Male revision rhinoplasty surgery is the most difficult and challenging procedure that facial plastic surgeons perform. Perfecting surgery with the three dimensional nose takes years to improve and maybe master. In rhinoplasty surgery, minor rhinoplasty maneuvers that we do today may lead to significant postoperative deformities three years from now. Many of us are taught that aggressive cartilage removal is a procedure of the past. Today’s concept is “less is more”. Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafting and suturing techniques are being taught in most residencies and fellowships and at our national meetings. When primary rhinoplasties are performed, the need for a future revision rhinoplasty is becoming increasingly common. Generally, revision rhinoplasty in males are more complex than females because males may have higher or unrealistic expectations and often, thick nasal skin, which is more difficult to re-support the nasal tip than in thin nasal skin.
In male primary rhinoplasty surgery, the key to prevention of complications is pre-diagnosis of potential anatomical and functional abnormalities. For example, a patient desires a dorsal hump reduction and you identify short nasal bones, thick skin and a long middle vault. Your thorough evaluation will warn you that this patient is at risk for upper lateral cartilage subluxation from the nasal bones (inverted-V deformity) and internal valve collapse following osteotomies.
For male revision rhinoplasty patients, initially perform a detailed anatomic and functional evaluation of the nose followed by documentation of the postoperative nasal deformities that are present and sites of nasal obstruction. After the problems and potential complications are identified, create a general surgical plan while studying the preoperative photographs and prepare to use everything in your surgical armamentarium since your preoperative plans for revision nasal surgery will usually change during surgery.
Below is my algorithm for a revision rhinoplasty consultation. When the appointment is made, the patient is asked to bring a copy of their medical records and operative reports from their rhinoplasty surgery or surgeries, in addition to photographs of their native nose. Review the notes and photos while the prospective patient is discussing surgery with your patient care coordinator. This will give you a head start on identifying the problems assuming that a problem exists. Next, a detailed history is performed while listening very carefully to the patient’s wishes. Does he have realistic expectations? This is by far the most important detail that the astute surgeon needs to attain from the history. What is the patient unhappy with – a pinched tip or polly-beak deformity?
Additionally, listen to the patient and see if negative comments are made or if the patient is seeking litigation against the prior surgeon. If this is the scenario, you may want to think twice prior to performing a revision rhinoplasty on this patient. If the male patient is not happy with the results of his surgery by you, there is a good chance that he will be saying unkind words about you in the subsequent surgeon’s office. Does he fit the SIMON profile (Single, Immature, Male, Obsessive, and Narcissistic)? If so, watch out since these patients are very difficult to please and are litiginous. During the initial five minutes of your history, the astute surgeon should know if the patient is a good candidate for revision surgery. Poor patient selection can lead to an unhappy patient and surgeon.
Another important detail is to ascertain if the patient has nasal obstruction. The incidence of postoperative nasal obstruction following a primary rhinoplasty is approximately 10%.1 Determine if the nasal obstruction was present preoperatively. If the obstruction is a result of the surgery, a number of questions need to be answered. Did the patient have reductive rhinoplasty surgery? Have the patient point out where the obstruction is. Is it static or dynamic? Present with normal or deep inspiration? What alleviates and worsens the nasal obstruction? What are the characteristics of the nasal obstruction? Was septal surgery performed? The physical examination ensues.
For the physical exam, I use a detailed nasal analysis worksheet Perform a detailed visual and tactile evaluation of the nose. Use an ungloved finger to palpate the nose. Examine the bony and cartilaginous skeleton, tip and skin-soft tissue envelope characteristics in frontal, oblique, lateral and base views. For the bony dorsum, examine the osteotomies, presence of open roof deformity or rocker deformity, and hump under- or over- resection. If inadequate hump reduction is in question, first examine for a deep radix and/or under-projected, ptotic nasal tip and for microgenia.
Look for middle vault abnormalities such as a narrow middle vault, inverted-V deformity or under-resection of the cartilaginous dorsum (polly-beak deformity). For the tip, examine tip projection, rotation, support, alar and columellar retraction, over-aggressive alar base reduction, and lower lateral crural characteristics such as over-resection, cephalically oriented or bossa formation. Over-resection of the lower lateral cartilage complex in males with a heavy sebaceous skin-soft tissue envelope can cause tip ptosis and subsequent, nasal obstruction. A deviated cartilaginous dorsum and tip can signify a deviated septum. This is only a partial list of anatomical problems that the surgeon needs to identify in nasal analysis.
For male patients with nasal obstruction, observe him performing normal and deep inspiration on frontal and basal views. Often, the diagnosis is easily identifiable as supra-alar, alar and/or rim collapse (slit-like nostrils) during static or dynamic states. External valve collapse (lower lateral cartilage pathology) can be evaluated with the soft end of a cotton swab while plugging the contra-lateral nostril. The cotton swab elevates the area of obstruction whether it’s the alar rim, lower lateral crura or supra-alar region. See if the nasal obstruction is alleviated by elevating the nasal tip in patients with ptosis of the nasal tip. Perform the Cottle maneuver (pulling laterally on the cheek) to check for internal valve collapse. Although this test is generally non-specific, internal nasal valve pathology caused by supra-alar pinching or a narrowed angle between the upper lateral cartilage and septum can be diagnosed. On basal view, examine the medial crura feet to identify if they are impinging into the nasal airway.
Following a thorough external nasal evaluation, the endonasal examination ensues. At minimum, perform anterior rhinoscopy with and without topical decongestion. In certain cases, nasal endoscopy and rhinomanometry may be useful. Evaluate the nasal septum for perforations, persistent deviation and for any remaining cartilaginous remnants to be used for grafting. Other causes of nasal obstruction to identify are: hypertrophic inferior turbinates, synechiae between the lateral nasal wall and septum, nasal masses and middle turbinate abnormalities (concha bullosa).
As you are examining the patient, create a mental problem list with solutions followed by documentation on your nasal analysis sheet, such as: 1. external valve collapse secondary to over-resected lower lateral crura with a plan of open rhinoplasty with alar batten grafts using conchal cartilage, 2. internal nasal valve collapse secondary to a narrow middle vault and supra-alar pinching with moderate inspiration with a plan of bilateral spreader grafts and supra-alar batten grafts using conchal cartilage, and 3. bilateral alar retraction with a plan of bilateral conchal composite grafts. If structural grafting is necessary, decide what material may be used. A thorough knowledge of the types of autologous (septal, conchal, costal cartilage, deep temporalis fascia, and calvarium) or alloplastic grafting is needed as well as harvesting techniques.
This is only an initial plan as you are creating your algorithm. Guaranteed, it will change as you get closer to surgery. Computer morphing can be extremely useful if patients are notified that the final image is not a guarantee of results. However, despite proper notification and consent, there have been reports of lawsuits filed by patients for outcomes that are different than what was generated by the computer imager. Computer imaging can give clues to the patient’s expectations. Unrealistic expectations can be identified when a conservative image is generated by the surgeon and the patient desires a radical change. Therefore, computer imaging can be a powerful tool in evaluating patients for surgery. I can’t count the number of times that I have rejected male patients for primary and revision surgery secondary to them having unrealistic expectations only being identified by the computer morphing. An additional use for the computer image is to use it as a goal in surgery. Bring the preoperative and computer imaging photos to the operating room.