Rhinoplasty: risks and pitfalls

Complications of Rhinoplasty
S.Valentine Fernandez

The operation of rhinoplasty demands a thorough understanding of an art and science.Some complications of rhinoplasty relate to anesthesia and do not fall within the bounds of this discussion.

Complications of rhinoplasty may be divided into 4 basic categories as follows: 

• Intraoperative
• Immediate post operative (in the recovery ward)
• Early postoperative
• Late postoperative

While recognizing obvious medical and surgical complications should present no difficulty, finer aesthetic complications are harder to define and are based on value judgments related to the aesthetic sense of the surgeon and the body-image demands of the patient Aesthetic sense is difficult to define, and it is much harder to agree on results. Aesthetics depend on variables, including the current fashion taste, the media, the public relations industry, and cultural and ethnic differences.

A practical approach to aesthetics in the nose begins with an accurate assessment. Frontal views define x-axis (width) and y-axis (height) deformities, lateral views define z-axis (depth/projection) and y-axis deformities, and basal views define x-axis and z-axis deformities. Based on these views, a 3-dimensional concept of the nose is made available for manipulation. The goal of rhinoplasty is to improve the existing harmony without causing functional impairment.

According to the literature, the complication rate for nasal surgery varies from 4-18.8%. In individual hands, this rate generally falls as surgical experience accumulates. Skin and associated soft tissue complications occur in up to 10% of cases. According to estimates, severe systemic or life-threatening complications occur in 1.7-5% of rhinoplasty cases. Intracranial complications are rare.

The clinical manifestation of rhinoplasty complications may broadly be classified as follows:

• Functional
• Infectious
• Aesthetic
• Psychological
• Specific to complication       

Intraoperative complication:

1. Excessive bleeding  2. Tears of mucoperichondrial flaps  3. Buttonholing of skin  4. Cautery burns

5. Collapse of bony pyramid:     

• Collapse of the bony pyramid may occur during removal of a bony hump with an osteotome, particularly when the patient has had previous nasal trauma or if the vomer or ethmoid have been weakened as a result of previous surgery. Rasping may be advisable in these circumstances.
• Rectification requires careful approximation of the segments and provision of adequate internal and external splint support during healing. 

6.  Disarticulation of upper lateral cartilage:  This complication may occur during rasping. Bilateral disarticulation produces an inverted-V deformity, and unilateral disarticulation produces asymmetry in the middle third of the nose. Spreader grafts may improve airway symptoms and aesthetics.

7. Osteotomy complications 

•  "Rocker" deformity: This deformity results when the medial osteotomy creates a cephalic fracture higher in the thicker part of the frontonasal junction. Attempted narrowing after the osteotomies results in lateralization of the superior segment of the fractured bones, based on a fulcrum at or about the radix. Repositioning the cephalic fracture lower on the nasal bone rectifies this deformity.

• "Open roof" deformity: When the lateral segments fail to align with the septal dorsum following osteotomies, a gap, which may be visually and palpably obvious, results. If neglected, the intranasal mucous membrane adheres to the overlying soft tissue and may create a depression at the site. If alignment failure is unilateral, the nose appears asymmetric. Correction involves assuring centralization of the septum and complete medial mobilization of the lateral segments following osteotomy. Usual causes of open roof deformity include the following:  

• Greenstick cephalic fracture during osteotomies (will return to its preoperative position)
• Failure to adequately mobilize the fractured segments medially
• Excessive nasal packing
• Uncorrected deviated perpendicular plate of the ethmoid (may prevent medialization of the lateral segments)

• "Step" deformity: This deformity may result if a single lateral osteotomy is performed too far medial to the nasofacial groove, with a visible ridge on the side of the nose. Correction involves repeating the osteotomy at the correct level. 

8. Perinasal trauma: During osteotomy, particularly in noses that have previously been traumatized, there is a tendency to recreate preexisting fractures. The proximity of the orbit and cranium renders these structures most susceptible to such occurrences. Malfunction can result directly or can manifest subsequent to infection.

