst Trenite [ 11 ] used the
Functional and Aesthetic Concerns
of Patients Seeking Revision
Rhinoplasty
Kathy Yu , Alyn Kim , and Steven J. Pearlman
K. Yu , M.D. ()
433 E Wardlow Rd. , Long Beach ,
CA 90807 , USA
e-mail: kathyyu80@hotmail.com
A. Kim , M.D.
435 East 70th Street, 27J , New York ,
NY 10021 , USA
e-mail: alynkim@gmail.com
S. J. Pearlman , M.D.
521 Park Avenue , New York ,
NY 10065 , USA
e-mail: mdface@aol.com

948
K. Yu et al.
Table 67.1 Incidences of the most common objective deformities as recognized in previous studies
Tip
asymmetry/
too wide/too
narrow/
bossae (%)
Tip
Pollybeak
deformity
(%)
Dorsal
saddle
(%)
Overresected
dorsum (%)
Open roof
deformity
(%)
Crooked
nose/
midnasal
asymmetry
(%)
Residual
hump/dorsal
irregularity
(%)
Columella
(retracted,
hanging,
wide) or
scar (%)
Alar
retraction/
distortion
(%)
Airway
obstruction
(%)
Overrotated
(%)
Depressed
(%)
Foda [ 6 ]
60
42
68
64
44
–
42
–
54
–
–
68
Thomson and
Mendelsohn
[ 1 ]
12
–
5
18
–
–
38
17
–
–
59
Kamer and
McQuown
[ 2 ]
22
–
56
16
–
–
15
17
22
11
–

949
67 Functional and Aesthetic Concerns of Patients Seeking Revision Rhinoplasty
Rhinoplasty Outcomes Evaluation to evaluate
long-term patient satisfaction after revision rhi-
noplasty. In patients with multiple revisions, they
believed that these outcome factors provided the
basis that motivates the patient to pursue his or
her next surgery.
One factor that we expect to affect patients
seeking revision rhinoplasty is nasal obstruction.
Nasal obstruction occurs in 59–68% of patients
after rhinoplasty and may become quite problem-
atic [ 1, 6 ] . Previous researchers have found that
nasal obstruction is most commonly caused by
residual septal deviation, with the most symp-
tomatic type involving the dorsal cartilaginous
septum in the internal nasal valve region. The
second most common cause of obstruction is
nasal valve problems from either valve collapse
or adhesions [ 6 ] . Previous rhinoplasty, especially
reduction rhinoplasty, is the most common cause
of nasal valve obstruction [ 7 ] and likely has a
signi fi cant role in leading patients to pursue revi-
sion rhinoplasty .
The harmonious balance of patient input and
surgeon insight provides a united surgical plan that
is vital to attaining favorable postoperative results.
The goal of this study is twofold: to determine in a
systematic manner the most common subjective
aesthetic and functional reasons that prompt
patients to seek revision rhinoplasty and then to
compare these with objective abnormalities found
on preoperative examination by the surgeon.
The most frequently cited reasons for seeking
revision rhinoplasty (aesthetic and functional
combined) were subjective patient aesthetic con-
cerns and objective aesthetic abnormalities noted
on physical examination. The subdivisions of the
nose are as follows: upper third (bony), middle
third, lower third (tip), nostrils, and columella.
For each subdivision, choices for patient fi ndings
included too high, too low, too wide, too narrow,
too prominent, underprojected, crooked, irregu-
lar/asymmetrical, too long, too short, and poorly
de fi ned. An inverted-V deformity was recorded
as the middle third being too narrow. An over-
projected tip was recorded as the tip being too
prominent. An increased nasolabial angle was
recorded as the tip being too high, and a decreased
nasolabial angle as too low. A retracted ala was
interpreted as the nostrils being too high. Excess
columellar show indicated that the columella was
too prominent. A long or wide columella–infratip
lobule indicated that the columella was too long
or too wide, respectively.
The frequency of patient and surgeon agree-
ment by anatomical subsite was arranged in a
table labeled as concomitant patient and surgeon
fi ndings. Patient aesthetic concerns that were
unaddressed by the surgeon were arranged in a
similar manner. The percentage of patient con-
cerns addressed by the surgeon was calculated
for each individual by dividing the total number
of individual patient fi ndings that were also con-
comitant surgeon fi ndings by the total number of
individual patient fi ndings and then multiplying
by 100. In addition, the percentage of surgeon
fi ndings noted by the patient was calculated for
each individual patient by dividing the total num-
ber of individual patient fi ndings that were also
concomitant surgeon fi ndings by the total num-
ber of surgeon fi ndings per individual patient and
multiplying by 100. Both of these values were
averaged for all the patients in the study.
Patients who noted subjective nasal obstruction
had speci fi c concerns that were (1) sensation of
nose blockage, (2) mouth breathing, (3) snoring,
(4) blockage with exercise, (5) dependence on
nasal spray use, and (6) the need to “pull the cheek
out” to breathe. Objective intranasal fi ndings con-
ducive to nasal obstruction included (1) deviated
nasal septum, (2) internal valve collapse, (3) exter-
nal valve collapse, (4) turbinate hypertrophy, (5)
septal perforation, and (6) synechiae.
The authors used a questionnaire (Table 67.2 )
to evaluate patients. There were 104 patients who
had undergone one or more rhinoplasties. There
were 83% females and 17% males, with a mean
age of 34 years (Table 67.3 ). The youngest patient
was aged 17 years; the oldest, 70 years. Seventy-
four percent of patients reported no medical prob-
lems. Eighty-seven percent were nonsmokers,
12% were current smokers, and 1% were previous
smokers. Patients reported taking, on average, one
home medication daily, and 43% of patients denied
any medication use. Examination of surgical his-
tory showed an average of 1.2 non-nasal opera-
tions, with the most common operation being

950
K. Yu et al.
Table 67.2 Questionnaire targeting the aesthetic and functional concerns of patients seeking revision rhinoplasty
Name a __________________________
REVISION RHINOPLASTY QUESTIONNAIRE
In order to help us achieve the nose you fi nd most pleasing, please take a few moments to encircle all of the
following options that apply:
Aesthetic Concerns (Nasal Appearance):
1. Upper portion of nose:
(a) Too high (hump/bump)
(b) Too low (“caved-in” appearance)
(c) Too wide
(d) Too narrow
(e) Crooked
(f) Irregular (not smooth)
(g) Other______________________
2. Middle portion of nose:
(a) Too high
(b) Too low
(c) Too wide
(d) Too narrow
(e) Crooked
(f) Irregular (not smooth)
(g) Other______________________
3. Tip of Nose:
(a) Too wide
(b) Too narrow/pinched
(c) Too high (points upward)
(d) Droopy (points downward)
(e) Too prominent (sticks out too far)
(f) Asymmetric
(g) Poorly de fi ned
(h) Other______________________
4. Other:
(a) Nostrils too wide
(b) Nostrils too narrow
(c) Columella (soft tissue portion between nostrils) too long
(d) Columella too short
(e) Other______________________
Functional Concerns (Breathing Issues):
5. If your fi rst surgery was for breathing problems, is it now?
(a) Better
(b) Worse
(c) The same
6. If your breathing was normal before the fi rst surgery, is it now?
(a) Better
(b) Worse
(c) The same
7. Do you have any of the following symptoms?
(a) Nose blocked
(b) Mouth breathing
(continued)

