Management of Deformed Nasal Dorsum

Introduction

Rhinoplasty is a surgical procedure performed to correct a deformed nasal dorsum. A surgeon can correct anatomical abnormalities, identify facial skeletal disproportions, and assess nasal features and angles to make necessary adjustments for proper alignment. Patient expectations might be different from the outcome of the surgery. Patients who seek rhinoplasty have psychological issues rather than anatomical abnormalities of the nose. Some patients have a gross nose deformity that affects their moral, social, psychological, and mental balance and makes them feel ugly about themselves. Revision rhinoplasty is performed in the following conditions:. 

• Rhinoplasty is performed by an untrained surgeon. 
• Change in the rules and modification of the techniques. 
• The outcome of the primary rhinoplasty doesn't meet patients' expectations.

Revision Rhinoplasty

Primary [first-time] rhinoplasty is a surgical procedure that is one among several challenging elective cosmetic procedures. Treatment of a failed rhinoplasty is called revision [secondary] rhinoplasty. It is more difficult to perform than the primary rhinoplasty. In primary rhinoplasty, scarring isn't observed, whereas in revision rhinoplasty, there's a chance for skeletal disruption [bone, cartilage, or tip of the nose can get destroyed], fibrosis, circulatory impairment, and soft tissue contracture. Challenges involved in revision rhinoplasty surgery are 

• Skeletal disruptions 
• Fibrosis resulting in contractures 
• Circulatory impairment

Important Points

Before performing the revision surgery, the surgeon should look out for the below situations and parameters. 

• Is there a bony or cartilage deformity in the patient? 
• Is the contracture due to excessive scarring? 
• Is the skin over the nose thin or thick? What is the status of the blood circulation below the nose?
• Most of the revision rhinoplasty patients are frequently burdened with apprehension, anxiety, and skepticism. 
• The surgeon should understand whether the patient has unrealistic expectations and goals or not.
• Perfect restoration of the devastated nose is seldom possible. 
• Carefully conceived and well-executed surgical treatment plans can result in good cosmetic and functional improvement. 

Also read: Measurement Of The Nasal Airway

3 Basic Rules of Rhinoplasty

1. Don't change the normal basic anatomy of the nose or anatomical relationship of the nose, and avoid complete removal of the nasal component.
2. Don't allow the skin and lining membrane to come in contact with each other, as this can lead to contracture or fibrosis and result in a bad surgical outcome.
3. Don't destroy the nasal cartilage.

Conditions Associated with Higher Risk of Revision

In the below conditions, there is a high possibility for revision rhinoplasty surgery. 

Categories of Revision Defined by Webster  

Revision is uncertain or unnecessary in cases where a patient has a good anatomical relationship of the nasion, rhinion, tip, nasolabial angle, and nasofrontal angle. Revision with skeletal reduction is necessary in conditions like excessive bone or excessive cartilage. Revision may involve skeletal augmentation in some cases. External soft tissue removal is required. In cases where a patient has congenital anomalies due to major trauma, revision rhinoplasty is required.

Also read: Understanding Rhinosporidiosis and Rhinoscleroma

Postsurgical Deformities of the Nose

After primary rhinoplasty, a patient might have either excessive or less skeletal tissue. This can happen due to excessive reconstruction or removal of the skeletal tissue. Skeletal tissue excess deformity 

• Incomplete or neglected treatment of congenital skeletal overgrowth, one may have
  • Persistent dorsal hump 
  • Persistent hanging columella 
• As a result of the overuse of augmentation graft material, the nose can be overgrown.

Skeletal Tissue Deficiency 

Skeletal tissue deficiency can occur in cases of overresected nose. The over-resected nose can happen due to 

• Excessive lowering of the nasal bridge. 
• Overzealous excision of the nasal tip cartilage.