Immediate post operative complications: 

1. Airway obstruction 2 Anaphylaxis: This is a distinct possibility when intraoperative antibiotic medication is used. Anaphylactic shock subsequent to bacitracin nasal packing has been reported, and latex anaphylaxis is well document 3. Visual impairment

Early post operative complications:                                                              
1. Hemorrhage: Reported prevalence of hemorrhage varies from 2-4%.   2. Septal hematoma:

3. Infection:  Wound infection, Septicemia, Toxic shock syndrome, subacute bacterial endocarditis, intracranial infections, and acute &/or chronic sinusitis.

4. Dehiscence of incisions: The transcolumellar incision must be attended to immediately, or a scar will form, contributing to a poor result.

5.Persistent edema: Persistent edema and numbness over the nasal tip region may occur following external rhinoplasty and may last several months. This is not a problem if the patient has been forewarned.

6. Skin necrosis: Excessive undermining, injudicious cautery use, and overzealous skin thinning may lead to skin necrosis. This may cause an impaired blood supply and infection. Similarly, a tight dressing may cause vascular impediment and skin necrosis. Debridement and secondary healing is encouraged if necrosis occurs. Later, local steroid injection, dermabrasion, laser modification, and/or flap reconstruction may be necessary to aid scar aesthetics. Skin necrosis may also result from dorsal augmentation, in which case removal of the augmenting material may be necessary.

7. Sequestra formation, 8. Cardiovascular insufficiency 9. Cerebrospinal fluid rhinorrhea 10. Contact dermatitis 11. Nasal blockage 12. Numbness and pain 13. Olfactory disturbance:  Patients with past facial trauma may be predisposed to injury of the olfactory apparatus during osteotomy. 14. Carotid-cavernous fistula 15. Reassurance demand:  A small number of patients need the surgeon to repeatedly express that the nasal blockage will disappear, the smell and taste sensation will return, the teeth anesthesia will subside, and the tip projection and swelling will decrease in time.Early psychological complications: Transient episodes of anxiety or depression are not uncommon and may last up to 6 weeks after the operation

Late postoperative complications

1. Scar hypertrophy: This may detract from a good result following an external rhinoplasty. Skin loss from infection and necrosis is a disaster. Aim initial attempts at reducing the size of the scar with intralesional steroids. Further treatment could include dermabrasion, lasers, and/or surgical scar revision.
2. Polly beak nasal deformity-This deformity is characterized by absence of the supratip dip (ptosis tip)  may present in degree.

3. Synechiae formation  4. Septal perforation: The prevalence of this complication has been described as 3-24.5%.

5. Nasal valve collapse: Aggressive cephalic trim of the lower lateral cartilages may provoke this complication. Collapse may cause airway distress and is a source of patient discontent. Cartilage spreader grafts may prove useful for internal valve collapse. Alar batten grafts improve external valve collapse.

6. Nasal stenosis  This is a disaster when it occurs, and it may be related to circumscribed incisions with excessive lining removal. Stenosis causes airway obstruction and is a source of persistent discomfort. Reconstructive surgery may provide some relief.

7. Bossa formation

• Bossae are protuberances that may arise in the region of the nasal tip. Their postoperative incidence is quoted at 2%.
• While bilateral symmetric occurrences may assume a pleasing appearance, bilateral asymmetric and unilateral bossae demand surgical attention. During operation, ensuring that the remnant lower lateral cartilages are of equal dimensions on both sides is important.
• Bossae usually occur in noses with preoperative asymmetry, use of destructive rhinoplasty techniques, thin skin, and excessive postoperative scarring. The triad of thin skin, strong cartilages, and bifidity also indicate the patient who is prone to the development of bossae. Tip graft movement may also contribute to bossa formation. 