951
67 Functional and Aesthetic Concerns of Patients Seeking Revision Rhinoplasty
breast augmentation (Table 67.3 ). The overall most
important reasons for seeking revision rhinoplasty
were (1) tip asymmetry, (2) dif fi culty breathing or
nasal blockage, and (3) crooked middle third.
67.2
Aesthetic Concerns
The most common patient aesthetic fi ndings
in order of frequency were (1) tip asymmetry,
(2) crooked middle third, and (3) upper third
irregularity (Table 67.4 ). The most common sur-
gical aesthetic fi ndings in order of frequency
were (1) tip asymmetry, (2) upper third irregular-
ity, and (3) crooked middle third (Table 67.4 ).
The three most common aesthetic fi ndings noted
concomitantly by the patient and surgeon were
(1) tip asymmetry, (2) crooked middle third, and
(3) upper third irregularity (Table 67.5 ).
Tip asymmetry was the most common concern
among patients (57%), the most frequent surgeon
fi nding (76%), and the most common reason for
seeking revision rhinoplasty. The surgeon
identi fi ed tip asymmetry in 98% of the patients
with subjective concern of tip asymmetry. Tip
asymmetry was also the most common fi nding
during the surgeon’s preoperative examination.
Crooked middle third was the second most
common aesthetic concern among patients (37%),
the third most common surgeon fi nding (44%),
and the third most common reason for seeking
revision rhinoplasty. Of the 38 patients with sub-
jective concerns of a crooked middle third, the
surgeon identi fi ed the same fi nding in 32 (84%).
In addition, most of the patients objectively found
Table 67.2 (continued)
(c) Snoring/sleeping issues
(d) Blocked only with exercise
(e) Dependence on nasal sprays (over the counter or prescription)
(f) “I need to pull my cheek out to breathe”
(g) Other____________________________
8. How many prior nasal operations have you had?
(a) 1
(b) 2
(c) 3 or greater
From the above choices, please select three concerns that contribute most to your decision to pursue a revision
rhinoplasty. Please indicate which choices above are of most concern (i.e., 2b).
1. __________________________________________________________________
2. __________________________________________________________________
3. __________________________________________________________________
O Dr. Pearlman did my original surgery.
O Someone else did my primary rhinoplasty.
If so, why didn’t you return to the original surgeon?
1. Surgery was too long ago.
2. The doctor is no longer in practice.
3. I moved from another state/region.
4. I felt that since surgery wasn’t successful, I would not go back.
5. My doctor was not receptive to my concerns with my nose.
6. Other_________________________________________
Table 67.3 Characteristics of the patient population
Average age
34 years
Youngest patient
17 years
Oldest patient
70 years
Percentage of female patients
83
Percentage of male patients
17
Percentage of smokers
12
Percentage of nonsmokers
87
Average number of daily
medications
1
Average number of nonnasal
operations
1.2

952
K. Yu et al.
to have a crooked middle third (72%) agreed with
this fi nding when assessing their own features.
Upper third irregularity was the third most
common aesthetic concern among patients seek-
ing revision rhinoplasty (36%) and the second
most common surgeon fi nding (48%). In the 37
patients with subjective concerns of upper nasal
irregularity, the surgeon identi fi ed the same
fi nding in 29 (78%). In addition, most of the
patients objectively found by the surgeon to have
an upper third irregularity (74%) agreed with this
fi nding when assessing their own features. The
Table 67.5 Frequency of concomitant patient and surgeon fi ndings in 104 patients by nasal anatomical site
Upper
Middle
Tip
Nostrils (ala)
Columella
Length of nose
Too high
21
10
9
5
Too low
11
3
19
Too wide
17
7
20
16
Too narrow
2
5
9
1
Too prominent
18
2
Underprojected
2
Crooked
22
32 a
1
Irregular/asymmetric
29 a
23
58 a
10
5
Too long
13
1
Too short
2
Poorly de fi ned
18
a Most frequent concomitant fi nding
Table 67.4 Frequency of patient and surgeon aesthetic concerns in 104 patients by nasal anatomical site
Upper
Middle
Tip
Nostrils
Columella
Length of nose
Too high
23
12
10
6
Too low
15
11
28
Too wide
25
22
30
18
Too narrow
5
8
12
3
Too prominent
1
26
3
Underprojected
2
Crooked
28
38 a
1
Irregular/asymmetric
37 a
29
59 a
11
5
Too long
17
1
Too short
4
Poorly de fi ned
1
31
Upper
Middle
Tip
Nostrils (ala) Columella
Length of nose
Too high
38
11
27
12
1 b
Too low
17
4
33
1 b
Too wide
25
9
40
17
8
Too narrow
3
40
21
3
Too prominent
32
1
27
Underprojected
17 b
3
Crooked
35
46 a
24
Irregular/asymmetric
50 a
37
79 a
18
11 b
Too long
1
25
10 b
Too short
1
4
20 b
Poorly de fi ned
19
a Most frequent surgeon fi ndings
b Surgeon fi ndings not directly addressed in patient questionnaire

953
67 Functional and Aesthetic Concerns of Patients Seeking Revision Rhinoplasty
most common patient aesthetic concerns that
were not validated by surgeon examination were
(1) wide middle third and (2) poorly de fi ned tip
(Table 67.6 ).
67.3
Functional Concerns
Sixty-four of the 104 patients (62%) experienced
subjective concerns of nasal obstruction: nasal
blockage in 38, mouth breathing in 27, snoring/
sleeping problems in 24, blockage with exercise
in 3, nasal spray use in 12, the need to pull the
cheek out to breathe in 5, and other (crusting) in
1. Sixty of these 64 patients with subjective nasal
obstruction (94%) also had concurrent objective
intranasal fi ndings noted by the surgeon. Seventy-
four of the 104 patients (71%) had objective intra-
nasal fi ndings conducive to nasal obstruction:
septum deviation in 39, internal valve collapse in
20, external valve collapse in 2, large turbinates
in 11, septal perforation in 10, synechiae in 8, and
spurs in 2. Sixty of these 74 patients with objec-
tive intranasal fi ndings (81%) also experienced
subjective concerns about nasal obstruction. Four
patients with subjective nasal obstruction did not
have any objective intranasal fi ndings, and 14
patients with objective intranasal fi ndings did not
experience any subjective nasal obstruction.
The most commonly cited reasons for not
returning to the original surgeon were that (1) the
surgery was not successful ( n = 59) and (2) the
physician was not receptive to the patient’s con-
cerns ( n = 24). Other reasons were that the physi-
cian was no longer in practice ( n = 14), the surgery
was too long ago ( n = 11), the patient had moved
from another region ( n = 10), and other ( n = 6).
67.4
Discussion
Distortion of the nasal anatomy, especially after
multiple revision rhinoplasties, continues to pro-
vide a challenge even for the experienced sur-
geon. In addition, patients undergoing revision
rhinoplasty experience psychological implica-
tions of previously failed rhinoplasties, making
satisfaction with postoperative results even less
likely. To optimize patient satisfaction from revi-
sion rhinoplasty, the surgeon must be keenly
aware of the functional and aesthetic de fi ciencies
that the patient considers most problematic.
When surveyed regarding their overall most
troublesome concerns and top reasons for seek-
ing revision rhinoplasty, patients reported aes-
thetic and functional concerns. The most
frequently cited reason for seeking revision rhi-
noplasty and the most frequent aesthetic fi nding
by both patient and surgeon was tip asymmetry.
The second most troublesome concern was
dif fi culty breathing or nasal blockage. More than
half of all patients reported functional concerns,
which proved to be a major factor in pursuing
revision rhinoplasty. The third most frequently
cited reason for seeking revision rhinoplasty was
a crooked middle third.
Table 67.6 Frequency of patient concerns not reported by the surgeon by nasal anatomical site
Upper
Middle
Tip
Nostrils
Columella
Length of nose
Too high
2 a
2
1 a
1
Too low
4
8
9
Too wide
8
15 a
10
2
Too narrow
3
3 a
3
2
Too prominent
1
8
1 a
Underprojected
0 a
Crooked
6
6
0 a
Irregular/asymmetric
8
5
1 a
1
0
Too long
4
0 a
Too short
2
Poorly de fi ned
1 a
13 a
a Statistically signi fi cant

