in: Revision Rhinoplasty, Daniel G Becker,Stephen S. Park, Editor, Thieme (U.S) , New-York, pp.224-245, 2008
Aesthetic and functional surgery of the nose presents a
variety of complex challenges. These are even more profound in revision rhinoplasty when the surgeon is
attempting to correct deformities in which loss of tissue,
scar contracture, and lack of autogenous grafting material
make optimal results more difficult. Over the years, we
have used multiple techniques to address specific situations that arise during both primary and revision rhinoplasty. It is important to learn from others and remain
current by techniques described in the literature.
Understanding these techniques, modifying them to meet
your needs, and perhaps, most importantly, knowing
when to use them, must be a continual process to improve
outcomes. We have chosen to discuss cases performed
within the last 6 months (except Case 5) to provide an
overview of our current rhinoplasty practice and the latest
techniques we use to address difficult problems in revision
The first step in evaluating a patient considering rhinoplasty is nasal analysis. Nasal analysis in revision cases
should include palpation of the nose to assess the tissues
remaining such as septal cartilage, bony pyramid, thickness of the overlying subcutaneous tissue, bossae formation and other tip symmetries, and middle vault contour.
Also important is intranasal examination for synechiae,
turbinate hypertrophy, persistent septal deviation or perforation, and evidence of valve collapse. Because these
patients have not had satisfactory initial results, they can
be more demanding. Realistic expectations and goals
should be discussed with the patient beforehand.
Depending on the anatomic problem, an appropriate incidence of further revisions is provided to the patient. For all
but minor revisions, we estimate a 1:15 rate for further
revisions. Photographic documentation is critical.
In some cases, overresection of tissue or scar contracture severely limits the ability to address cosmetic concerns and thus functional improvement should be
considered the primary goal; however, both can often be
achieved with careful planning and execution. Camouflage
grafts can help improve cosmetic appearance when
rearrangement of the primary structures is not possible.
Generally, for small contour deformities, cartilage grafts
are placed in precise pockets endonasally. More major
revision of the tip and middle vault are usually performed
through an external approach. Timing of surgery is important as well; major revisions should be approached when
an adequate amount of time has allowed for scar maturation, whereas minor revisions may be approached with
We describe techniques we routinely use in revision
rhinoplasty cases to address specific problems in the middle vault and tip. These are discussed in a case format for
graphical clarity. All but Case 5 were performed in the last
6 months to give a true “snapshot” of our current preferences. This, of course, limits our ability to provide longterm follow-up and photographs for this group of patients.
Selected cases involved middle vault and tip deformities,
but many revisions involve the bony pyramid. Minor irregularities of the dorsum are treated with a rasp or camouflage with autogenous cartilage—frequently lightly
morselized cartilage. Osteotomies are usually performed
with a perforating technique: external to move the nasal
bones medially and internal to move them laterall