8. Recurrent meningitis, 9. Oleogranuloma  10. Dorsal cyst:

11. Aesthetic surgical misjudgments

• Undercorrection or overcorrection of a preexisting deformity leads to either persistence of the deformity or to introduction of a new one. A new deformity may introduce a functional deficit. Some of these deformities are illusory, and correction only follows after an accurate diagnosis is made. Ideally, revision rhinoplasty should not be performed until at least 12 months after the initial operation.
• These deformities may occur singly or in combination and may relate as an x-axis (width), y-axis (height), or z-axis (depth) deformity/deformities in the various segments.

Upper third deformities 
Deep nasofrontal angle, Shallow nasofrontal angle, Upper third widening, Upper third convexity, Upper third overreduction:,  & Upper third asymmetry.

Middle third deformities 
Middle third widening:, Middle third convexity, Middle third saddling,  & Middle third asymmetry

Lower third deformities
Lower third widening or flaring,  Tip widening or boxy tip, Tip narrowing or pinched tip, Tip asymmetry,   Tip projection deformities, Wide columella, Hanging columella or "columella show", "Hanging" or "veiled" alae , Alar notching, Nostril asymmetry, Retracted nasolabial angle, Protracted nasolabial angle,   &

Alar collapse: Excessive removal of the lateral crura dampens support afforded by these structures, causing alar collapse and airway discordance. Reconstructive techniques with alar battens may be necessary in difficult cases.

Other

• Graft/implant migration: Migration may comprise resorption, displacement, or extrusion; it may be provoked by trauma and infection. Allografts have a higher extrusion and infection rate than autografts. An infected implant must be removed if antibiotics do not help. Revise displaced grafts causing aesthetic inconvenience with appropriate stabilization.

• The disproportionate nose: This nose does not fit the face and is not a credit to the surgeon's artistic skill. Reconstructive rhinoplasty techniques follow the patient's expression of discontent with original results.
• Underlying maxillofacial deformity: A superb rhinoplasty result may be ruined by the unmasking of a previously unnoticed or undiagnosed maxillofacial deformity. The maxillae and mandible with labial and dental components must be considered preoperatively and the patient must be forewarned. Attendance by a cosmetic dentist and inclusion of chin surgery may be necessary.

A revision rhinoplasty may be required in 5-15% of patients. Any attempt at correction must always be accompanied by a rider promising only improvement and warning that a further "touch-up" operation may be necessary.

Persistent psychological complications: Several contradictory studies are available.
Thoracic and thoracolumbar instability, Gustatory rhinorrhea, Human adjuvant disease:, Lacrimal fistula, Enophthalmos and silent sinus syndrome. 

For more detailed analysis see:
http://emedicine.medscape.com/article/843439-overview#showall

Some other complications not mentioned above: Neuropathic pain (temporary or permanent),  Empty Nose Syndrome, Graft warping and resorption and complications from injectable material in the nose. For more info on this subjects check out  my other blog posts. (See labels on right side column of my blog and click on any of the labels.)

See also:
http://www.youtube.com/watch?v=sj4RrAlAwXo
http://yourguidetoplasticsurgery.com/rhinoplasty-risks
http://www.emptynosesyndrome.org/what_is_ens.php
http://www.therhinoplastycenter.com/ComplicationsofRhinoplasty/complications1.html

Refining the nasal tip with Newer VDD techniques.

Vertical Dome Divison Rhinoplasty: 
 Author: John Hilinski, CoAuthors: Anil R. Shah & Kris S Moe

Nasal tip surgery is among the most complex and difficult tasks in rhinoplasty surgery. Vertical dome division (VDD) is one of a variety of techniques that may be used in refining nasal tip appearance. Collectively, vertical dome division (VDD) refers to one of many methods of vertically dividing the lower alar cartilage at or near the dome to modify nasal tip aesthetics. The technique was originally recommended as an alternative in altering tip projection and appearance while minimizing use of implants and the degree of postoperative tip ptosis. Vertical dome division (VDD) targets various nasal deformities, including overprojection or underprojection, suboptimal rotation, disproportionate lobule ratios, and broad or asymmetric tip. The surgeon must strive to achieve an aesthetically pleasing nasal tip that is in balance with the remainder of the nose without compromising nasal airway function.

