Issues Following Primary Rhinoplasty, Requiring Revision
Rhinoplasty is a complicated and delicate surgery with both aesthetic and functional aspects that take years of surgical experience to master. For this reason, regrettably, revision rates are very high. As a top revision rhinoplasty specialist, Dr. Rawnsley encounters a variety of problems that can result when rhinoplasty is performed by less experienced surgeons. Each problem requires its own specific corrective treatment.
Some of the most common problems Dr. Rawnsley corrects include:
Bridge and Central Nose Problems
Polly Beak Deformity-Cartilaginous or Soft Tissue
In a natural-looking nose, there is a slight depression as the nose transitions from the bridge to the tip. In the case of the polly beak deformity, however, this bridge area above the tip is too high, giving the nose an appearance like a parrot's beak. Three different complications during rhinoplasty can lead to this problem, which is one of the most common seen after rhinoplasty surgery.
A cartilaginous polly beak deformity occurs when too much cartilage is left after surgery. Revision rhinoplasty in this case involves shaving down the extra cartilage. A soft tissue polly beak deformity occurs when a surgeon removes too much soft tissue on a patient with thick skin so the skin doesn't properly contract and flatten out, causing excessive scar tissue to form in the area. In this situation, corrective surgery involves removal of the scar tissue and the proper placement of an absorbable suture or skin tape to make sure the skin redrapes and heals appropriately. In the third type of polly beak deformity, the original surgeon fails to leave enough support for the tip of the nose and it droops over time, making the area above the tip appear to project too far. Revision rhinoplasty to address the problem requires the surgeon to reconstruct the nasal tip so it has adequate support.
Profile Deformity: Persistent Bump or Scooped Out Bridge
Two post-operative profile deformities can result when a rhinoplasty attempts to address a bump (or bumps) in the nose. In the situation of the "persistent bump," the surgeon fails to completely smooth all of the bone or cartilage of the nose. In the contrasting case of a "scooped out bridge," the surgeon misjudges and takes out too much bone, leaving the patient with an area that looks "scooped out" in his or her profile and too washed out from a front view.
Revision rhinoplasty to address a persistent bump requires additional smoothing with a nasal rasp, a precise tool that allows for an extremely controlled removal of the problematic bone or cartilage. Correcting a scooped out bridge requires build up of the missing area with the patient's own cartilage.
Collapsed Central Nose: Middle Vault / Inverted "V" Deformity and Internal Valve Collapse
The "Middle Vault," also known as the "Inverted V Deformity," occurs when a bump is removed from the central nose, but inadequate support is provided. The center of the nose collapses, both inhibiting breathing and making the nasal bones visible to the naked eye in the shape of an inverted "V." Breathing will also be inhibited when the removal of a bump causes the collapse of the narrowest area inside the nose, the internal nasal valve. As with a scooped out bridge, a revision rhinoplasty to address a collapsed central nose or internal valve collapse involves rebuilding the missing area with the patient's own cartilage.
Irregular Bridge or a Poor Bridge to Tip Relationship
Other general aesthetic concerns relating to the bridge can occur after a rhinoplasty procedure. At times, the problem is simply that irregularities appear in how the bridge heals after the removal of a bump. In addition, there can be issues with the middle one third of the nose, called the central nose. The central nose forms the transition from the bridge to the tip and must be in proper proportion to seamlessly blend the two together in an aesthetically harmonious relationship. If any of the three parts are out of balance, the final result will be unsatisfactory.
Deviated Nose Issues
Deviated Nose or Persistent Deviation After Surgery
A deviated nose is a nose with twist-either in the upper, middle, or tip of the nose. It is one of the most difficult problems to address through rhinoplasty and can persist after a original rhinoplasty or a revision rhinoplasty. It can even be introduced through a rhinoplasty or revision rhinoplasty procedure. A frequent cause of a pre-existing deviation is crooked nasal bones. When the problem is introduced through surgery, it is sometimes because the efforts to remove a bump or other issue cause bones to shift. The techniques to address deviations vary widely depending on where the twist occurs and all the details are highly technical. If your problem involves a deviation in the nose, please discuss it with Dr. Rawnsley one-on-one, for an expert analysis of your particular situation and the best approach to address it.