954
K. Yu et al.
In terms of aesthetics, tip asymmetry was the
most frequent patient aesthetic concern and the
most common surgeon aesthetic fi nding. This
could be owing to a variety of causes leading to
uneven width or length of the lower lateral carti-
laginous framework from previous surgery, or it
could be due to asymmetrical scarring from the
skin soft tissue envelope. Creating a natural-
appearing nasal tip is a complex three-dimen-
sional task [ 11 ] that is complicated by the changes
that often occur with time as tissue heals and
scars, altering the ultimate shape of the tip.
The second and third most common patient
aesthetic concerns were a crooked middle third
and upper third irregularity. Patients who have
undergone rhinoplasty frequently present with an
asymmetrical or crooked middle nasal vault,
which can distort the harmonious balance of the
face and would be a reasonable cause for patient
concern. However, not all patients with these
fi ndings reported them as being problematic.
Many patients with a crooked middle third or
upper third irregularity misreported these con-
cerns as a widened middle or upper third. In addi-
tion, in patients with objective fi ndings of upper
third irregularity, it went unnoticed by 25% of the
patients. This could be owing to the addition of
tactile to visual input that the surgeon consis-
tently uses while examining the patient during
preoperative consultation, which increases the
likelihood of detecting irregularity.
67.5
Concerns Not Reported
by the Surgeon
From this study, it is evident that the surgeon
addressed most (79%) of the patients’ aesthetic
concerns. The discrepancy between patient con-
cerns and surgeon fi ndings arose for a variety of
reasons. One of the main reasons is the surgeon’s
use of a conventional set of anatomical boundar-
ies, speci fi cally regarding the upper vs middle
third of the nose. Patients often do not have intri-
cate knowledge of nasal anatomy to properly dis-
tinguish between nasal thirds. It is also unlikely
for the patient to possess the ability to evaluate
the nasal anatomy in the context of the remainder
of the patient’s features, which may alter the
perception of a perceived aesthetic nasal defect,
while the surgeon does have the ability and skill
to do so.
The most common concern of the patient that
was unaddressed by the surgeon was a widened
middle third (Table 67.5 ). Only 32% of the patients
who noted a wide middle third were validated by
surgeon agreement. Many of the patients who
noted a wide upper or middle third were found to
have not a wide but rather a crooked or asymmetri-
cal nasal vault. Asymmetry can create the illusion
of a widened nasal vault, a fi nding that is better
discerned by the surgeon’s skilled visual inspec-
tion and palpation. This discrepancy may also arise
from the surgeon’s cautionary recognition that
overresection of the cartilaginous dorsum or upper
lateral cartilages in an attempt to narrow the mid-
dle third may result in an inverted-V deformity.
Poor tip de fi nition was the second most com-
mon concern that was unaddressed by the surgeon.
Only 58% of the patients who noted poor tip
de fi nition were validated by surgeon agreement. A
wide nasal tip, on the other hand, was a common
fi nding during the surgeon’s evaluation of patients
seeking revision rhinoplasty. What patients per-
ceive as “poor tip de fi nition” was actually “exces-
sive tip width” secondary to lack of lower lateral
cartilage integrity causing splay and poor
de fi nition. In fact, 43% of patients with subjective
concern of poor tip de fi nition were found by the
surgeon to have a wide nasal tip. In addition, tip
asymmetry was often perceived by the patient as
poor de fi nition. Twenty-three percent of patients
who were concerned about a poorly de fi ned tip
had deep alar creases that created a pinched
appearance and the illusion of tip width. Toriumi
[ 13 ] describes patients with deep alar creases not-
ing a poorly de fi ned or bulbous tip when, in fact,
the tip is narrow. We conclude that these differ-
ences in patient perception and physician assess-
ment result not from a lack of acknowledgment of
the patient’s concern but from a fundamental dif-
ference in patient and surgeon’s perspective of tip
aesthetics. This also emphasizes the importance of
the surgeon’s explanation of perceptual differ-
ences when evaluating patients for rhinoplasty.
Another common concern that was not com-
pletely validated by the surgeon was that of a low
middle third, which gives the patient a “caved-in

955
67 Functional and Aesthetic Concerns of Patients Seeking Revision Rhinoplasty
appearance.” These patients often had a promi-
nent tip, creating the illusion of a low dorsum. In
addition, the patient’s de fi nition of upper vs mid-
dle third often differed from the surgeon’s
de fi nition of these locations. Again, this may be
secondary to the surgeon’s more objective bound-
aries of upper vs middle third of the nose.
In addition to recognition of most of the
patients’ concerns, the surgeon also noted
signi fi cantly more areas that could bene fi t from
improvement than the patient did. Patients noted
only 55% of the surgeon’s fi ndings to be of con-
cern. This is consistent with the fi nding by Tobin
and Webster [ 14 ] that patients are often less criti-
cal of postoperative appearance than are surgeons.
Their study demonstrated that surgeons are most
critical of their own work, followed by the work of
other surgeons. The lower percentage of surgeon
fi ndings noted by the patients in the present study
may also be owing to the more comprehensive
review of nasal anatomy by the trained eye of the
surgeon, who follows a systematic method of eval-
uating the nose against a classical standard.
Patients, on the other hand, may have more subjec-
tive and varied opinions on their ideal appearance.
What is noted to be an abnormality by the surgeon
may not be a concern of the patient simply because
it is not perceived by the patient as a problem. This
was the case for the fi ndings of upper nasal irregu-
larity, narrow middle third, wide tip, narrow tip,
tip asymmetry, and columellar show.
The reason most frequently cited by patients
for not returning to their original surgeon was that
“because the surgery was not successful, I would
not go back.” This fi nding suggests that patients’
assessment of the technical ability of their sur-
geon is a common reason for seeking a new phy-
sician. This was an expected fi nding [ 2 ] . The
second most common reason was that “the origi-
nal surgeon was not receptive to the concerns” of
the patient. This fi nding suggests that many
patients addressed their concerns with the primary
surgeon and felt that their needs were not acknowl-
edged. This was unexpected, however, given that
surgeons tend to be more critical of their own
results than their patients are their patients [ 13 ] . It
is possible that (1) the surgeon recognized the
patient’s concerns but did not feel comfortable
operating on the patient again, (2) patients could
not express their dissatisfaction thoroughly
because of dif fi culty discerning and communicat-
ing the concerning aspects of nasal anatomy, or
(3) the surgeon is not listening appropriately. This
fi nding should drive us to further improve patient
satisfaction with rhinoplasty.
67.6
Functional Concerns
Subjective nasal obstruction was experienced by
more than half of the patients (62%) seeking revi-
sion rhinoplasty. This is consistent with previous
data provided by Foda [ 6 ] and Thomson and
Mendelsohn [ 1 ] that 59–68% of patients persis-
tently note nasal obstruction after primary rhino-
plasty. From the present results, the top three
patient concerns in order of frequency were (1)
sensation of nasal blockage, (2) mouth breathing,
and (3) snoring. There was a strong correlation
(94%) between patients undergoing revision rhi-
noplasty with subjective nasal obstruction and the
presence of one or more objective intranasal
fi ndings on physician examination contributory to
nasal obstruction. Dif fi culty breathing and nasal
obstruction were the second most frequent rea-
sons for seeking revision rhinoplasty. Functional
concerns remain a signi fi cant factor in patient
satisfaction and should be adequately addressed
with thorough intranasal evaluation.
On intranasal examination, the most common
cause of nasal obstruction in patients undergo-
ing revision rhinoplasty was a persistently devi-
ated septum, which was most likely due to
incomplete or lack of treatment for a deviated
septum during the original rhinoplasty. The sec-
ond and third most common physical examination
fi ndings leading to persistent nasal obstruction
were external and internal nasal valve collapse.
The causes of postoperative valve collapse are
numerous and beyond the scope of this chapter.
This is consistent with the fi ndings of Foda [ 6 ] ,
who, on intranasal examination of patients,
noted nasal obstruction after primary rhino-
plasty. The most common fi nding by Foda was
residual septal deviation, with the most symp-
tomatic type involving the dorsal cartilaginous
septum in the internal nasal valve region. The
second most common fi nding was nasal valve

