ANATOMY AND ANALYSIS IN REVISION RHINOPLASTY
Rhinoplasty is among the most challenging of facial plastic surgical procedures. Not only is the nose the central aesthetic feature of the face, but if it is misshapen a functional problem may compound the cosmetic distortion. Potential difficulties the surgeon might encounter in primary rhinoplasty are only made more challenging when the patient has already had one attempt at surgery.
Revision rhinoplasty is not simply a second surgery in the same anatomic location. At best, the patient wants a little better result than the one he was left with after one surgery. At worst, the patient is devastated by a crippling functional problem coupled with a deformity lying in the middle of the face. The high expectations the revision rhinoplasty patient places on the surgeon make accurate preoperative diagnosis imperative. The surgeon must have the skill to analyze a deformity, decide how to repair it, and have several alternatives available to him if his diagnosis is inaccurate or his technique of repair is suboptimal. Anatomic variations, already a challenge to the primary rhinoplasty surgeon, become hurdles of uncertainty the revision surgeon must overcome through accurate diagnosis and sound repair.
Although the techniques for analyzing an unoperated and a previously operated nose are the same, the underlying structure and anatomy may be vastly different. Proper correlation between analysis and aberrant anatomy will lead to more successful outcomes in revision rhinoplasty.
Patients seeking revision rhinoplasty tend to be highly selective in their choice of surgeon. Their revision surgery represents a significant financial, emotional, and time consuming investment and they are naturally more apprehensive about their subsequent procedure. The surgeon must restore the patient’s confidence while mitigating realistic outcomes.
Each patient consulting for revision rhinoplasty has vastly different expectations; the surgeon should advise the patient about how pragmatic these expectations are. An open consultation will help the patient to understand the difficulty and degree of improvement in correcting specific nasal deformities. For example, a patient with an overly narrowed nostril sill as a result of overly aggressive Weir excisions should be advised on the challenge revision surgery represents.
During the interview, it is important to seek out not only aesthetic change, but also functional issues. Often, patients with longstanding nasal obstruction do not realize their degree of nasal air flow impairment. This is especially true in patients with uncorrected septal deviations from previous surgeons and narrow internal valves.
Patients ideally should obtain before and after photographs for each nasal operation and the previous surgeon’s operative notes. Unfortunately, a previous rhinoplasty surgeon’s operative history may harbor gross inaccuracies and should only be used as a rough guide. Photographs may demonstrate a temporal relationship between the complication and when it occurred. An illustration of this is the dynamics of middle vault narrowing which occurs gradually over a period of years rather than months. The patient’s pictorial record may demonstrate subsequent narrowing and coinciding nasal obstruction.
Correlation of the physical exam with controlled quality photographic stills of the patient will provide a better understanding of the patient’s residual nasal deformity. Each of these necessary diagnostic arms provides information which complements the other.
The thickness and character of the skin-soft tissue envelope (S-STE) should be determined. Patients with previous surgery may have extensive thinning of the skin, damage due to extrusion of alloplastic implants, or significant scarring with thickening. Palpation of the S-STE will reveal the extent of damage and mobility of the skin, which may temper expectations of both patient and surgeon. For instance, in a patient seeking dorsal augmentation and added length to his nose, a severely scarred and contracted envelope will limit the amount of surgical improvement possible.
The bony pyramid is examined and palpated for asymmetries, irregularities, and width. The nasal dorsum should follow a gentle curving line from the medial brow to the tip. (1). Persistent dorsal humps should be palpated to help identify their constitution. When the middle vault is examined, it is important to note any asymmetries, the width, deviations, and saddling. Collapse of the upper lateral cartilages should also be noted. It is imperative to examine the dorsal septum in the middle vault area. Deviations in the middle vault can be due to upper lateral cartilage depressions, dorsal septal deviations, or both.
The tip’s rotation, projection, and its relation to the dorsum are then evaluated. Domal asymmetries, fullness, depressions, and the overall shape of the nasal tip should be noted. Palpation of the cartilaginous framework is essential to diagnose the deformity. Tip strength should be determined in order to successfully plan the reconstruction of the medial and lateral tip components, and determine the residual strength of the nasal base. The nasal-labial angle is next examined. Its contributions from the nasal spine and posterior septal angle should be palpated to distinguish soft tissue from cartilaginous excess. Although frequently overlooked, the position of the nasal tip can also contribute to nasal obstruction. Ptotic tips should be manually elevated to determine if any improvement to the obstruction occurs.
The functional examination begins by watching the patient breathe. Does he breathe primarily through his mouth, or does he use his nose? When breathing through his nose, is there dynamic collapse with normal inspiration? When breathing more forcefully, which side collapses first or most severely?
The intranasal examination concentrates on each nasal functional subsection independently. The external nasal valves, septum, internal nasal valves, inferior turbinates, middle meatuses, and nasopharynx are examined serially. Inspection of the nasal septum for any residual deviations and contributions, if any, to dorsal deviations is performed. Any crusting must be removed to reveal the condition of the mucoperichondrium and possibility of occult nasal perforation. The presence of perforations should be noted and explained to the patient. Although they may be complications of previous surgeries, the social history should be reviewed with the patient regarding drug consumption. The septum may be palpated with a cotton tip applicator to help determine whether cartilage is present. In addition, both auricles should be palpated to determine the amount and character of residual cartilage of the concha cymba and cavum. Turbinate hypertrophy should be noted, as well as the nasal mucosa and vestibule examined for scaring or webbing. Webbing is a common source of postoperative nasal obstruction, often due to scarring or failure to properly close endonasal incisions.
Next, a careful analysis is performed of the external and internal nasal valves. No decongestant is initially applied. The nasal valves are carefully examined without the use of a nasal speculum at first, in order not to distort the natural anatomy. A speculum is then used to better evaluate the internal nasal valves. Still without decongestant, the patient is asked to grade his airflow through each side of his nose from 0 to 10. A cerumen curette is inserted into one side of the nose to gently support and lateralize the external and internal nasal valves. The patient is asked to grade the resultant airflow again from 0 to 10 while gently occluding the contralateral nostril. The location of support that gives maximal improvement is carefully recorded. The procedure is then repeated on the other side.(See Figure/Table) After decongestion, the entire evaluation is repeated again in order to weigh the effects of mucosal edema on obstruction. These maneuvers, when combined with a thorough examination, can accurately predict the area of maximal obstruction, and can help guide the surgeon as to the best surgical treatment. (2)
Finally, the nose is examined endoscopically to exclude contributing pathology from the middle meatus or nasopharynx.