Why revision rhinoplasty surgeons should ask to see pictures of future patients unoperated fully developed nose

When a new revision patient visits a rhinoplasty revision surgeon for a consult the surgeon has no idea how much work was done prior in the reduction of the size of the patients original nose unless patient presents them with pictures of their un-operated fully developed nose. The patient may of presented their operative report at time of consult to the revision rhinoplasty surgeon however it still leaves the surgeon guessing & imagining what the nose looked like prior to the previous/original surgery.  I believe this is a critical error that could easily be rectified by new patients presenting the revision surgeon with images of their original [innate] fully developed nose. If you have had multiple surgery's I believe it would be beneficial as well to present the revision surgeon with all the before/after pictures the previous surgeon's took of your nose. The reason I feel so strongly about this is based on my own personal experience. When you have a very large natural nose and end up having a number of revision surgery's by surgeons who 'blindly' and unwisely keep reducing the size of it, this may lead to serious irreversible consequences.

 Example: The last revision surgeon i went to  wasn't very experienced or knowledgeable in complicated revision surgery and reduced my already surgically reduced tip. It was angled slightly too far upwards and was over projected. It wasn't in line with the bridge of my nose which was over-resected from previous surgery's. From previous surgery's I had my tip reduced/repositioned twice. I had made him aware of this and brought him my O.R's and my before/after from my previous surgery, but no pictures of my original un-operated fully developed nose. I had a consult with another revision surgeon before this last inexperienced surgeon operated on me, and his opinion in regards to how to correct my disproportionate tip/bridge profile  problem would of been the correct and safer approach. Let's refer to this experienced revision surgeon as Dr. C. and my last inexperienced surgeon as Dr. S. Dr. C.'s approach was to not reduce my tip but to increase the projection of my bridge (known as dorsal augmentation) thereby  bringing it in line with my tip by adding *1 rib cartilage. The estimated time of surgery was between 4 to 6 hours. Dr.S. told me he could prevent me from going through the pain of having rib cartilage and use some ear cartilage (however not in my bridge) but for collapsing nasal valves' which he ended up not doing, and he could 'bring down' my tip and do surgery all within 1and 1/2 hours.  I should of asked Dr. S. what he meant by 'bringing down ' my tip because I was under the impression he would simply rotate it downwards possibly with sutures instead of removing more of my lower lateral/medial cartilages which was already deficient, and remove what he considered heavy scar tissue all along my columella. In the end my tip was reduced and not as out of proportion with my bridge. Small consolation considering the grave consequences I ended up with. Cosmetically my profile looks short/weak for a male; structurally the tip is somewhat collapsed due to the accumulated effect of over re-sectioning of the supporting tip cartilages and physiologically I ended up with permanent painful neuropathy with associated side effects of allodynia/ hyperesthesia. 

Fig.1  Profile: Disproportionate tip to bridge ratio

Now whether presenting Dr.S. with pictures of my original sized un-operated nose would of changed his mind of doing another tip reduction like he did is unfortunately left to hindsight. To be clear Dr.S. just as previous surgeons including Dr.C. never requested or had such a picture of me. Considering Dr.S. had all my operative reports however he would of seen I had two prior tip reductions which should of been a red flag for doing another one especially when a different but more complicated approach would of achieved the desired results.  He also was aware I had two prior inferior turbinectomy's but that didn't stop him in doing another one in both nostrils, which he made a condition for going ahead with the surgery.  So in all probability presenting original pictures of my nose to Dr.S. would not of made the slightest of difference. But not all surgeons think alike. Each one is an individual who has their own beliefs, thoughts, idea's, aside from their education, preferred surgical methods and experience. The more information you can supply your future revision surgeon with the better informed he/she will be, presuming they take the time to study your past history. So I would still recommend strongly for a revision patient to dig up some old photo's of your un-operated fully developed nose and present it to your future revision surgeon making him aware of all the transformations which have already taken place. 

It's important to understand that your original un-operated fully developed nose contains/contained within it a proportionately developed network of nerve endings, vascular system, turbinate bone and tissue. Over re-sectioning of any specific area containing the aforementioned anatomy can lead to a breaking point where one can end up with serious consequences.

This hopefully will make your next revision nose surgeon think twice as to which surgical approach he/she will take with you and deter him/her from doing another reduction or aggressive reduction on your tip (as was done on me) *2 where you end up with similar disastrous results.

*1 The reason rib graft was recommended was because I didn't have sufficient septal cartilage to spare.