Pinnochio Deformity/Overprojected Tip
One of the most common mistakes seen following rhinoplasty is the over-protected tip. Once a prominent bump is removed, patients often discover that the tip of the nose projects too far from the face. The problem can be exacerbated if the bridge of the nose slopes too much post-surgery. In many cases, surgeons simply do not dare tackle the issue of the over-protected tip during a rhinoplasty because the techniques to deproject the tip are highly technical and require advanced skill and a deep well of experience. The surgeon would rather avoid the procedure entirely than risk reducing the tip too much. In addition, it is practically impossible to meaningfully reduce the tip in a standard "closed" rhinoplasty procedure. Only an "open" procedure, such as those performed by Dr. Rawnsley (where the flesh between the nostrils is cut), can effectively achieve true deprojection of the tip. The good news is that once a proper open procedure has been performed the structural support for the tip of the nose is far stronger than it would have been without revision rhinoplasty.
Overly Shortened Nose/Over-Rotated Tip
Overresection is the technical term applied when too much of the supporting structure for an area of the nose is removed during a rhinoplasty. The problem can lead to several tip-related abnormalities. If an overresection occurs in the front end of the septum (the structure dividing the two nasal cavities), the tip of the nose can fall backward, causing an overly shortened appearance where the tip is over-rotated upward, like a "pig's snout." Correcting this problem requires the restoration of proper supporting structures in the septum.
Droopy Tip/Under-Rotated or Poorly Supported Tip
Conversely, overresection can also lead to the opposite problem where the tip of the nose droops, called a ptotic tip. In this situation, too much of the tip's support structure cartilage is removed and the end of the nose collapses downward. To lift the tip and correct the problem, the revision rhinoplasty surgeon must rebuild the weakened or missing underlying structure and thus restore support strength to the tip.
Tip Bossae (Knuckling)
If the two projecting points of cartilage that support the nose tip are too aggressively removed they will lose their springy structure and remaining cartilage will begin to bend and twist. This causes a problem called "bossae" or "knuckling" where the cartilage turns upon itself and the weakest points at the joints of the cartilage form very noticeable bumps or "knuckles." Attempting to trim these knuckles as some surgeons do will only further weaken the tip structure in the long term. Instead, the entire tip structure must be reconstructed so it has the strength to last the test of time.
It is important to remember that whenever a rhinoplasty is performed, it involves two separate procedures, one to the right side of the nose and one to the left. In every stage of the surgery, great attention must be paid to symmetry. The cartilage on both sides of the nose tip must be removed to exactly the same degree or and asymmetric tip will result. Asymmetries may also occur due to unequal scarring during the healing process and not reveal themselves until months or even years after the fact. For a successful revision rhinoplasty, the surgeon must pay careful attention to symmetry at every stage of the procedure and through extensive experience anticipate how the scar tissue is likely to form and adjust accordingly for a final, aesthetically satisfying result.
Rhinoplasty procedures using open technique (where the flesh between the nostrils is cut) is an innovation of the last decade. Before that "reductive" rhinoplasty was performed with closed technique, a much simpler approach where cartilage and bone were quickly removed to narrow and shrink the nose, allowing the entire procedure to be completed in about half an hour. Unfortunately, when this approach is used, over time the skin, the soft-tissue envelope, and areas of scar tissue around the nose invariably contract and can look distorted. One of the most common defects and a telltale sign of this style nose job is the "pinched tip," where too much tip cartilage was removed. Revision rhinoplasty to correct the problem involves the restoration of cartilage to restore proper fullness to the tip.
A "unitip deformity" is the term given to the problem where the two points of cartilage (like two wings) that form the nose tip are pulled so close together it appears as if the nose comes to a single point. The problem usually occurs when a surgeon cinches down the suture between the tip points too tightly. To correct the problem, the points must be separated and rebuilt with cartilage to achieve the proper balance.