The typical patient presenting for vertical dome division (VDD) usually has a poorly defined or malpositioned tip with a combination of abnormal projection/rotation, broad or amorphous lobule, asymmetric tip defining points, and/or boxy, trapezoidal base.

Adherents to this principle argue that horizontal excisional techniques rely too heavily on unpredictable and uncontrollable postoperative scarring to produce desired tip results. Proponents of vertical dome division (VDD) believe that vertical incisional and excisional techniques, on the other hand, offer a more definitive and reliable means to achieve desired tip changes.

In principle, the technique of vertical dome division (VDD) separates the medial and lateral crura into 2 independent units. By transecting the dome, the inherent spring within the arch is released and allows realignment of the newly divided medial and lateral segments to reconstruct the nasal tip.

Vertical dome division (VDD) is typically reserved for more complicated cases that require greater changes to effect tip refinement than could be achieved using other techniques. Nearly all variations of vertical dome division (VDD) used today involve some modification of the original Goldman technique

The lobule is defined as the portion of the nasal tip complex that is situated anterior to the nostrils; it extends from the tip defining point to the junction with the columella, as observed on base view. The alar cartilage (lower lateral cartilage) is C-shaped and can be divided into the medial, middle, and lateral crus. The middle (intermediate) crus comprises the domal segment and largely influences the shape of the lobule and, therefore, the form and definition of the nasal tip. The dome is considered the highest arching segment within the nasal vestibule.

The lobule size can be assessed in comparison to the columellar length. If the base view demonstrates a columellar-to-lobule ratio of approximately 2:1, the structural support and configuration of the nasal tip is considered adequate. A long nasal length reflects an acute nasolabial angle; a short length reflects an obtuse nasolabial angle.

The anatomy of the nasal tip is often described using the tripod concept to facilitate understanding of the key structural components and to provide a simple explanation of tip dynamics. According to this analogy, the cartilaginous framework of the lower third of the nose is compared to a tripod that is attached to the facial frontal plane. The 2 individual lateral crura represent 2 legs of the tripod, and the conjoined medial crura and caudal septal attachments correspond to the third leg.

By lengthening or shortening any or all legs of the tripod, the changes that will be effected in tip projection and rotation can be predicted. For instance, techniques that augment or lengthen the medial crural segment enhance projection. Shortening the medial crura or disrupting their septal attachments without reduction of lateral crural length decreases projection and rotation of the nasal tip. Shortening the lateral crura and maintaining or lengthening the medial crural segment would be expected to increase rotation.

Contraindications

Vertical dome division (VDD) is predominantly contraindicated in patients with relatively thin skin. These patients are particularly prone to developing visible cartilage edges along the nasal tip region. This results from contraction of the thin overlying skin and soft tissue envelope around the new and more prominent medial cartilaginous strut. A thick overlying skin and soft tissue envelope is better able to cushion the appearance of prominent cartilaginous structures, such as those in vertical dome division (VDD).

Avoid classic vertical dome division (VDD) in patients who show evidence of already weakened lateral nasal walls. Dividing the domal region without reapproximation of the cartilage segments disrupts the integrity and continuity of the lower lateral cartilage. The lateral nasal wall is more susceptible to structural collapse than the newly reinforced medial footplates. As a result, lateral wall weakening and collapse are further potentiated.

The original technique is highly focused on manipulation and repositioning of only the medial crura, with no attempt made to reconstruct the remaining lateral crural segment and alar rim. Postoperatively, the medial crura and columella are sufficiently stable to resist loss of projection. Some loss of lateral support, which could result in lateral wall collapse and alar retraction, may occur. Vertical dome division (VDD) is also associated with bossae formation. This is most frequently seen in patients with thin skin and firm cartilages. Disruption of the underlying vestibular mucosa and skin, such as in the Goldman technique, also predisposes the patient to possible stenosis.

