Secondary rhinoplasty operations

In recent years the number of plastic surgery has grown exponentially and cosmetic rhinoplasty is, among many, the most requested. Consequently, both the failures and the number of legal disputes between doctors and patients have increased. It is my opinion that the shape of the nose after the operation and the elimination of defects, should go unnoticed and be well integrated in the context of the facial features, and not stand out in a positive or in a negative sense. Unfortunately, however, even after a correct intervention, unexpected minor defects may remain. For example, small nasal septum deviations due to a different compression force of the two nasal swabs, or small differences in the degree of tilt of the nasal walls caused by a different pressure from the plaster splint on one side, or imperfect closure of the nasal dorsum after lateral osteotomies made to narrow the nose. Typically, these small defects go unnoticed, or are accepted by the patient because of a significant overall aesthetic improvement; if not, they can be repaired with minor editing to be performed at least six months after the primary surgery.

There is a growing number of dissatisfied patients in the offices of plastic surgeons that require a second, or even a third or a fourth, "repairer" operation. The doctor who accepts the secondary task assumes a big responsibility, because of the presence of scar tissue, which makes the healing process more difficult, and because will not be saved from criticism in the event of another even partially disappointing result.

Therefore, many corrective techniques, which make up the vast universe of secondary rhinoplasty, have been developed and refined.

Let's start by saying that the types of defects detected after a botched rhinoplasty and septoplasty are numerous and difficult to classify, as well as often being variously combined with each other. Each case is unique, and requires special plan. In the decision to "re-operate” the magnitude of the defect present relative to the previous state of the initial intervention (with the resulting visual impact) is the most important factor; in fact, the assessment of a defect after a rinoplasty without knowing the initial situation makes no sense, because what looks like a defect could also be the residual result of the correction of an obvious deformity.

A) Saddle nose deformity ("boxer’s nose "). Causes: excessive reduction of the back of the nose caused during the process of the osteo-cartilaginous hump removal, or by a collapse of the septal cartilage after a too aggressive of "septoplasty" with excess removal of septal cartilage, and loss of the support function of the septum itself.

Correction: is done by using cartilage grafts "affixed" on the dorsum of the nose to increase its height and make it more balanced with respect to the tip of the nose. The cartilage is taken from the septum itself if available or from the ear, and variously shaped according to the defect to be corrected.

B) Nasal tip too raised and nostrils "on top" (Can be associated with saddle nose deformity))

Causes:

1) Excessive shortening of the nose for excessive resection of the septum and of the mucosa that covers it, just below the tip of the nose. In this case in the profile view the columella can be hidden by the rising edge of the wing of the nose (so you do not see the arch of the nostril).

2) Excessive removal of the cartilage of the tip and the terminal tract of the triangular cartilage of the dorsum. In this case the side walls of the nose appear collapsed when viewed from the front, and we have what is called "pinched nose"; also unlike the first instance, in the profile view of the arch of the nose appears more open.

3) Coexistence of both factors.

Correction: If the exaggerated lifting of the tip is due to excessive shortening of the anterior septum, and especially of the mucosa that covers it, we proceed to extend the nose, turning it down, by "placing" of a graft of cartilage to replace the part of the septum removed in excess, while the two layers of the mucosa (mucoperichondrium) present on both sides of the septum, are mobilized and moved forward to cover the graft.

C) The "Supratip" or "Raven's Beak": This is an abnormal bulge present above the nasal tip, which alters the profile line.

Cause: due to insufficient resection of the cartilaginous dorsum of the nose, or of the alar cartilages of the tip, especially in the presence of bulky tissues

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Correction: the lowering of the corresponding section of the dorsum (triangular septal cartilages and possibly of the alar cartilages of the tip), thinning of the subcutaneous fat of the tip.

D) Nasal dorsum deviation:

Causes: may be linked to an asymmetry in the two lateral osteotomies, (after the removal of a hump of the nasal dorsum, the dorsum is open and the bony walls of the nose must be approximated to close it, after being cut with an osteotome; this maneuver, which is called "lateral osteotomy, causes a deviation of the dorsum if it is carried out in staggered levels on both sides, or is incomplete on one side).

In some cases a deviated nose after a rhinoplasty, is the result of a high deviation of the bony septum, which can present with a ledge with convexity to the right or to the left; this septal deformity, that before the operation did not involve any asymmetry, the can cause it after the rhinoplasty; in fact, when we pinch the nose with lateral osteotomies, as described above, the protrusion of the bony part of the septum on either side, prevents a correct translation of the bone to the midline.

Correction: In the first case it is necessary to repeat the lateral osteotomy correctly on the bad side. In the second case (high bony septum deviation, which prevents from a combination of the two sides of the nasal bone during rhinoplasty), the "crooked nose", can be corrected with a graft on the dorsum, possibly after it is lowered. This graft is shaped like a stick and it is identical to the one used for increasing the saddled dorsum; it, superimposed on a deviated septum, covering it and giving it a straight configuration.

E) The open roof: It is defined by this term a broad nasal bridge with an opening present on both sides between the septum and lateral bony walls.

Causes: the defect is caused by lateral osteotomies that are absent, or bilaterally insufficient.

Correction: repeat osteotomies side.