Secondary Rhinoplasty

The most prevalent nasal dorsum abnormalities are under-resection, over-resection, and persistent deviations.

• Under-resection: Repeat hump removal with osteotomes or raspatories (a surgical instrument for abrading) can correct the under-resection of the bony nasal dorsum.
• Over-resection: Dorsal grafting can be used to repair an over-resected or scooped dorsum. 

1. To strengthen the dorsum, diced cartilage grafts or carved “onlay” dorsal struts may be applied.
2. As a dorsal onlay, a long piece of cartilage from the septum or rib is preferable.
3. The disadvantages of employing a single piece of cartilage as a dorsal onlay include the requirement for a relatively long straight piece of cartilage as well as the potential of warping.

• The septum is the nose’s backbone, and any remaining septal deviation should be treated during the correction.

1. Failure to straighten the nose is associated with increased incidence for persistent crookedness. Straightening rhinoplasty is one of the most difficult technical procedures in rhinoplasty, requiring the surgeon to overcome not only bony and cartilaginous abnormalities, but also tissue memory and soft tissue.
2. Extracorporeal septoplasty can be used to replace the whole septum. When doing full septal replacements, surgeons prefer to leave a dorsal strut in situ to prevent dorsal asymmetries, improve reconstruction, and provide dorsal support.
3. To straighten the nose, bilateral lateral osteotomies (cutting the bone) with either an intermediate osteotomy on the longer side or bilateral medial osteotomies.
4. The doctors prefer the intermediate osteotomy because it retains dorsal support at the rhinion (the lower end of the median suture joining the nasal bones) and prevents asymmetries in the nose’s weakest skin region.
5. In extreme cases, a transverse osteotomy to remove the ethmoid’s perpendicular plate from the base of the skull may be required.
6. Both intermediate and bilateral medial osteotomies can be performed effectively. Camouflage grafts are useful in correcting residual dorsal asymmetries or deviations. 

Middle Third of the Nose

A typical finding in revision surgery is nasal blockage caused by persisting asymmetries in the middle portion of the nose. High septal deviations that were not previously corrected are frequently addressed during revision septoplasty. Internal nasal valve stenosis and/or inverted V deformities can be treated using spreader grafts.

Pollybeak deformity (extra tissue over the supratip area) with supratip prominence (region over the bridge of the nose directly before the nasal tip) can be caused by insufficient cartilage lowering and/or soft tissue scarring. The combination of a relatively high anterior septal angle and poor tip support is a cause for postoperative pollybeak as scarring causes nasal tip contraction and deprojection.

• The cartilaginous pollybeak can be corrected by reducing the anterior septal angles and projecting and supporting the nasal tip.
• Soft tissue pollybeak is frequently the consequence of scarring caused by an extensive supratip break. Patients may be predisposed to this consequence if the subdermal plexus is disrupted. In the early postoperative phase, steroid injections in the supratip region can be beneficial in correcting soft tissue pollybeak deformity. 

Lower Third of the Nose

The most difficult aspect of revision rhinoplasty is frequently nasal tip revision. Surgeons’ approach to the nasal tip begins with a columellar strut, tongue-in-groove, or caudal septal extension graft to provide support and a stable foundation for the nasal tip’s core complex.

Many of the tip support mechanisms are damaged during primary rhinoplasty, and regaining the support is required to get outcomes that will withstand the stress of healing and time.

Crura: The segment of alar cartilage found above the nostril and below the nasal dome.

The medial crura are commonly secured to the central stabilizing graft and to each other. Following that, the direction and symmetry of the lower lateral crura is addressed. Lateral crural struts, and, if necessary, lateral crura relocation are technical measures to strengthen the lower lateral crura.

The final stage is to determine whether or not the tip and dome projection is adequate. A dome division might be considered if the nasal tip is over-projected. At this time, lateral crura overlaps can also be applied.

Alar retraction, whether hereditary or as a result of rhinoplasty, is quite obvious and disturbing.

• When evaluating patients with alar retraction, determine whether the nose is over-rotated and shortened, and distinguish between excessive columellar show and real alar retraction are important aspects.
• Alar rim graft, lateral crura repositioning, and composite auricular grafts to the vestibule are all techniques used to repair and prevent alar retraction.

After deprojection on a reduction rhinoplasty, alar base widening might occur. Following considerable deprojection, the alar base should be examined for excess alar flare, enlarged nostril size, or a combination of these conditions. Local anesthesia is used to accomplish an alar base reduction in the office. 

Soft Tissue of the Nose

The most difficult abnormality to correct in rhinoplasty is soft tissue scarring and contracture. Infection or vascular damage can both damage the skin.

Severe alar notching caused by a soft tissue injury is sometimes treated solely by enlarging the soft tissue envelope, and composite grafts are useful in these cases.

Incisions that are improperly placed are difficult to repair.

• Incisions made in the alar rim and soft tissue triangle rather than the margins frequently result in noticeable scars that change the contour of the nostril. Composite grafts can be used to improve a scarred soft tissue triangle.
• Lowering the lar base Incisions that destroy the alar-facial sulcus will give the patient a strange look. V-to-Y advances can be used to correct alar base reduction and assist restore the previously effaced alar-facial sulcus.
• Finally, laser or skin resurfacing with Dermabrasion can help heal external scars. This abrasive action improves skin contour as it scrapes away top layers of skin to unveil smooth new skin.