956
K. Yu et al.
problems from either valve collapse or adhesions.
These data highlight the importance of considering
functional changes when addressing patients for
revision rhinoplasty.
67.7
Survey Validity
A valid survey is acceptable to the study popula-
tion, easily completed, accurate, valuable when
completed, sensitive to change, and reproducible
[ 14, 15 ] . Acceptability and ease of completion of
the survey were demonstrated by the 100% com-
pletion rate. Accuracy was demonstrated by the
high percentage of patient concerns that were
also fi ndings reported by the surgeon (79%).
Results are of inherent value in evaluating a
patient for revision rhinoplasty because the sur-
vey highlights the patient’s main concerns.
Sensitivity to change was less relevant because
this survey sought to identify patients’ reasons
for seeking revision rhinoplasty and not to assess
quality of life before and after a procedure. Based
on these criteria, the questionnaire used in this
study meets most of the criteria for a valid survey.
Reproducibility was not tested but remains a
potential area of further research.
Conclusions
Tip asymmetry is the most common reason for
seeking revision rhinoplasty. It is also the most
frequent aesthetic deformity noted subjectively
by the patient and objectively by the surgeon.
Crooked middle third and upper third irregu-
larity were other common deformities noted
by the patient and surgeon. Discrepancies
between patient concerns and assessment by
the surgeon were largely owing to differences
in subjective perception by the patient vs
skilled, objective visual and tactile evaluation
by the surgeon. Overall, there were more objec-
tive surgeon fi ndings than subjective patient
concerns. More than half of the patients under-
going revision rhinoplasty have symptoms of
nasal obstruction, the second most frequently
cited reason for seeking revision rhinoplasty.
Almost all of these patients had intranasal
fi ndings of obstruction. In conclusion, this
study sheds light on the major concerns of
patients seeking revision rhinoplasty and com-
pares them with the surgeon’s objective
fi ndings. These fi ndings emphasize the impor-
tance of physician awareness of patients’
concerns, understanding the causes of post-
surgical nasal obstruction, and clearly explain-
ing nasal aesthetics to patients seeking revision
rhinoplasty.
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M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_68, © Springer-Verlag Berlin Heidelberg 2013
68
68.1
Introduction
Depending on the quoted source, current revision
rhinoplasty rates may be as high as 20%. Specu-
lation attributes the recent increase in revision
surgery to widespread media in fl uences and pre-
operative digital analysis [ 1 ] . It is regarded by
many plastic surgeons as the most technically
challenging cosmetic procedure. Furthermore,
patient dissatisfaction with their previous sur-
gery, surgeries, and/or surgeon exacerbates an
already dif fi cult task. To ensure success, the sur-
geon must clearly identify the patient’s motives
and objectives, recognize the surgical deformity,
and create a logical plan. If the surgeon per-
formed the previous rhinoplasty, he/she must be
introspective and critically analyze technical
mistakes. Finally, the physician must gain the
trust of the patient to successfully execute the
discussed plan and decide when not to intervene.
There is a wide range of post-rhinoplasty surgi-
cal deformities, and these varying degrees of
deformity may not coincide with the patient’s
perceptions. Therefore, revision rhinoplasty may
be performed for both subtle abnormalities and
gross dis fi gurement. Figures 68.1 and 68.2 dem-
onstrate two patients who underwent revision
rhinoplasty and serve to demonstrate the exten-
sive variability in post-rhinoplasty defects.
68.2
Preoperative Evaluation
68.2.1 Patient Considerations
Whether real or perceived, the patient seeks
modi fi cation of their previous surgery. The per-
ception of a surgical defect may simply be the
result of a poor patient-physician relationship or
surgical experience and not a technical shortfall
[ 2 ] . The surgeon must clearly delineate the rea-
sons for disappointment. The patient’s concerns
and expectations must be identi fi ed. Previous lit-
erature suggests that the revision rate in ethnic
rhinoplasty is higher than in Caucasian rhino-
plasty. This may be in part due to surgical elimi-
nation of ethnic-de fi ning characteristics [ 3 ] . Body
dysmorphic disorder, which can accompany per-
sonality disorders, must be ruled out. Once the
surgeon and patient agree that a real and correct-
able deformity exists, only then can revision sur-
gery be considered. If there is any doubt regarding
the patient’s expectations, the patient should be
appropriately counseled and referred for psychi-
atric review [ 1 ] . It is the authors’ opinion that if
psychological consultation is considered, then
surgical intervention is rarely indicated.
Revision Rhinoplasty: Evaluating
the Patient and the Problem
Keith Ladner and Edward H. Farrior
K. Ladner , M.D. ()
Lander Facial Plastic Surgery ,
3701 S. Clarkson St. , # 200 ,
Eaglewood CO 80113 , USA
e-mail: keithladner@gmail.com
E. H. Farrior , M.D.
Farrior Facial Plastic and Cosmetic Surgery Center ,
2908 West Azeele St. , Tampa ,
FL 33609-3110 , USA
e-mail: ed@drfarrior.com

958
K. Ladner and E.H. Farrior
68.2.2 Timing and Referral
Rhinoplasty surgeons agree that it is best to wait
a full year prior to considering additional nasal
surgery. This delay allows for soft tissue edema
resolution, scar maturation, and suf fi cient delib-
eration by the patient. A minor, but bothersome,
deformity frequently improves to an acceptable,
Fig. 68.1 This patient sought revision rhinoplasty for an obvious short-nose deformity ( a ) AP view ( b ) Oblique View
( c ) Pro fi le View
Fig. 68.2 This patient sought revision rhinoplasty for a subtle dorsal prominence ( a ) AP view ( b ) Oblique view
( c ) Pro fi le view

