Oftentimes in revision rhinoplasty, I see patients who have had their dorsum too aggressively removed with previous procedures. These patients typically initially had a hump on their nose which was removed. However, the hump may have been removed too aggressively leaving the patient with a ‘scooped out’ appearance to their nose. This appearance is very concerning to patients as it is the obvious sign of a previous rhinoplasty. I try to impart to patients in when I perform primary rhinoplasty that if you carefully appreciate the dorsum of models none has a ‘scooped out’ appearance or a very low dorsum (unless, of course, if they have had a rhinoplasty). Analyzing the aethestically pleasing noses of models shows that it is not the low dorsum which imparts the aesthetic appearance but rather the creation of an appropriate supratip break. The supratip break is the step-off or the demarcation between the tip of the nose and the dorsum of the nose. It is essentially where the dorsum ends and the tip begins. This concept is often misunderstood by surgeons. They try to create an aesthetic profile by lowering the dorsum to a degree where it begins to take on the scooped out appearance. Rather the dorsum should lie straight with a very subtle lowering beyond what is straight in women. The distinction of the tip can them be made with the creation of the supratip break. Because of an over aggressive lowering of the dorsum, it often needs to be rebuilt in the revision rhinoplasty case. This is a complex maneuver where the revision rhinoplasty surgeon needs to graft and augment the profile.
Dr. Bared prefers to use only one’s own cartilage to accomplish this task, avoiding foreign materials in the nose such as Gortex. Because of the scar tissue present in revision rhinoplasty cases, there is a higher risk of infection. Dr. Bared takes every precaution in order to diminish this risk both by antibiotics which are taken orally as well as with antibiotic irrigations during surgery and with antibiotic soaks after surgery. Additionally, Dr. Bared feels it is important to only use your body’s own cartilage for grafts in the surgery. In this manner the cartilage can be more readily assimilated and incorporated into your body while nourishing it with your own blood supply.
These factors are important so that in this manner one avoids the introduction of foreign materials into the nose. For most cases, in order to augment the dorsum, Dr. Bared carves rib cartilage in the shape of a dorsal graft. The graft is then camouflaged with the perichondrium of the rib cartilage which is the cartilage’s natural covering, allowing for a sturdy, biological graft material.