With use of newer modified techniques (Hockey stick excision, Lipsett, Simons, Adamson, and others) and caution, vertical dome division (VDD) can be used successfully in nasal tip refinement with limited postoperative complications and reliable long-term results. 

Most practitioners using vertical dome division (VDD) today perform some modification of the original Goldman tip procedure.

Adamson reported that approximately 5% of patients required revision surgery for postoperative tip abnormalities and irregularities attributed to use of vertical dome division (VDD).^[10] These abnormalities were primarily nasal bossae and lobule asymmetries. Abnormalities were nearly 3 times as likely to occur in revision cases as in primary rhinoplasty; incidence was lower with use of the incision and overlap method.

 Vertical dome division (VDD) is likely to remain controversial in the future. As knowledge of nasal tip surgery evolves, so too will further modifications of our existing tip techniques to attain more predictable outcomes.
 http://emedicine.medscape.com/article/841313-overview

The Endonasal Approach to Rhinoplasty
Robert L. Simons and Lisa D. Grunebaum Ch.68 Rhinology and Facial Plastic Surgery 

Today's trends in nasal tip surgeries are for improved visualization with preservation of the cartilage as well as better medial stabilization and support. These tenets are inherent in vertical dome division techniques. It is important to remember that VDD is an incisional technique that allows for repositioning of the nasal tissue and should not be combined with excisional techniques. One should always leave behind more than one takes. Preservation of at least 6-8mm of lateral crus will help prevent alar collapse and help stabilize the nasal base as well as allow for a strong natural-appearing tip.VDD allows for narrowing, rotation, and change in tip projection by repositioning rather than excision of any sizable amount of cartilage.

The Effectiveness of modified VDD Technique in reducing nasal tip projection in rhinoplasty

B.Gandomi, M.H. Arzaghi, M. Rafatbakhsh

The employed technique is a new modification of previous techniques. 3-10 The technique employs an open approach in which a strong columellar strut inserted and a portion of crura is removed near the dome (the cornerstone of our new technique of tip surgery). Depending on the deformity, this segment may involve intermediate, middle or lateral crura with or without removal of vestibular skin considering its thickness: thin skins are not resected, but thick skins are usually removed.

Our technique involves the overlapping of the incised edges of the medial and lateral segments, and suture approximation to restore the integrity of the alar cartilage. The technique allows a more stable configuration for the maintenance of nasal tip support. The overlapping and reapproximation of the medial and lateral units ensure the long-term stability of the newly reconstructed nasal tip complex, and reduce the tendency towards postoperative cartilaginous abnormalities that may accompany scar fibrosis and contracture. 

 http://ijms.sums.ac.ir/files/PDFfiles/07-Dr.%20Gandomi.pdf

Nasal tip complications and optional operative fixes

Complications in Rhinoplasty-Daniel G. Becker.  Ch.49 facial plastic and reconstructive surgery by Ira D. Papel

In the nasal tip;  

Over-reduction may violate critical tip support mechanisms (Table 49.1) which can lead to complications including tip ptosis and inadequate tip projection. Alternatively, overresection of the caudal septum can result in overrotation of the nasal tip with excessive shortening of the nose. Overresection may also contribute to other complication such as bossae, alar retraction, and alar collapse (external nasal valve collapse).

Under-reduction may be simply due to overcaution but is commonly due to a failure to correctly assess preoperatively the anatomical situation. For example, failure to recognize an overprojected nose, or to diagnose the steps required based on the patient's anatomy to adequately address this, can lead to a persistent overprojected state. Failure to adequately resect cartilaginous dorsum may result in a pollybeak deformity.

Asymmetries of the nasal tip may be due to unequal reduction of the lower lateral cartilages or to asymmetric application of dome-binding sutures. It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery. Also, assymmetry is often present preoperatively and should be recognized and pointed out to the patient prior to surgery.