959
68 Revision Rhinoplasty: Evaluating the Patient and the Problem
and nearly imperceptible, abnormality. During
this time, additional abnormalities that may not
have been apparent immediately after surgery
may present themselves. If surgical intervention
is executed prematurely, then unnecessary sur-
gery may be performed; conversely, necessary
surgery may be overlooked.
Efforts are made to refer the dissatis fi ed patient
back to the primary surgeon. There is seldom any-
one more aware of the cause of failure of a rhino-
plasty than the original surgeon. In spite of a
thorough physical exam and careful review of the
medical record, operative report, and patient his-
tory, it is impossible for a secondary surgeon to
have a visual record of what was done. Frequently,
patients will verbalize that they have lost con fi dence
in their primary surgeon. Although this con fi dence
may not be restored with reassurance, the sur-
geon’s reputation should certainly not be further
undermined. All surgeons have experienced unac-
ceptable results, and we must not assume that we
are superior to the previous surgeon.
68.2.3 Examination
A complete external and internal nasal exam is
required. This includes careful inspection and
palpation of the nose. Palpation cannot be over-
emphasized. The intricacies of the distorted anat-
omy are frequently identi fi ed in this manner.
Deformities should be identi fi ed and classi fi ed
based on the plane of view (i.e., frontal, oblique,
pro fi le). A complete, detailed, descriptive sum-
mary of the deformity should be recorded. Nasal
functionality should be evaluated with anterior
rhinoscopy and nasal valve assessment. Review
of the original clinical, photographic, and opera-
tive reports is imperative to understand the
attempted and achieved surgical changes. Of these,
the photographic record is the most consistently
helpful. Operative reports are frequently vague
and can be misleading.
68.2.4 Photos
If the patient is referred by a colleague or
seeks a second opinion, both preoperative and
postoperative photos should be obtained. Equally
important, additional photos should be taken on
the day of consultation. This allows for an objec-
tive analysis of the surgical changes and evolu-
tion of the irregularities. Frontal, oblique, lateral,
lateral smiling, base, and occasionally helicop-
ter views are taken. Digital analysis may provide
a useful adjunct to the preoperative evaluation;
however, it must be used realistically and should
not be misunderstood as a guaranteed result.
68.2.5 Surgical Approach
Subtle deformities of the dorsum, sidewall, tip, or
base can be dealt with via a limited endonasal
approach. Other than for the correction of these
subtle deformities, it has been abandoned in revi-
sion rhinoplasty. The advantages of an endonasal
approach include an internal incision, a more
direct and limited approach, and the possibility of
decreased operative time, healing time, and
destruction of normal nasal structure [ 4 ] . Direct
access to the dorsum or sidewall can be achieved
with unilateral or bilateral intercartilaginous inci-
sions. These can be combined with hemitrans fi xion
or complete trans fi xion incisions for improved
exposure. Meanwhile, the nasal tip can be accessed
through cartilage delivery, transcartilaginous, or
retrograde approaches.
For more substantial deformities, an open exter-
nal rhinoplasty offers improved visualization and
more dependable results. In patients who have
undergone multiple rhinoplasties, an open approach
should always be considered. Transcolumellar and
marginal incisions are combined to allow for soft
tissue (EHF) preference to begin nasal tip dissec-
tion laterally, away from the dome. With this tech-
nique, normal anatomic landmarks are more easily
identi fi ed, and dissection can continue medially.
68.2.6 Grafts and Implants
Autologous grafts, including septal, auricular,
and rib cartilage, are preferred for nasal recon-
struction. The easy accessibility and preven-
tion of a second donor site make septal cartilage
the optimal and preferred source. Simple and

960
K. Ladner and E.H. Farrior
composite auricular grafts provide cartilage,
and skin in the case of the latter, for reconstruc-
tion of the lower lateral cartilage and alar rim
defects (Fig. 68.3 ). When large postsurgical
defects are encountered and/or structural sup-
port is imperative, rib grafts become necessary.
Christophel and Hilger [ 5 ] recently published
their results of rib grafts for major dorsal
reconstruction. In this review, 39 rib grafts (33
osseocartilaginous and 6 cartilaginous) were
performed for major dorsal augmentation over
a 10-year period. At an average follow-up time
of 24 months, all 33 osseocartilaginous grafts
were viable, and there was no loss of dorsal
Fig. 68.3 Harvesting of conchal cartilage graft for alar restructuring: ( a ) Postauricular approach is use. ( b ) Conchal
cartilage with perichondrium intact. ( c , d ) Conchal cartilage used as alar rim grafts for enhanced support

961
68 Revision Rhinoplasty: Evaluating the Patient and the Problem
projection. Twenty-nine of the 33 patients (88%)
demonstrated persistent relief of nasal obstruc-
tion. This study highlights the long-term via-
bility and consistency of rib grafting.
In addition to autologous cartilage grafts, calva-
rial bone grafts and temporalis fascial grafts serve
a useful role. Bone grafts are an excellent option
for correction of an overresected bony dorsum or
low radix. In patients with thin skin or prominent
nasal cartilages, temporalis fascia can be used to
camou fl age and soften transition points.
Synthetic implants offer a good alternative to
autologous grafts, especially in patients who
either lack a reliable graft source or do not desire
a second operative site. Various options exist, but
the senior author’s (EHF) preference is expanded-
porous polytetra fl uoroethylene or Gore-Tex (W.L.
Gore & Associates, Inc., Flagstaff, AZ). The con-
sistency, reliability, low rate of infection and/or
extrusion, and ease of use make Gore-Tex an
excellent option in major dorsal reconstruction.
68.3
Etiology
The need to perform revision rhinoplasty will
arise from issues of underreduction, overreduc-
tion, asymmetry, and disproportion. These will
most often occur in some combination and arise
for a variety of reasons alluded to earlier.
68.3.1 Dorsum
Most dorsal deformities result from either over-
zealous removal or underresection of the original
dorsum. These defects can be further classi fi ed
based on location. The radix, the rhinion (bony-
septal con fl uence), and the supratip must all be
individually assessed. A dorsal prominence or
de fi ciency may not be immediately obvious on
frontal view, highlighting the importance of
examination from all viewpoints. In the tip, issues
of skin thickness can also contribute to an unac-
ceptable dorsal outcome and confounding prob-
lem for the surgeon.
68.3.2 Saddle Nose
Saddle nose deformities may occur in the bony or
cartilaginous nose. A cartilaginous saddle result
when there is a loss of cartilaginous dorsal support.
It can involve any segment or length of the dorsum
and can result from overresection of the dorsal
cartilage, disarticulation of the caudal strut, and
postoperative septal hematoma and/or infection.
Non surgical causes include trauma, intranasal drug
use, and autoimmune destruction. The perception
of a saddle nose can also occur from a high nasal
frontal angle and overprojected nasal tip [ 6 ] . In
Fig. 68.4 , a patient with a classic postsurgical saddle
Fig. 68.4 Saddle nose
deformity. The overresected
dorsum and overrotated tip
are clearly demonstrated
( a ) Pro fi le view ( b ) Oblique
view

962
K. Ladner and E.H. Farrior
nose is displayed. As evident in these photographs,
a saddle nose also exaggerates the bony and tip pro-
jections and overstates tip rotation. Augmentation
of the saddle deformity, dorsal length ening, coun-
terrotation, and columellar augmentation are
required to restore appropriate nasal contour
(Figs. 68.5 , 68.6 , 68.7 , and 68.8 ). After these revi-
sions are executed, a more natural appearing dor-
sum and tip are achieved (Fig. 68.9 ).
68.3.3 Pollybeak
Persistent supratip fullness, or pollybeak, follow-
ing rhinoplasty is usually the result of an under-
resected distal cartilaginous dorsum, overresection
of the superior dorsum. Loss of tip support will
give the illusion of a pollybeak deformity or can
exaggerate real supratip fullness. Aggressive
supratip augmentation can similarly lead to a pol-
lybeak deformity. Figure 68.10 shows an obvious
pollybeak deformity and amorphous tip appear-
ance resulting from an aggressive augmenting
Fig. 68.5 In order to reconstruct the saddle nose, pre-
maxillary, caudal septal extension, dorsal augmenting,
alar batten, and shielded tip grafts were carved
Fig. 68.6 Caudal septal extension graft and dorsal onlay
graft in the classic tongue and groove formation
Fig. 68.7 Premaxillary and caudal septal extension grafts
Fig. 68.8 A shielded tip graft and alar batten grafts were
used to help strengthen, project, counterrotate, and soften
the tip and ala