[Picture 1: Basal view of the nose] 

In picture 1, the patient has lobular pinching that is causing the collapse of the nasal valve. This showcases that there is a cosmetic deformity, and the patient is suffering from breathing difficulty. 

[Picture 2: Profile view of the nose] 

In picture 2, there is a severe alar retraction with a poor tip projection.

[Picture 3: Frontal view of the nose]

In the frontal view picture [pic-3], there is a lobular pinching and alar retraction on the frontal view.

[Picture 4: Frontal view of the nose]

In this picture, the nasal deformity is visible. A disruption of the browtip aesthetic lines can be seen. Also, distinctive inverted V-shaped shadow transversing the nasal dorsum.

[Picture 5: Lateral view of the nose]

Lateral view of a patient with a retracted ala and excessive show.

[Picture 6: Frontal view of the nose]

In picture 6, the patient has undergone a rhinoplasty that resulted in excessive base reduction and significant airway obstruction. To repair this, placement of auricular composite grafts is required, and this helps to widen the nostril sills. Restoration of over-resection requires re-expansion of the undersized and collapsed skeletal framework against a scarred and inelastic soft tissue envelope. Successful skeletal re-expansion requires 

• A newly constructed framework of sufficient rigidity to distend the scarred and non-compliant nasal skin without causing skeletal distortion. 
• Avoid cutaneous vascular insufficiency that is caused by tight closure with tension. Closing with tension can disrupt nutrient blood flow. 

Also read: Nasal Septal Deviation: Causes, Types, Clinical Features and

Severe Surgical Deformities Require a Combination of More Than One Surgery,

• Over-resected skeletal tissues. 
• Untreated deformities of the original nose. 
• Coexisting nasal airway dysfunction. 
• Twisting and/or asymmetry of the damaged framework.

Surgical Errors and Resulting Deformities

Also read: Tumors of Nose and Sinuses Types

Patient Evaluation and Treatment Planning

The reason for a revision Rhinoplasty, in most cases, is due to the failure of proper evaluation of the nose. The importance of preoperative nasal history, physical examination, and cosmetic analysis cannot be overemphasized. Through rhinoplasty history includes 

• Taking details about the number of prior surgeries. 
• What was the interval between surgeries? 
• What was the specific intervention for each surgery? 
• Subsequent tissue responses. 

All this information can help to characterize the type and degree of prior tissue alteration and the overall woundhealing tendencies. Nasal examination is important, and it includes 

• Existing nasal support 
• Airway patency 
• Nasal contour 
• Tissue quality

This helps the surgeon to customize the surgery plan to compensate for anticipated tissue deficiencies and adverse wound healing responses. Psychological assessment is important in clinical practice to know whether the patient is psychologically affected and to know the motive for the cosmetic procedure. This assessment includes - 

• Careful assessment of the patient's personality 
• Underlying motives 
• Cosmetic objectives 

This assessment helps to reduce the likelihood of disappointment and confrontation stemming from unmet surgical expectations. 

Key Prognostic Indicators in Secondary Rhinoplasty

Age is an important factor since nasal healing responses often decline with age. Noses that have been allowed a prolonged period of recovery are often far more tolerant of secondary surgery. Nasal skin quality is also a crucial indicator of wound healing. Intrinsic cartilage strength is another critical determinant of surgical success rate. The body's genetically predetermined response to tissue injury is an important single factor in the surgical prognosis.

Also read: Nasal Polyposis: Clinical Types, Causes, Pathogenesis And

Physical Assessment of the Nose

Physical assessment of the nose is important as it helps to understand the cosmetic abnormality. Usually, it is done with the help of standardized rhinoplasty photographs. The preoperative nasal examination is performed to 

• Evaluate the structural integrity of the bony and cartilaginous skeletal framework.
• Check the thickness, elasticity, and perfusion of the inner ear and outer nasal lining. 
• Know the status of the entire nasal airway, including external and internal nasal valves, nasal septum, and nasal turbinates. 