Table 49.1 Tip-Support Mechanisms

Major tip-support mechanisms
1. Size, shape, and strength of lower lateral cartilages
2. Medial crural attachment to caudal septum
3. Attachment of caudal border of upper lateral cartilages to cephalic border of lower lateral cartilages
[the nasal septum is also considered a major support mechanism of the nose]

Minor tip-support mechanisms
1.Ligamentous sling spanning the domes of the lower lateral cartilages (i.e. interdomal ligament)
2.Cartilaginous dorsal septum
3.Sesamoid complex of lower lateral cartilages
4.Attachment of lower lateral cartilages to overlying skin-soft tissue envelope
5. Nasal spine
6. Membranous septum

Specific Complications:

Ptotic tip-loss of tip support may lead to a droopy tip (tip ptosis with an overly acute nasolabial angle (angle defined by columellar point to subnasale line intercepting with subnasale to labrale superious line) is 90 to 120 degrees.Within this range, a more obtuse angle is more favorable in females, a more acute angle in males. Loss of tip support can lead to a ptotic, underprojected drooping nose. Treatment of complications relating to a ptotic nose rely on restoration of tip support and tip projection.

Overrotated Tip-Conversely, one may face a patient with a nose that has been overrotated, with an overly obtuse angle. Overresection of the caudal septum is a common cause of overrotation of the tip. Overrotation of the nose creates an unsightly, overshortened appearance. Treatment rely on maneuvers that lengthen and counterrotate the nose.

Bossae- a bossae is a knuckling of the lower lateral cartilage at the nasal tip due to contractural healing forces acting on weakened cartilages. Patients with thin skin, strong cartilages, and nasal tip bifidity are especially at risk. Excessive resection of lateral crus and failure to eliminate excessive interdomal width may play some role in bossae formation. As an isolated deformity, bossae are typically treated through a small marginal incision with minimal undermining over the offending site followed by trimming or excising the offending cartilage. In some cases, the area is covered with a thin wafer of cartilage, fascia, or other material to further smooth and mask the area.

Alar retraction

Cephalic resection of the lateral crus of the lower lateral cartilages is commonly undertaken to effect refinement of the nasal tip. If inadequate cartilage is left, then the contractile forces of healing over time will cause the ala to retract. This is commonly seen squelae of overresection of the lateral crus. The surgical rule of thumb is to preserve at least 6 to 9mm of complete strip. From a study 20 percent of patients had a thin alar rim. These patients may require even more conservative approaches to avoid the risk of alar retraction and/or external nasal valve collapse. Also vestibular mucosa should be preserved, as excision of vestibular muscosa contributes to scar contracture with alar retraction. Alar retraction may be treated by cartilage grafts in more minor cases (1-2 mm). Auricular composite grafts are commonly used in more severe cases.

Alar-Columellar Disproportions (protruding or hanging columella)

The range of normal columellar show is generally considered to be 2 to 4 mm. The surgeon should avoid excessive resection of the caudal septum and should avoid resection of the nasal spine. Treatment of a protruding or hanging columella may include resecting full thickness tissue from the membranous columella, including skin, soft tissue, and perhaps a portion of the caudal end of the septum itself. If the medial crura is excessively wide, excision may include a conservative excision of the caudal margin of the medial crura. Retracted columella may be improved with plumping grafts inserted at the base of the columella to address an acute nasolabial angle; columellar struts may also be helpful for minor deformities. A cartilage graft may be used to lengthen the overshortened nose. The use of composite grafts have also been described.

Pollybeak- A pollybeak refers to postoperative fullness of the supratip region, with an abnormal tip-supratip relationship This may have several causes, including failure to maintain adequate tip support (postoperative loss of tip projection), inadequate cartilaginous hump (anterior septal angle) removal, and/or supratip dead space/scar formation. Management of the pollybeak deformity depends on the anatomical cause. If the cartilaginous hump was underre­sected, then the surgeon should resect additional dorsal sep­tum. Adequate tip support must be ensured; maneuvers such as placement of a columellar strut may be of benefit. If the bony hump was overresected, a graft to augment the bony dorsum may be beneficial. If pollybeak is the result of exces­sive scar formation, Kenalog injection or skin taping in the early postoperative period should be undertaken prior to any consideration of surgical revision.