963
68 Revision Rhinoplasty: Evaluating the Patient and the Problem
rhinoplasty. Correction of the supratip deformity
varies depending on the associated abnormalities.
One must consider augmentation of the radix,
strengthening and projecting the nasal tip, and
further resection of the distal cartilaginous sep-
tum [ 7 ] . In this particular patient, a supratip aug-
mentation graft, butter fl y tip graft, multiple
columellar strut grafts, and a four-layered alar
batten graft were found (Figs. 68.11 , 68.12 , and
68.13 ). These cartilage grafts were all removed.
The deformity was then further repaired with
lowering of the supratip septal cartilage, cephalic
and medial crural trimming, and placement of
spreader, tip, alar camou fl age, and Peck grafts
(Fig. 68.14 ).
68.3.4 Inverted-V deformity
The inverted-V deformity occurs when there is
disruption of the natural con fl uence of the bony
vault, upper lateral cartilages (ULCs), and sep-
tum resulting in the loss of the keystone affect in
the dorsum. The ULCs become displaced posteri-
orly and inferiorly giving the appearance of an
inverted V. This phenomenon occurs with over-
resection of the upper cartilaginous dorsum and
with failure to reconstitute the ULCs to the sep-
tum. An inverted-V deformity may accompany
saddle
or
pollybeak
dorsal
deformities
(Fig. 68.15 ). Correction usually necessitates the
use of spreader grafts and reconstitution of the
ULCs in their proper anatomic position. Onlay
grafts can be performed but are not the preferred
technique because they do not reconstruct normal
structural support to the middle vault.
68.3.5 Short Nose
The short nose usually results from overaggres-
sive resection of the nasal tip, anterior septal
angle, upper lateral cartilages, and/or the loss of
septal support. A low radix, an overrotated or
underprojected tip, and a saddle nose can all con-
tribute to the appearance of a shortened nose [ 8 ] .
Revision rhinoplasty for a short nose attempts to
reestablish nasal length and tip projection with
counterrotation. Radix grafts and caudal septal
extension grafts are often necessary. In addition,
projection of the tip can be reestablished with
alar struts, extended spreader grafts, a tip graft, or
a columellar strut. It is paramount to reconstruct
the support mechanisms of the tip, and it is often
necessary to perform all of the previously men-
tioned techniques to overcome the contractile
forces of the restricted skin envelope.
68.3.6 Tip
Various deformities of the nasal tip can result
when the normal support mechanisms are vio-
lated. Ptosis, overrotation, alar retraction and
Fig. 68.9 Postoperative result
( a ) Pro fi le view ( b ) Oblique
view

964
K. Ladner and E.H. Farrior
collapse, bossae, and a pinched tip are among the
more common complications. Any of these can
result in asymmetry which is the most common
abnormality in the postsurgical tip in the senior
author’s experience. Correction of these abnor-
malities requires restoration of the tripod and
M-arch support [ 9 ] . Surgical modi fi cation usu-
ally requires cartilage augmentation. Depending
Fig. 68.10 Pollybeak deformity resulting from aggressive tip and supratip augmentation ( a ) AP view ( b ) Oblique view
( c ) Pro fi le view ( d ) Base view

965
68 Revision Rhinoplasty: Evaluating the Patient and the Problem
on the speci fi c deformity, caudal septal extension
grafts, columellar strut grafts, shielded tip grafts,
and alar batten, strut, rim, and camou fl age grafts
may be necessary in any and all combinations.
68.3.7 Bossae
Prominent cartilaginous protrusions, or bossae,
are more common in thin-skinned patients. In
these patients, soft transition points are more
dif fi cult to create. Tip bi fi dity, failure to narrow the
interdomal segment, and complete vertical dome
division can produce this complication. In such
patients, trimming of angulated cartilage segments
should be executed. Furthermore, camou fl aging of
harsh cartilaginous protrusions can be achieved
with use of a temporalis fascia graft or cadaveric
acellular dermal graft. Figure 68.16 demonstrates
the harvested temporalis fascia graft and its proper
insertion.
As with all deformities, the key to avoidance
of bossae is to recognize their potential appear-
ance at the time of primary rhinoplasty.
Preserving the caudal margin of the lower lateral
cartilage, if possible, is imperative. Tip grafts
should be tapered and the margins of any grafts
camou fl aged.
68.3.8 Alar-Columellar Relationship
Increased columellar show as a result of rhino-
plasty is far more common than the reduced
show. This can occur as a result of a preexisting
hanging columella or retracted ala. A hanging
columella is frequently a preoperative phenome-
non that is either not addressed or is exaggerated
through surgical maneuvers. For example, a tip
graft can unintentionally lengthen the columella.
Any surgical technique that is designed to nar-
row the angle of divergence may inferiorly dis-
place the caudal margin of the medial crus.
Additionally, widened medial crura or an exces-
sive membranous septum must also be consid-
ered. Trimming of these structures can correct
the irregularity.
Alar retraction from surgery is seen with
overzealous lateral crural cephalic trimming,
Fig. 68.11 Large supratip and butter fl y tip grafts were
removed to reduce fullness
Fig. 68.12 Four-layered alar batten graft was removed
Fig. 68.13 Bulky resected cartilage is demonstrated
overlying tip and supratip regions

966
K. Ladner and E.H. Farrior
endonasal scar contraction, aggressive lateral
crural spanning sutures, and excessive scroll
resection. Depending on the cause, restoration of
the normal alar-columella relationship requires
alar rim cartilage grafts or auricular composite
grafts.
Fig. 68.14 Postoperative results demonstrating correction of the pollybeak deformity ( a ) AP view ( b ) Oblique view
( c ) Pro fi le view ( d ) Base view

967
68 Revision Rhinoplasty: Evaluating the Patient and the Problem
68.3.9 Bony Vault
Failure to straighten or narrow the bony dorsum
with adequate osteotomies will lead to persistent
deformities of the upper bony vault. With any
substantial dorsal hump reduction, osteotomies
must be performed to avoid the open-roof
deformity. Improvement of bony irregularities
typically necessitates medial and lateral osteoto-
mies. Subtle widening of the upper third can be
addressed with simple rasping. A rocker defor-
mity occurs when the osteotomies are carried too
far into the frontal bone leading to a lateral bony
projection. A superior osteotomy can be
employed to reverse this abnormality.
Conclusions
The intricacy of primary and revision rhino-
plasty cannot be overstated. Should a surgeon
choose to ignore the potential pitfalls of rhino-
plasty complication abounds. When choosing
to perform a revision, the patient and physician
must enter into a detailed discussion and under-
standing regarding the proposed goals of sur-
gery. These goals must be rational and should
serve to correct a real deformity. A detailed
algorithm of the causes and management of
rhinoplasty complications will serve the plas-
tic surgeon well.
Of course, it is always best if revision rhi-
noplasty can be avoided. However, this is an
unrealistic expectation and lofty goal in your
own primary rhinoplasty patients. When
posed with the need to revise a nasal defor-
mity, it is paramount to be deliberate, realistic,
respectful, cautious, and apprehensive. Even
perfect preoperative planning can go astray,
again.
Fig. 68.15 Overresection of the upper cartilaginous dor-
sum can result in both an inverted-V and saddle nose
deformity
Fig. 68.16 ( a ) Harvested temporalis fascia graft. ( b ) Graft displayed over the dorsal skin to demonstrate its placement
position. ( c ) Graft inserted over the dorsum with use of absorbable sutures