 *2 SEE http://noserevisionsurgeryandsurgeons.blogspot.ca/2010/08/neuropathy-caused-by-nose-surgery-it.html

Deviated Septum vs Crooked Nose

All crooked/twisted noses have an underlying septal deformity that requires correction and reconstruction to achieve and maintain a long term straightening of the deviated septum.  It is not uncommon for both septal  and pyramid deviations to be corrected at the same time A deviated septum  is corrected by having a septoplasty to improve breathing. This is normally addressed by  correcting the abnormal curvature of the nasal wall consisting of the septal cartilage (the quadrangular cartilage) and bones at back (vomer and ethmoid bone).  This can be done with a closed (endonasal) approach. A localized deviation or spur is purely a functional problem and has no translation to the external shape of the nose.  A crooked/twisted nose usually involves more then just surgical repair or partial removal of the inner quadrangular septal cartilage . Having a septoplasty alone does not mean you will see a external physical change regarding the asymmetry of your nose. A crooked/twisted nose could involve many or all components of the nose cartilage and bone structures from the top/down (cephalic/caudal) region of the nose this would involve anything from the bony pyramid (upper third of your nose) all the way down to the caudal septum (deviation in this region is known as having a caudal deflection), nasal spine & maxillary crest. From the front/back (anterior/posterior) region of the nose this would involve anything from the side of the bridge (medial section of the bony pyramid) of the nose to the most lateral aspect of the nasal bones, or to where the quadrangular cartilage adjoins to the maxillary crest, nasal spine, vomer and perpendicular plate of the ethmoid bone. Sometimes the aforementioned bones need to be corrected to assist with aligning the nasal wall. . The pair of upper lateral and lower lateral cartilage, and medial cartilage are usually evaluated and those which are found asymmetrical after all other corrections to the septum has been made will be modified in this type of surgery. Technically this is referred to as having a septorhinoplasty because there will be a visible cosmetic change to the external shape of your nose.

Pietro Palma M.D. and Paolo Castelnuovo M.D.Chapter 29 p. 320 Correcting the crooked nose from textbook Advanced therapy in Facial Plastic & Reconstructive surgery edited by T. Regan Thomas M.D

Authors classify crooked noses in three basic variations. However, it is important to realize that any of these three categories may be found in various combinations with each other.

Type 1: Single Opposing Convexity/Concavity

The C-shaped and inverted C-shaped noses represent the paradigmatic expression of type 1 deformity. The midnose is invariably involved. Tip-definition point and nasion can be correctly located on the midline axis.

Type 2: Double Opposing Convexity/Concavity

Type 2 crooked nose includes S-shaped and inverted S-shaped. The three framework arches (bony vault, cartilaginous dorsum, and inferior nasal third ) are the most frequently involved with variable combinations of convexity/concavity. Interdomal midpoint and midline rhinion are often out of the midsagittal axis.

Type 3: Laterally Deviated Noses

The typical laterally deviated nose appears straight in terms of alignment of the nasal structures but presents different heights of the two halves. The interdomal midpoint is invariably displaced off center of the midline axis. The angulation may start at the nasion or the rhinion. When the angulation is located at the nasion the halves of all three nasal arches present different heights. Angulation starting at the rhinion implies a straight or near-straight bony pyramid.

Some other major findings which the authors point out are:

• The crooked nose should be considered an anatomical 'three-level unit": skin-soft tissue envelope (SSTE),bony- cartilaginous framework, and internal lining. Each of these 3 layers plays a specific role for making the nose appear crooked.

• Total septal reconstruction of the quadrangular cartilage maybe required in severe cases where there is extensive post traumatic or iatrogenic alteration of the cartilage. According to above authors reshaping techniques under those conditions provides poor long term functional and cosmetic results because the original deformities tend to reoccur. 

• Camouflage procedures are used to achieve better symmetry of the nasal contour anatomy  &/or emphasis some crucial surface landmarks (rhinion, tip definition points, pronasale, colemellar break, subnasale). Autogenous softly crushed septal cartilage, remnants of the cephalic alar resections, & mature scar tissue are the authors preferred additive camouflage material. 

• The poor success rate of septum surgery reported by many studies is probably due to the failure to treat concomitant valve derangement & alterations of the lateral nasal wall. In fact, concomitant surgery on the nasal lateral wall is often required for a satisfactory functional outcome.  

