A revision rhinoplasty, or secondary rhinoplasty, is performed to correct problems that were not treated adequately at the original rhinoplasty, or to deal with complications from the original rhinoplasty. Or, the revision may be needed to correct problems that have developed due to scaring, or to inadequate or excessive surgery at the original rhinoplasty.
Goals of a Revision Rhinoplasty
The key goals of a revision rhinoplasty, as with primary rhinoplasty, are to keep it as simple as possible, create a natural contour that harmonizes with the individual’s face, and improve the airway.
Occasionally, people are not satisfied with the result of their surgery. They may want their nose to be smaller, or narrower, or more reduction of the hump or asymmetry. All of these issues can be improved with a revision rhinoplasty. Most revision rhinoplasties are relatively simple, because they are only focusing on a small residual problem. Or, it may be more complex if complications are being treated or the whole rhinoplasty needs to be redone.
There is always some scaring deep under the skin after a rhinoplasty, and this tissue is harder, and more time consuming, to manipulate. The scar does not flex or move as easily as un-operated tissue, so extra effort is required to obtain the best result. Even though the procedure is more difficult for the surgeon, it will typically produce the desired improvements.
Asymmetry is one of the most difficult problems to correct. This is because the main support of the shape of the nose is cartilage, which is like Tupperware. It is flexible and elastic, so it tends to go back to its original shape. The septum is cartilage and bony wall that divides the airway into two sides. It is also the structure that gets distorted during growth, or from trauma, and creates the asymmetry.
The septum must be reinforced with cartilage taken from the center of the septum, where it is not needed, and sutured to the distorted portion of the septum. If some cartilage was removed from the septum during the primary rhinoplasty, there may not be enough left to help reinforce the septum as much as necessary. However, it is usually possible to restore good symmetry.
Some people have difficulty breathing through their nose before a primary rhinoplasty, but choose not to correct the problem at that time. Later, they may seek correction of the airway with a revision rhinoplasty. Other people may develop a limited airway after a primary rhinoplasty for various reasons including external valve collapse, internal valve collapse, scaring, septal deformity, and enlarged turbinates. The limited airway may be present on only one side, or on both sides.
The airway can be improved with a revision rhinoplasty that may or may not change the appearance of the nose. If the nose looks good, then only the airway is modified. If the appearance is not satisfactory to the patient, it can be improved along with the airway.
External Valve Collapse
The external nasal valve is the area just inside the nasal opening on each side. It is bounded by the septum (wall dividing the airway into two sides) in the middle, and the lower cartilage of the sidewall of the nose (ala) on the outside. The sidewall of the nose is flexible. If it is too thin or weak it can collapse and prevent the normal volume of air from entering the nose. The problem is worse during heavy breathing because the valve collapses more completely under the added strain.
Reasons for external valve collapse:
- Congenital malformation or weakness of the sidewall or septum
- Weakness of the sidewall due to removal of cartilage while trying to narrow the tip of the nose during rhinoplasty
- Excessive scaring after rhinoplasy
- An injury that leads to scaring or loss of tissue
- Aging changes that produce weakening of the sidewall
- The tip of the nose is excessively protruded, causing narrowing of the valve
Diagnosing External Valve Collapse
The patient can apply an external adhesive nasal strip (Breathe Right strips) just above the tip of the nose to spread the nostril openings. If the strip substantially improves the breathing, then there is a good chance that the external valve is the cause of the obstruction. The strip can be moved about a third of the way up the nose and the breathing evaluated again. If there is no improvement over the breathing without the strip, the test confirms that the external valve is probably the primary problem. An examination by Dr. McBride must be done to confirm these preliminary findings and determine the appropriate treatment.
Treatment of External Valve Collapse
- Steroid injections to soften and reduce thick scars
- Septoplasty to correct deviation
- Cartilage grafts to stiffen the sidewall and prevent collapse
- Reposition the lower lateral cartilage
- Scar removal
Most cases of external valve correction will result in some negative cosmetic changes. The sidewall must be moved out in most cases, resulting in more fullness in one or both sides of the nose. If a patient considers cosmetic changes in the shape of the nose unacceptable, he or she is a poor candidate for any attempt at surgical correction of a collapsing external nasal valve.
Internal Nasal Valve
The internal nasal valve is the slit-like opening above the external valve. It is bounded by the septum in the midline and the upper cartilage of the sidewall of the nose.
However, patients who have internal obstructions secondary to scarring or a narrow vestibule may be helped by procedures designed to increase the cross-sectional area of the external nasal valve.
Dallas Surgical Arts offers Revision Rhinoplasty for patients in Dallas & Highland Park TX. Call Dallas Office Phone Number 972-566-4900 to schedule a free consultation.