The most challenging procedure in facial plastic surgery is revision rhinoplasty
It is widely accepted that the complexity of this procedure supersedes all other surgeries in facial plastic surgery. Many factors contribute to the complexity of revision rhinoplasty. Chief amongst these factors making revision rhinoplasty very complex is the unknown state of the underlying anatomy of the nose. Even with prior operative reports, it is unknown the degree of scarring which could be present in the revision rhinoplasty surgery. Scarring of the underlying anatomy is the primary “X” factor which the revision surgeon needs to be prepared to handle. The focus of this article will be on handling the refinements of the nasal tip during revision rhinoplasty.
In nearly all of the revision rhinoplasties I perform I find that the underlying cartilages of the nasal tip have been over-aggressively removed. The over-aggressive removal of these cartilages leads to the external deformities often seen in these cases as well as to the breathing difficulties present. The nasal tip cartilages are composed of two fairly symmetric cartilages which have been described to be in the shape of “wings.” The wings of the cartilages are called the lateral crura of the lower lateral cartilages (tip cartilages). In many revision rhinoplasty cases I find these cartilages to have been nearly entirely removed. The nose requires the strong underlying support structure of the cartilages to be able to withstand the contraction and healing that takes place after any rhinoplasty. When a wound is initiated which happens with any rhinoplasty (whether open or closed) the wound’s physiological response is to heal. Wounds, in part, heal by contracture and scarring. The scarring places forces onto the cartilages of the nose which need to be withstood to prevent unwanted deformities. In most cases, when the tip cartilages have been aggressively removed they are not able to withstand the healing, contraction forces of the nose and therefore deformities and breathing problems ensue. With the absence of tip cartilages the revision rhinoplasty surgeon, needs to reconstruct the nasal tip to not only give immediate support to the nose but also long-lasting results. This task is clearly extremely challenging and not undertaken by most rhinoplasty surgeons. It is important that during a revision procedure the deformities present are not merely camouflaged by the surgeon, as these will inevitably only lead to further problems and not address any breathing difficulties. Instead the tip should be adequately supported in such a manner as to help counteract and withstand the contractile forces that take place during the healing process after surgery. The degree of scarring after surgery is an unpredictable variable and you and your revision rhinoplasty surgeon’s only defense is that of supporting the tip adequately during the revision procedure. I have seen cases where patient’s had undergone multiple previous revisions and persist with breathing difficulties and tip deformities. When elevating the skin to view the underlying anatomy, I notice that the patient had received multiple previous grafts which had been laid on top of one another in an attempt to hide or camouflage the issue. These cases are often extremely complicated in that the nasal cartilages need to be rebuilt in an aesthetically pleasing manner to both give a good cosmetic outcome as well as a sound functional outcome.