•  Precise mini-invasive endoscopic procedures on turbinates and ostiomeatal complex produce excellent functional results.

•  Conventional osteotomy techniques do not always accomplish what was intended. Double and in special cases, triple osteotomies are necessary to mobilize completely the bony pyramid and change excessive broadness, convexity, or bowing of the nasal lateral walls.  

• An often neglected region is the premaxillary area including the inferior nasal spine and the premaxillary wings. 

For further reading on chapter by above mentioned authors

http://books.google.ca/books?id=j0_r6YZIvbYC&pg=PA319&dq=correcting+the+crooked+nose&hl=en&sa=X&ei=gLDuUe_mBpSj8gHXwoC4BA&ved=0CDkQ6AEwAg#v=onepage&q=correcting%20the%20crooked%20nose&f=false

Additional reading sources
http://www.plasticsurgeryassociatesny.com/crooked_nose_article.pdf

http://emedicine.medscape.com/article/840384-overview

http://dwkimmd.com/papers/Mgmt_postraum_deform.pdf

Diagrams
http://eng.idhospital.com/nose/nose03.php

http://lifecaremedi.wordpress.com/2012/07/24/types-of-dns-deviated-nasal-septum/

http://noserevisionsurgeryandsurgeons.blogspot.ca/2010/12/nomenclature-of-nose-this-could-be.html

Video

Identity Loss Syndrome after rhinoplasty

One of the possible unexpected  psychological effects patients may experience after having rhinoplasty can be a sense of loss of identity. This occurs when one experiences a disconnect with their new physical appearance which they either can't accept or takes a long transition period to get accustomed to.One who undergoes a multitude of  initial cosmetic procedures at once or within a short period of time, are more  prone to suffer from this syndrome, versus someone who has a single or few minor cosmetic changes. However the nose is a prominent feature of the face, and therefore a very large proboscis that is dramatically reduced or reshaped after initial rhinoplasty can have dramatic psychological effect creating a self identity crisis. For example pre-rhinoplasty I had a very large hooked crooked nose. After my initial rhinoplasty i ended up with a over shaved bridge, which created a ski sloped nose with a over projected tip. The look (which was very contrasting with my original nose) never fitted in with  my round face, and looked unnaturally long resulting in a Cyranno type appearance. Others who may likely experience this syndrome are those belonging to certain ethnicity, race or have a family physical trait. A middle eastern person or a descendant of, may want to keep a more rounded profile or lowered tip then a 'perfectly' straight septum, or a Colored or Asian individual may want a wider nose then the Caucasian standard ideal nose. Another group who would be susceptible to this identity loss syndrome (I.L.S.) would be those who feel a reduction in their gender defined degree of physical characteristics. A male may feel emasculated if he always had a more rugged 'Roman like' shaped nose , and then after rhinoplasty ended up with more feminine looking nose (more obtuse nasolabial or nasofrontal angle). Same could hold true for women who have petite features and end up with a more masculine nose, due to more acute tip angle, or increase in size/shape of their new nose due to cartilage replacement grafts. Another subgroup are those who feel a disharmony between their physical appearance and their personality type. This  can occur where one ends up with a  nose shape that makes them look rugged/ more aggressive looking or weaker/softer looking  which is in disharmony with their  type of personality.  A person may also associate and develop a strong negative feeling  with their new look not based on gender issue's but because their new look simply resembles a character type they view negatively or very foreign. One other group who may experience  I.L S. are people who have become very accustomed to their facial imperfection (i.e.slight deviated septum, or asymmetric nose), which had become subconsciously a personal identity marker. This is why it is critical for the surgeon and patient to be on the same page, as to what result the patient is seeking. However a patient seeking primary rhinoplasty may not know what they really want.  It may be wise for the surgeon to have a questionnaire that can address these questions, and issue's, just before consult, so the surgeon can further explore these possible issue's that even the patient may not of been cognizant of prior to making the appointment. A follow up appointment may be needed to give time to the patient to be more specific about what cosmetic change their seeking, and to figure out what they like and don't like about their nose. The use of a picture or computer imaging is very useful to experiment with different looks at different angle views to give the patient an idea of how they may appear post rhinoplasty. Young patients may need to realize and be counseled that their favorite celebrities nose(s) may look totally wrong with their facial features.

http://www.dailymail.co.uk/femail/article-2127322/Can-plastic-surgery-change-personality-Excessive-cosmetic-procedures-lead-identity-crisis-warn-psychologists.html