Revision rhinoplasty, also commonly referred to as secondary rhinoplasty, is any time the nose has surgery performed on it after the first surgery. Revision rhinoplasty is more often than not more difficult to perform than a primary (first time) procedure. It takes more time to complete, will often require materials gained from other parts of the body, and requires more knowledge, experience, and technical skills on the surgeon’s side. 

So why is secondary rhinoplasty much tougher to perform? Well, to begin with, the anatomy is no longer pristine, but rather, there will often be an abundance of thick, hard scar tissue from the previous operation. Scar tissue obscures the natural tissue planes that separate the various cartilages, bone, and soft tissue within the nose. Precise and careful dissection is often painstakingly necessary to separate the scar tissue from normal structures of the nose.

Defining the normal existing anatomy of the nose is only the beginning and this alone can take hours. Once the existing anatomy of the nose has been clearly defined, the surgeon then has to assess what’s present, what’s absent, what’s normal, and what’s abnormal. This assessment is followed by correlation with the current clinical picture and what is the desired final outcome. To achieve this desired result, the surgeon then has to begin formulating a plan to “re-build” the nose. 

The nose is like a tent, supported by its poles. Underneath the skin of the nose, there are inter-related cartilage structures that give shape to the nose. More importantly, these cartilages also keep the nostrils open and allows a patent airway to breathe through. Not uncommonly, a revision rhinoplasty case will present a nose that lacks structural support. Imagine a tent which has weak tent poles. A nose like this will lack strength and is at risk of collapse. One of the reasons why this type of nose may lack support may be due to over-removal of tissue from the previous operation.

To restore structural support to the nose, one has to find material (usually cartilage) to build and also support the construct of the nose. The cartilage that is used is often taken from the septum (the structure that runs down the middle of the nose), the ear, or the rib. “Harvesting” this cartilage material is another factor which adds to the complexity and time required for a revision rhinoplasty. It also adds to another scar on the patient. 

At the outset at any rhinoplasty, one has to devise a plan together with the patient that aims to achieve the ideal outcome through one, first, and final, procedure. That been said, as with any other surgery, there is always the chance that the outcome achieved may not be 100% in line with what the patient expects. Complications can occur, and revision surgery is always a possibility. With nose surgery, both surgeon and patient need to be extra patient before they evaluate the final result. Swelling in the nose can persist for many months after surgery, especially in men and in thick skinned people.

One must be careful not to rush into performing a revision before the final shape of the nose is realised. The shape and function of the nose will continue to change and often improve as swelling subsides and the scar mature. Regular follow up between the patient and surgeon is therefore crucial to ensure that the patient is progressing in the right direction. 

Talk to Dr.Raymond Goh one of the best Rhinoplasty surgeons in Brisbane.

 

Dr Raymond Goh is a fully qualified Australian trained Plastic Surgeon from theRoyal Australasian College of Surgeons (FRACS). He is a certified member of theAustralian Society of Plastic Surgeons (ASPS), and the Australian Society of Aesthetic Plastic Surgery (ASAPS).

Plastic Surgeons who perform rhinoplasty on a regular basis and who apply the latest techniques in both primary and secondary rhinoplasty will be more than familiar with the term “spreader graft”.

This term will occasionally be mentioned during a rhinoplasty consultation, whether it be for functional or cosmetic reasons, or both. Many patients however remain confused about what exactly is a spreader graft and it’s role in rhinoplasty.

Essentially a spreader graft is a small (and usually long) block of material (usually cartilage) placed in the middle portion of the nose. It is placed between the septum (the midline structure of the nose) and the side of the nose, and usually as a pair, although occasionally only one may be used. The cartilage used in spreader grafts can be taken from the non-essential portion of the septum, the ear, or the rib. Spreader grafts are not necessary in all rhinoplasties. They are often applied in the following circumstances:

1. To open up the internal part of the nose in situations where the airway is narrowed (and therefore causing breathing problems).
2. To fill in deficiencies on the dorsum (roof) of the nose after it has been reduced.
3. To create pleasing vertical lines on the dorsum of the nose. This is often referred to as “dorsal aesthetic lines”.
4. To support the septum in cases where it is weak and pose a risk to collapse of the nose.
5. To support the nose after it has been straightened.

Rhinoplasty is more than just making a nose bigger, smaller, or straighter. It is about removing or adjusting parts of the nose that may be causing aesthetic or functional problems, and re-building the nose in a structural fashion. Structural Rhinoplasty is now considered the gold standard in functional and aesthetic rhinoplasty.

The nose is made up of its various components (dorsum, tip, radix, columella etc.), and reconstituting and supporting the structures that make up these components is paramount to having an aesthetically pleasing as well as long-lasting result.

When a patient comes in with a deficient chin desiring a chin enhancement, they’ve often done some research on the different techniques that can be utilised. A question that is often raised is the choice between using a chin implant versus getting an osseous genioplasty. A chin implant is quite self-defining in what it is and how it can be used to enhance the chin. An osseous genioplasty, where the bone of the chin is actually cut and moved, is less understood.

In most circumstances, a patient’s chin can be enhanced with either an implant or an advancement genioplasty. There are certain circumstances however, whereby an implant will not get a good result and an osseous genioplasty is a better option.

Let’s take an example of a patient who comes in with a deficient chin. Examination may reveal that her chin is deficient more so in vertical height and just a little deficient in terms of projection. She may already have a well defined labial-mental fold (the fold between the lower lip and the chin). If we used a chin implant in this case, it will only increase the projection of her chin, and not address the height of the chin. Doing this runs the risk of resulting in a “witch’s chin”. This is a situation whereby the patient is better suited to an osseous genioplasty, where we can adjust the height as well as the projection of the chin. The ability to define the chin three-dimensionally is one advantage of an osseous genioplasty. The other advantage is the absence of foreign materials, which reduces the risk of infection.

Subtle improvement is the key to chin surgery. Enhancing it such that it no longer is a point of deficiency but, at the same time, not so much that it becomes a point of attention.

This principle applies to facial aesthetics, and in particular, nose and chin surgery.

An easy way of considering vertical facial proportions is to break it up into thirds: the upper third, made up of the forehead and eyes; the middle third, dominated by the nose; and the lower third, composed of the mouth and chin. When there is a good even balance in size and dominance between the thirds, the face presents itself in a very pleasing manner. Given that there is generally minimal variation in forehead size, vertical facial balance is essentially determined by the size of the nose and the chin.

I see many patients who come in and wish to have their nose reduced in size. Patient will often comment that they look at a photo of themselves or in the mirror, and the first (and only!) thing that they see is their nose. Indeed, a prominent nose will instinctively draw the observing eye to itself. If a prominent nose is coupled with a deficient chin, then this will make the situation worse, can portray an obvious “top heavy” facial appearance. The impact that the chin plays in facial balance is often underplayed. It is often the sole cause of facial imbalance, and will frequently make the nose appear larger and more prominent than it actually is.

In my clinical assessment, it is important to first examine the nose and the chin on their own, and then the two structures together in unison. The fulcrum or pivot point in terms of balancing the nose and the chin is usually around the upper lip region.  A quick look at a lateral or profile photograph will give us a general impression of whether a patient is “top heavy” or not. The next step in deciding whether we perform a reduction rhinoplasty, a chin augmentation, or both will be governed by the outcome of this assessment.