Palpitation is indispensable as it helps to know 

• The thickness of the skin 
• Skin elasticity 
• Cartilage strength 
• Tip support 
• Smoothness of the nasal dorsum 

Below are a few of the hallmarks of pending surgical intolerance. 

• Severely collapsed nasal framework 
• Scarred and inelastic nasal skin 
• Reduced tissue perforation 
• Dense cicatricial stenosis of the vestibular skin 

These findings should prompt a sober reassessment of the need for further surgical treatment. Debilitating functional impairments such as obstructive sleep apnea and airway obstruction may justify further intervention despite the increased surgical risk. 

Optimal Timing for Revision Rhinoplasty

Healthy microcirculation is essential to any secondary rhinoplasty. It is recommended to postpone revision surgery for 1 year as microcirculatory impairment is often present in the first year of the primary rhinoplasty

Also read: Olfactory Disorders – Pathway, Work up And Causes

Treatment Strategies

Pollybeak Deformity

Pollybeak deformity is the drooping of the tip of the nose. It is caused by excessive underresected caudal septum and buildup of scar tissue. This also occurs due to poor reconstruction of lower lateral cartilages and poor tip support.

There are 3 types of pollybeak deformity 

• Supratip prominence: This is due to inadequate elevation of the radix and projection of the tip. 
• Soft tip pollybeak: It is caused by the inability of thick and inelastic skin. In this, underlying nasal structures are dripped. 
• Supratip fullness: It is caused by postoperative loss of tip projection due to inadequate stabilization. 

There are 3 options for reconstruction and are 

• Increase of tip projection 
• Reduction of nasal dorsum 
• Combination of the above 2 options 

The most reliable technique to increase tip projection and protection is columella cartilage strut with fixation of the medical crura using an external approach.

Irregularities of the Nasal Dorsum

Irregularities of the nasal dorsum can become visible after excessive hump removal, especially in thin-skinned people with prominent nose syndrome [tension nose]. Very often they are found at the, where the nasal K-area bones overlap with upper lateral cartilage [triangular cartilages]. 

Minor irregularities can be easily rasped. For a cartilaginous deformity, the surface of the cartilage must be made smooth with scissors or a knife. Cartilage graft may be used in some cases to cover the whole distance from the radix to the septal angle. For the same, either a crushed septal cartilage with smooth edges, ear cartilage, temporalis fascia, or alloplasts like Gore-tex can be used.

Also read: Epistaxis: Understanding Anatomy, Classification, and Treatment

Columella Deformities

Acute nasolabial angle with retraction of the columella is often associated with a wide columella base. It is caused by 

• Over-resection or malposition of the caudal septal end. 
• Resection of the anterior nasal spine. 
• Slide of soft tissue posteriorly due to the creation of columella packet between the medial crura. 
• Endorotation of the nasal septum after septoplasty 

The distance between the columellar skin and caudal septum can be increased by inserting a cartilage strut after closing the space between the medial crura footplates with a nonresorbable U suture In case of malposition of the septal cartilage, it can be repositioned [exorotation] and fixed to the anterior nasal spine.

Overshortened Noses   

Typical maneuvers to shorten the nose include: 

• Resection of the triangular part from the caudal septum. 
• Resection of cephalic margins of the lateral crural. 
• Resection of the inferior border of the triangular cartilage. 

Reconstruction of retracted columella bases can be impossible since too many scars can prevent the mobilization of the soft tissue envelope. 

The new position of soft tissues and the infrastructure must be secured by any of the following grafts. 

• Flying buttress graft 
• Caudal septal graft 
• Tip grafts 
• Radix grafts 
• Interposition grafts

Conclusion 

Revision rhinoplasty is both technically and cosmetically challenging. Technical challenges are associated with profound cosmetic derangements and can have unexpected nasal deformities. 

Proper treatment planning is very important for effective outcomes of the surgery. New reconstructive and grafting techniques are available.

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