Operative Maneuvers:

 Increase Rotation: Lateral crural steal, Transdomal suture that recruits lateral crura medially, Base-up resection of caudal septum (variable effect), Cephalic resection (variable effect), Lateral crural overlay, Columellar struct(variable effect), Plumping grafts (variable effect) Illusions of rotation: increase double break, plumping grafts (blunting nasolabial angle)

Decrease Rotation (Counter-rotate) Full -transfixion incision, Double-layer tip graft, Shorten medial crura, Caudal extension graft, Reconstruct L strut as in rib graft reconstruction (integrated dorsal graft/columellar strut) of saddle nose.

Increase Projection: Lateral crural steal (increased projection, increased rotation), Tip graft, Plumping grafts, Premaxillary graft, Septocolumellar sutures (buried) Columellar strut (variable effect), Caudal extension graft,

Decrease Projection: High-partial or full transfixion- incision, Lateral crural overlay (decreased projection, increased rotation), Nasal spine reduction, Vertical dome division with excision of excess medial crura with suture reattachment

Increase Length: Caudal extension graft, Radix graft, Double-layer tip graft, reconstruct L strut

Decrease Length: See "increase Rotation, Deepen nasofrontal angle

Secondary External Rhinoplasty
David W.Kim, Benjamin A. Bassichis, and Dean M. Toriumi,  Chapter 31; Revision Surgery in Otolaryngology. By David R. Edelstein.

Persistently Wide or Bulbous Tip

A persistently wide tip after primary rhinoplasty may be due to the failure of the surgeon to account for a thick, inelastic SSTE (soft-skin tissue envelope) when modifying the dome region. In these patients, performing dome-binding sutures alone may improve the shape of the alar cartilages themselves, but this change will not necessarily  transmit through the thick SSTE. Failure to project the tip into the skin envelope and effectively stretch it to conform to the underlying tip shape will lead to this problem. Study of the overall projection and rotation of the tip, the nasolabial angle, and nasal length should be performed to determine how best to project the tip and restore optimal tip shape. A shield-shaped tip graft may be sutured to the intermediate and medial crura to provide the desired augmentation to the infratip lobule and tip. Although the nasal base remains unchanged, the leading edge of the shield graft may project the domes by as much as 8mm. A buttress or cap graft may be placed cephalad to the leading edge of the graft to support the graft and camouflage the transition to the supratip. Lateral crural grafts are placed on the existing lateral edge of the shield graft when the tip graft projects > 3mm above the existing domes. These also provide additional support and camouflage to the shield graft. Lateral crural grafts also bolster lateral alar support in cases in which the native lateral crura have been weakened or removed.

  Another common error of omission leading to a persistently wide tip is the failure to straighten convex lateral crura. Domal narrowing will not result in a defined triangular tip appearance if the lateral walls of the triangle are curving outward. Unless the curvature is straightened with suture technique or lateral crural struts, persistent tip width will be present. These problems may be detected through the study of the base view of the nose. If lateral crural struts will be needed, strong segments of cartilage are required to overcome the curvature of the existing alar cartilage. These grafts are placed between the undersurface of the lateral crura and the vestibular skin that should be carefully elevated. The caudal attachment of the lateral crus and skin should remain intact to prevent caudal migration of the graft. The graft should extend from just lateral to the domes to the lateral aspect of the lateral crura. The lateral crural strut graft may be stabilized with a full thickness chromic suture, but it should be finally secured to the lower lateral crura with a 5-0 clear nylon suture.


Nasal Tip Management Utilizing the Open Approach. Russell W.H. Kridel and Peyman Soliemanzadeh  Ch.69 Rhinology and facial plastic surgery by Fred J. Stucker
Prior to contouring the nasal tip, the surgeon must stabilize the base of the nose. If tip support is found to be lacking, a sutured in place columellar strut can effectively stabilize the base. This graft is placed into a pocket dissected between the medial crura. When it is necessary to alter tip projection, the alar columellar relationship, and the nasolabial angle the Tongue-in-groove technique can be utilized to stabilize the base. Specifically, if the patient has a hanging columella and prominent caudal septum that would otherwise require trimming, the surgeon can set the medial crura back on the midline caudal septum. Bilateral membranous septum excision is almost always necessary to remove excess tissue which results from the TIG technique. The TIG can also be varied in order to enhance rotation and or to increase projection.

