Male revision rhinoplasty surgery is the most difficult and challenging procedure performed by facial plastic surgeons. Perfecting 3D nose surgery takes years to master and perhaps master. In rhinoplasty surgery, the minor rhinoplasty maneuvers we do today can lead to significant postoperative deformities three years from now. Many of us are taught that aggressive cartilage removal is a procedure of the past. Today’s concept is “less is more”. Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafting, and suturing techniques are taught at most residencies and fellowships and at our national meetings. When primary rhinoplasties are performed, the need for a future revision rhinoplasty is becoming more common. In general, revision rhinoplasty in men is more complex than in women because men may have higher or unrealistic expectations and often thick nasal skin, which is more difficult to re-support the nasal tip than in men. thin nasal skin.
In male primary rhinoplasty surgery, the key to the prevention of complications is the prior diagnosis of possible anatomical and functional abnormalities. For example, a patient wants a dorsal hump reduction and you identify short nasal bones, thick skin, and a long mid-vault. Your thorough evaluation will alert you that this patient is at risk for superior lateral cartilage subluxation of the nasal bones (inverted V deformity) and internal valve collapse after osteotomies.
For male revision rhinoplasty patients, initially perform a detailed anatomical and functional evaluation of the nose followed by documentation of any postoperative nasal deformities that are present and sites of nasal obstruction. After identifying problems and potential complications, create an overall surgical plan while reviewing pre-op photos and be prepared to use your entire surgical arsenal, as your pre-op plans for revision nasal surgery will often change during surgery.
Below is my algorithm for a revision rhinoplasty consultation. When the appointment is made, the patient is asked to bring a copy of their medical records and operative reports from their rhinoplasty surgery(s), in addition to photographs of their native nose. Review the notes and photos as the prospective patient discusses the surgery with their patient care coordinator. This will give you a head start in identifying problems, assuming a problem exists. A detailed history is then taken while listening carefully to the patient’s wishes. Do you have realistic expectations? This is by far the most important detail the astute surgeon needs to elicit from the story. What is the patient unhappy with: a pinched tip or a chicken beak deformity?
Also, listen to the patient and see if any negative comments are made or if the patient seeks litigation against the previous surgeon. If this is the scenario, you may want to think twice before performing a revision rhinoplasty on this patient. If the male patient is dissatisfied with the results of your surgery, he is likely to say unpleasant words about you in the surgeon’s office afterward. Does SIMON fit the profile (Single, Immature, Masculine, Obsessive and Narcissistic)? If so, beware as these patients are very difficult to please and are contentious. During the first five minutes of his history, the astute surgeon must know if the patient is a good candidate for revision surgery. Poor patient selection can lead to a dissatisfied patient and surgeon.
Another important detail is knowing if the patient has nasal obstruction. The incidence of postoperative nasal obstruction after primary rhinoplasty is approximately 10%.1 Determines if nasal obstruction was present preoperatively. If the obstruction is the result of surgery, a number of questions need to be answered. Did the patient undergo reduction rhinoplasty surgery? Have the patient point to where the obstruction is. Is it static or dynamic? Does it present with normal or deep inspiration? What relieves and worsens nasal obstruction? What are the characteristics of nasal obstruction? Was septum surgery performed? Follow the physical exam.
For the physical exam, I use a detailed nasal analysis worksheet. I perform a detailed visual and tactile evaluation of the nose. Use a bare finger to feel the nose. Examine the bony and cartilaginous skeleton, tip, and skin and soft tissue envelope features in frontal, oblique, lateral, and base views. For the bony dorsum, examine osteotomies, presence of open roof deformity or rocker deformity, and over or under resection of the hump. If inadequate hump reduction is in question, first look for a deep root and/or underprojected ptotic nasal tip and microgenia.
Look for abnormalities of the median vault, such as a narrow median vault, an inverted V deformity, or underresection of the cartilaginous dorsum (chicken beak deformity). For the tip, examine tip projection, rotation, support, alar and columellar retraction, overly aggressive alar base reduction, and lower lateral crural characteristics such as overresection, head orientation, or bossa formation . Excessive resection of the lower lateral cartilage complex in men with a dense sebaceous covering of skin and soft tissue can cause ptosis of the tip and subsequent nasal obstruction. A deviated cartilaginous dorsum and tip may signify a deviated septum. This is only a partial list of anatomical problems that the surgeon should identify on nasal analysis.
For male patients with nasal obstruction, observe him taking a normal deep inspiration in frontal and basal views. The diagnosis is often easily identifiable as supraalar, alar, and/or rim collapse (slit-shaped nostrils) during static or dynamic states. External valve collapse (inferior lateral cartilage pathology) can be assessed with the soft end of a cotton swab while the contralateral nostril is plugged. The cotton swab elevates the area of obstruction, be it the alar rim, lower lateral pillar, or supraalar region. See if nasal obstruction is relieved by elevating the nasal tip in patients with ptosis of the nasal tip. Perform the Cottle maneuver (pulling the cheek laterally) to check for internal valve collapse. Although this test is generally not specific, it can diagnose internal nasal valve pathology caused by supraalar pinching or a narrow angle between the upper lateral cartilage and the septum. In the basal view, examine the feet of the medial pillars to identify if they are compressing the nasal airways.
After a thorough external nasal evaluation, the endonasal examination is performed. At a minimum, perform anterior rhinoscopy with and without topical decongestion. In certain cases, nasal endoscopy and rhinomanometry may be helpful. Evaluate the nasal septum for perforations, persistent deviations, and any remaining cartilaginous remnants to be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae between the lateral nasal wall and the septum, nasal masses and anomalies in the middle turbinates (concha bullosa).
As you examine the patient, create a list of mental problems with solutions followed by documentation on your nasal worksheet, such as: 1. External valve collapse secondary to overexcision of the lower lateral pillars with an open rhinoplasty plan with alar slat grafts using concha cartilage, 2. collapse of the internal nasal valve secondary to mid and supraalar narrow pinch with moderate inspiration with a plan of bilateral widening grafts and supraalar slat grafts using concha cartilage, and 3. Bilateral alar retraction with a plan of composite shell grafts. If a structural graft is necessary, she decides what material can be used. A thorough understanding of the types of autologous grafts (septal, conchal, costal cartilage, deep temporal fascia, and cranial vault) or alloplastic grafts, as well as harvesting techniques, is required.
This is just an initial plan as you are creating your algorithm. Guaranteed, it will change as you get closer to surgery. Computer transformation can be extremely helpful if patients are notified that the final image is not a guarantee of results. However, despite proper notice and consent, there have been reports of lawsuits filed by patients for results that are different from those generated by the computer imaging camera. Computer images can give clues about the patient’s expectations. Unrealistic expectations can be identified when the surgeon creates a conservative image and the patient wants radical change. Therefore, computer imaging can be a powerful tool in evaluating patients for surgery. I cannot count the number of times I have turned away male patients for primary and secondary revision surgery because they had unrealistic expectations and were only identified by computer transformation. An additional use of the computer image is to use it as a target in surgery. Bring the preoperative and computer imaging photographs to the operating room.
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