Other Tip Problems: Wide Tip, Bulbous Tip, and Deviated Tip
If too much of the supporting cartilage for the tip is removed, the resulting tip can collapse and wind up looking too wide or too bulbous. Excessive scar tissue formation after a rhinoplasty can also lead to these same two aesthetic problems. Just as with a drooping tip, the underlying support for the wide or bulbous tip must be strengthened, while scar tissue needs to be carefully reshaped with sutures.
A pre-existing deviated or twisted tip can persist after a rhinoplasty or it can result from a rhinoplasty when too much cartilage is removed on one side and the nose buckles and warps. In a best case scenario, the problem can be corrected by stabilizing or resuspending the tip cartilage with sutures. However, when the problem is the result of missing or damaged underlying structures from a previous rhinoplasty, grafts of cartilage from the septum or the ear must be used to rebuild the necessary support.
Collapsed Nostrils/External Valve Collapse
The narrowest area in the inner structure of the nose is termed the "nasal valve." For normal, unobstructed breathing, it is essential that the entire valve area remain open. While internal nasal valve problems can occur during the removal of bumps on the bridge of the nose, external valve collapse happens when too much tip cartilage is removed during a rhinoplasty procedure. Without proper tip cartilage support, a blockage occurs in the nasal valves just above the nostrils. Addressing the problem means reconstructing tip cartilage to provide adequate support.
Hanging Columella, Retracted Nostril, or Alar Retraction
Failure to ensure proper tip support can lead to other nostril-related problems. The "columella" is the name of the structure that separates the two nostrils. Ideally, this area should only be a few millimeters lower than the edge of the nostrils. If too much of the nasal spine or the bottom of the septum is removed (the structures that support the nasal tip), the columella will appear to hang down too much, called a "hanging columella," and the rim of the nostrils will retract, or pull back, excessively. Not only will the face take on an unflattering "snarl-like" appearance, but breathing can be adversely affected. Fixing the problem requires complex cartilage grafting.
When too much cartilage is removed and excessive upward scarring occurs inside the nostril sidewall after surgery, patients can experience a different problem called alar retraction, where the inside nostril sidewall shows too much. The problem can be corrected with cartilage grafts in minor cases or composite grafts of cartilage and skin (usually from the ear) in severe cases.
General Aesthetic Problems
Aesthetic Imbalance: High Radix
Radix height relates to the angle formed between the frontal and nasal bones of the nose. This height must be in proper proportion to the length, tip projection, and dorsal height to bring about a perfectly balanced, elegant result. If the radix is left too high or if too large a radix graft is put in place during surgery, the nose will have an inelegant, Romanesque quality afterward. The revision rhinoplasty procedure to correct the problem involves the reduction of the radix to its proper, most aesthetically pleasing proportions, given the other aspects of the nose and overall facial shape.
Other Aesthetic Imbalance Issues: Long Nose, Overly Wide Nose, Overly Narrowed Nose
Rhinoplasty is as much an art as it is a science. Not only does a surgeon need to take into account all the proper aesthetic proportions and unique characteristics of a patient's face during the surgery itself, the doctor must also anticipate how the patient will heal and how his or her face will change over time so that the final result achieves all that was intended. Sometimes a rhinoplasty procedure is successful in medical terms, but aesthetically, the nose is simply left too long, or too wide, or too narrow, and only a revision rhinoplasty by an aesthetic expert like Dr. Rawnsley can manage the complications introduced by the previous surgery and achieve the balance and beauty that was originally intended.
Revision Rhinoplasty: Open Procedures
All Dr. Rawnsley's revision surgeries are performed using open procedures where he starts by cutting through the flesh between the nostrils. This allows him better exposure for optimum visualization and the highest possible level of precision. For more detailed information on the procedure used to address your particular situation, please contact Dr. Rawnsley's office at (310) 570-0244 for a one-on-one consultation.