968
K. Ladner and E.H. Farrior
References
1. Paun SH, Nolste Trenite GJ (2008) Revision rhino-
plasty: an overview of deformities and techniques.
Facial Plast Surg 24(3):271–287
2. Adamson PA, Litner JA (2006) Psychological aspects
of revision rhinoplasty. Facial Plast Surg Clin North
Am 14:269–277
3. Nolste Trenite GJ (2003) Considerations in ethnic rhi-
noplasty. Facial Plast Surg 19(3):239–244
4. Fedok FG (2008) Revision rhinoplasty using the endo-
nasal approach. Facial Plast Surg 24(3):293–309
5. Christophel JJ, Hilger PA (2011) Osseocartilaginous
rib graft rhinoplasty: a stable, predictable technique for
major dorsal reconstruction. Arch Facial Plast Surg
13(2):78–83
6. Farrior EH (1997) Revision rhinoplasty for mono-
graphs in facial plastic surgery contemporary rhino-
plasty. Facial Plast Surg 13(4):299–308
7. Papel I (2009) Secondary rhinoplasty. In: Papel I,
Frodel JL, Holt GR, Larrabee WF Jr, Nachlas NE et al
(eds) Facial plastic and reconstructive surgery. Thieme,
New York, pp 589–603
8. Sandel HD 4th, Perkins SW (2008) Management of the
short nose deformity in revision rhinoplasty. Facial
Plast Surg 24(3):310–325
9. Funk E, Chauhan N, Adamson PA (2009) Re fi ning ver-
tical lobule division in open septorhinoplasty. Arch
Facial Plast Surg 11(2):120–125

969
M.A. Shiffman, A. Di Giuseppe (eds.), Advanced Aesthetic Rhinoplasty,
DOI 10.1007/978-3-642-28053-5_69, © Springer-Verlag Berlin Heidelberg 2013
69
69.1
Introduction
There is an increasing recognition of a relatively
high incidence of nasal airway obstruction after
rhinoplasty. Elwany and Thabet [ 1 ] reported that
72% of patients had signi fi cant nasal airway
obstruction after rhinoplasty. Grymer [ 2 ] and
Sheen [ 3 ] independently reported a high inci-
dence of nasal valve narrowing with the external
valve compromised in 85% and the internal valve
in 25% of patients after rhinoplasty. Reductive
rhinoplasty, by its very nature, removes a portion
of the bony and cartilaginous support of the nasal
airway. Many patients may have a degree of pre-
operative obstruction which is not recognized
and is made worse after aesthetic rhinoplasty.
Patients who have had previous nasal surgery are
at highest risk for postoperative airway obstruc-
tion after secondary correction of aesthetic defor-
mities. Others may have certain facial morphologic
or structural characteristics which put them at high
risk for nasal airway obstruction after rhinoplasty.
Recognition of potential airway problems allows
the surgeon to initially incorporate surgical tech-
niques in aesthetic nasal surgery to prevent post-
operative nasal airway obstruction and many
times to improve the existing airway. Revisional
rhinoplasty often requires aesthetic re fi nement
and airway reconstruction with the additional
challenges posed by mucosal scarring, thin nasal
skin, and absent or inadequate intranasal graft
material.
69.2
Examination
In addition to a standard general physical exami-
nation, a speci fi c nasal history and exam proto-
col is recommended to document any preexisting
conditions. Previous nasal trauma, surgery, aller-
gies, sinus procedures, or obstructive symptoms
are noted. Medications are noted with emphasis
on any nasal sprays, allergy shots, smoking, and
antihistamines which may directly affect the nasal
mucosa. Airway obstruction which is relieved by
topical sprays or antihistamines should not be
treated with surgery since it often has an allergic
causation. Smoking can compromise nasal ciliary
function, cause in fl ammation, and prevent proper
healing. Patients are required to cease smoking
for at least 6 weeks before and after nasal surgery.
Examination includes external and internal nasal
inspection, noting any areas of abnormal exter-
nal or internal anatomy. A dynamic examination
is mandatory to ascertain any structural problems
Airway Patency in Aesthetic
Rhinoplasty: Primary
and Revisional Techniques
Fernando D. Burstein
F. D. Burstein , M.D., FACS, FAAP
Clinical Professor Plastic and Reconstructive Surgery ,
Emory University , Atlanta , GA , USA
Director Center for Craniofacial Disorders,
Childrens Healthcare of Atlanta ,
Atlanta , GA , USA
e-mail: fernandoburstein@yahoo.com

970
F.D. Burstein
such as internal or external valve collapse with
inspiration. This can be performed by having
the patient breathe while keeping the mouth
closed and alternatively obstructing each nostril.
Dynamic collapse is generally evident, and the
exact anatomic location can be noted. The level
of obstruction can often be determined by sup-
porting the external and or internal valve with
cotton tipped applicator (Fig. 69.1 ). The patient
will often report a marked improvement in air
fl ow during this maneuver as the examiner sup-
ports the airway at different points. Often, a sim-
ple maneuver such as slightly rotating the tip in a
cephalic direction can markedly improve the air-
way. The ef fi cacy of these maneuvers is carefully
documented and applied to surgical planning. The
positions of the septum and nasal spine and sizes
of the turbinates are also noted. The oral pharynx
should be examined to rule out adenotonsillar
hypertrophy as a contributing factor, especially
in younger patients. If the site of obstruction can-
not be determined with these simple maneuvers,
fl exible nasal endoscopy is indicated to rule out
posterior nasal masses, adenoidal hypertrophy, or
in rare cases choanal stenosis or unilateral atre-
sia. Patients with relative midface hypoplasia or
a very narrow midface and maxilla may be at risk
for pyriform aperture stenosis. Often, patients
with vertical midface hyperplasia have a rela-
tively stenotic pyriform diameter. A CAT scan
with both axial and direct coronal examinations
can con fi rm the bony aperture stenosis if clinical
examination is not diagnostic.
69.3
Anatomy
The surgical anatomy of the nose is of utmost
importance to the surgeon performing aesthetic
or reconstructive rhinoplasty. Air enters the nose
through the external nasal aperture comprised of
the pyriform aperture which is part of the maxilla
and external nasal valve comprised of the paired
lower lateral cartilages. Next, fl ows are directed
Fig. 69.1 ( a ) Patient with airway compromise after aesthetic rhinoplasty being examined prior to secondary reconstruction.
( b ) Cotton tip applicator used to simulate effect of reconstruction of the external and internal nasal valves

