Rhinoplasty Revision Featured Patient
Secondary rhinoplasty is indicated for patients who desire a revision rhinoplasty. Patients who had prior rhinoplasty are frequently referred to Dr. Mowlavi for various reasons including nasal dorsum contour irregularities, suboptimal nasal tip shape or malpositioning and compromise of nasal structural support infrastructure leading to difficulty breathing.
Irregularities in nasal dorsum contour can result from wither nasal dorsal bony irregularities of the upper third of the nose or from poorly supported upper lateral cartilages which results in “an inverted V” deformity of the middle third of the nose. Irregularity in nasal dorsal bony contour can arise either from prominent bony spicules that create compromise of the overlaying nasal skin or from asymmetric infrastructure and medialization of the nasal bones causing a crooked nose deformity. Either deformity can be corrected by revising the previously performed osteotomies. The correction of the inverted V deformity requires reinforcement of the upper lateral cartilage to the dorsal septum utilizing a spreader graft. Suboptimal nasal tip shape is characterised as an amorphous tip, in contrast to a refines nasal tip shape, and result from improperly performed nasal tip cartilage stitching (intradomal and interdomal stitches). This deformity can be corrected by revising the nasal tip cartilage stitches and infrequently introducing onlay cartilage grafts. Since onlay cartilage grafts are vulnerable to resulting in an operated look, Dr. Mowlavi advocated softening all onlay graft edges and camoflauging the grafts with a temporalis fascia. Suboptimal nasal tip positioning is frequently observed and results from poorly reinforced nasal tip cartilage structures resulting in a tip that is lower than the nasal dorsum. When the nasal tip does not lead the nasal dorsum, the tip appears droopy as characterized by the parrot beak deformity.
Patients who develop difficulty breathing following rhinoplasty demonstrate constriction of their internal nares due to poorly supported upper lateral cartilage and nasal dorsal septum junction resulting in constriction (internal nasal valve constriction), concavity of the middle third nasal side wall due to a weak upper lateral cartilage canopy, or from pinching of the nares entry way at the alar rim (external nasal valve constriction). Correction of the internal nasal valve constriction requires placement of spreader grafts. Collapse of the middle third nasal side wall can be corrected with placement of alar batten grafts which are placed in the nasal side wall and which stent up the middle nose soft tissue. Finally, correction of a pinched external nasal valve requires placement of alar contour graft that is placed directly into the alar rim and help stent open the entry way.