971
69 Airway Patency in Aesthetic Rhinoplasty: Primary and Revisional Techniques
through the internal nasal valve which is at the
juncture of the upper and lower lateral carti-
lages and the septum. Posterior to the valve, the
air stream fl ows past the septum and turbinates
through the choanal openings and fi nally into the
nasopharynx. Many anatomic and physiologic
factors can compromise laminar air fl ow in the
nasal cavity, and the areas of potential airway
obstruction need to be noted prior to surgery
(Fig. 69.2 ). Nasal airway obstruction may be due
to bony obstruction, inadequate cartilaginous
support, and mucosal scarring in any combination
or location.
69.4
Planning
The patient’s aesthetic and functional goals are
noted during the initial consultation. Realistic
goals should be agreed upon. If the patient has
unrealistic expectations, a second opinion is sug-
gested. Standard photography along with com-
puterized imaging allows optimal communication
between the surgeon and patient. Functional con-
siderations are also discussed at this time. If
signi fi cant septal deviation or turbinate hypertro-
phy is noted, correction should be offered in a
prospective fashion. If external or internal valves
are compromised, they should be reconstructed
as part of the procedure. In revisional cases,
compromises due to preexisting scars, thin skin,
and inadequate materials for grafting are often nec-
essary. Secondary graft donor sites such as the
conchal and rib cartilage are discussed with the
patient including additional potential risks. My
fi rst choice is always septal cartilage, but this
may not be available in adequate quantity or qual-
ity in the previously operated patient. Patients
requiring revisional surgery may have thin atro-
phic skin which is tight, painful, and discolored
over angulated cartilage, putting this skin at risk
of compromise. This risk is discussed with the
patient. Often, these patients will bene fi t from a
thin facial graft to thicken the cartilage soft tissue
cover at the time of revisional rhinoplasty. Despite
these considerations, I prefer an external approach
to both primary and revisional nasal surgeries
and have not experienced loss of nasal skin cover.
The external approach allows full visualization of
the nasal anatomy which is vital to precise execu-
tion of the surgical plan. This is especially critical
in revisional cases where normal anatomic struc-
tures may be compromised or absent.
69.5
Technique
The author has applied a method of preoperative
evaluation with attention to the nasal airway
along with aesthetic consideration in over 4,000
Fig. 69.2 Critical nasal airway anatomy. ( a ) Potential
sites of airway obstruction are illustrated including the
pyriform aperture, septum, and turbinates. ( b ) Internal
valve. ( c ) External valve. Note that the internal and external
valves can be compromised if structurally weakened by
resection of cartilage

972
F.D. Burstein
patients, over 23 years, presenting with a variety
of primary and secondary nasal deformities.
Bony deformities such as pyriform stenosis, max-
illary hypoplasia, and microgenia are often cor-
rected as part of the comprehensive approach to
the nose (Fig. 69.3 ).
In dealing with primary and secondary nasal
deformities, cartilaginous graft tissue must often
be harvested for either aesthetic enhancement or
structural airway support. Autologous cartilage is
the best material for use under the relatively thin
nasal skin (Fig. 69.4 ). In the author’s experience,
cranial bone iliac crest and radiated cartilage all
lose volume over time and often have an undesir-
able edge effect when they adhere to the skin.
There are several donor sites, which may provide
adequate autologous cartilage, available for this
purpose. Septal cartilage is usually abundant in
primary rhinoplasty and can be easily harvested
as outlined in my previous chapter. It can provide
long structural struts which resist fl exion and
compression, making septal cartilage the ideal
material for alar spreader and columellar grafts.
Septal cartilage must be thinned if it is to be used
as a batten graft between the septum and pyriform
aperture to prevent excessive tip width. It holds a
stitch quite well and is seldom brittle. When used
for tip enhancement, the cartilage should be either
beveled or bruised to prevent seeing an edge
under the skin. A variety of shapes can be carved,
including shield, button, and rectangle, depend-
ing on the desired tip shape. Septal grafts are
ideal for enhancing tip aesthetics in patients with
thicker sebaceous skin in which softer more sub-
tle grafts will not suf fi ce. In primary cases, the
lower lateral cartilages are often modi fi ed by
removing a cephalic strip, while leaving at least
4 mm, to support the external nasal valve. In sec-
ondary cases, tip re fi nement may require cephalic
trimming of the lower lateral cartilages. The
overlying perichondrium is left on these strips.
This enhances the structural integrity of this
material. These strips are not adequate for struc-
tural purposes but provide volumetric tip enhance-
ment and can also be used to cover concavities or
other irregularities in revisional cases. When
folded, and if necessary bruised, they can be used
as subtle tip grafts even in patients with thin
Fig. 69.3 ( Left ) Pyriform
stenosis at bony nasal inlet.
( Right ) Small bone rongeur
is being used to enlarge the
diameter of the pyriform
aperture via a transnasal
approach

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69 Airway Patency in Aesthetic Rhinoplasty: Primary and Revisional Techniques
atrophic skin, without creating a visible edge.
The perichondrium is placed against the skin sur-
face, offering additional padding. This has
become my preferred method for providing tip
enhancing volumetric highlights in patients with
thin skin (Fig. 69.4 ).
Conchal grafts may be necessary if there is
inadequate septal cartilage as is often the case in
revisional rhinoplasty. Conchal cartilage can be
easily harvested through a posterior midconchal
skin incision. A needle is passed from the lateral
limit of the concha posteriorly to mark the lateral
harvesting limit and avoid ear deformation.
A generous amount of cartilage can be obtained
from one or both ears as needed (Fig. 69.5 ). It is
important to keep the posterior perichondrium
intact to prevent graft fragmentation. The graft
can be used to make batten grafts for internal or
external valve reconstruction. It can also be used
as a boomerang graft for tip and columellar
reconstruction. If a small amount of dorsal aug-
mentation is desired, I use bruised stacked con-
chal strip grafts. The disadvantages of conchal
grafts include occasional donor site morbidity,
lack of compressive strength, and their inherently
curved nature. Eventually, the intact perichon-
drium will exert some tension and oppose this
curvature.
In some revisional cases, the skin has become
attenuated and atrophic as it contacts sharp carti-
lage edges from previous surgery, or there may
be many small defects and surface irregularities.
Over time, these sharp edges may be painful to
touch. This is most problematic in the thin-
skinned patient. In these cases, a fascial graft can
be obtained through the postauricular incision
from the mastoid and sternocleidomastoid. These
grafts can be sizable, up to 6 cm in length, and are
quite sturdy with a uniform thickness. They can
be pressed into a thin sheet to provide a soft layer
beneath thin skin or cover underlying irregulari-
ties. I have found them to retain volume over
time. In some cases, I have folded the fascia to
augment a small dorsal defect.
Costal cartilage grafts are used when the
reoperative case requires large amounts of mate-
rial for a severe saddle nose deformity, external
valve collapse, and columellar support. The
inframammary fold is avoided since incisions in
this area can result in breast deformity. I make a
small incision at the costal margin which allows
me to select the shapes that will be required.
I draw the desired grafts on the rib cartilages in
situ and harvest them without removing the
whole rib segment. Often, dissection at the syn-
chondrosis will reveal a plethora of shapes and
sizes. By keeping a small rim of rib intact, chest
wall deformities are prevented. It is important to
scrape off all of the perichondrium to minimize
warping. I have used K wires for dorsal grafts to
prevent bending in the past but have abandoned
that practice after seeing some long-term K wire
extrusion.
Fig. 69.4 Autologous grafts. Left to right : paired
extended alar spreader grafts from septal cartilage, paired
trimmings from lower lateral cartilage reduction with per-
ichondrium attached, and shield graft carved from septal
cartilage
Fig. 69.5 Conchal graft. Note inherently curved shape
and thickness. Perichondrium is left attached to preserve
structural integrity