 Tip deprojection can be accomplished by removing an equal amount of lateral crura and medial crura in a technique called dome truncation (DT). 

 http://archfaci.ama-assn.org/content/7/6/374.full

 http://www.drphilipmiller.com/Assets/Structuralapproach.pdf 

Who's the best revision nose surgeon?

The most common question, asked, researched, googled, by people seeking revision nose surgery (and for very legitimate reason's) is "who's the best revision nose surgeon". Obviously, your primary or revision nose surgery didn't go as planned or wished for. You might not like the aesthetic appearance of your nose for various reasons, or you have functional issue's which weren't resolved or are new, or combination of those issue's. It's very frustrating to have to go through another surgery, especially one which is labeled "elective" surgery, meaning you have to pay out of pocket for and may include the stress and cost of air travel. I put in quotes "elective" because many unhappy with the results of their operated nose would disagree with that term, since they feel it's a "necessity" now for reasons i already explained above. It's also about regaining trust. How can you trust that the next surgeon will do what he/she promises, since you already were told by your last surgeon, that you would receive what you desired, but didn't. [Note: I'm not simply blaming the surgeon here, because there may of been an issue of miscommunication] That's a major step to take and the most challenging for you the prospective secondary/revision patient and the secondary/revision surgeon. This of course occurs in every profession and business. You have to make it clear to your surgeon what your expectations are from the surgery, and your surgeon needs to make clear to you what you can realistically expect. Of course there's a lot more to it then that as I have already written about on my other posts regarding questions to be asked, and doing your research ="due diligence".Even after seeing a few surgeons that your happy with you may be apprehensive,which is normal but at some point given long thought out consideration, you need to take a leap of faith or decide your not really ready for another surgery. Maybe you just need to see a few more surgeons before being sure you found the right one.

*Note; you should never feel pressured or rushed into elective surgery!!! Not by the surgeon or by someone else, including yourself!!! If the surgeon seems hesitant that he/she can help you but is still willing to try, then DON"T do it!!! [Even if you've already paid for airfare and put down a deposit]. That's what happen to me with my last surgeon in 2005. If you've been reading my posts, then you already know the dangerous consequences of a bad outcome (neuropathy, empty nose syndrome) from nose surgery.  I can't emphasize this enough... do not ever take nose surgery lightly!!!

So I assume most of you seeking revision nose surgery have seen different lists of "who are the best nose revision surgeons" recommended online and have noted which surgeons appear repeatedly, and you have searched forums and other sites to see what others have to say about each of them.Which is all good. But now that you have your own "A" list, narrowed down to let's say a half dozen, your having difficulty deciding which two or three to consult with for various reasons. You may of just read a bad review about the surgeon you were so keen to seeing in person, called their office and realized that surgeon's prices are way out of your price range, or spoke to that surgeon by phone or in person and didn't like the way you were treated or something or other.

So the point I want to make is, rather then driving yourself obsessively crazy by limiting your quest with "who's the best revision nose surgeon in the world or USA or Europe" It would be wise to ask   "What surgeons or type of surgeons should I be avoiding" so I don't make the same mistake again of choosing a similar type of surgeon. Note: I don't mean to blame the patient, because sometimes we can take all the right steps and yet not get the results we were hoping for or were promised! STEP 1. [make a list of things you didn't like about your last surgeon(s)]. This should help you towards finding a surgeon who you feel understands you (on the same page), cares about his/her patients, and has the expertise and proven experience of  getting  the job done.  STEP 2.[make a list of things your looking for in your next surgeon].ie. You will want to find out what percentage of his/her practice is devoted to Rhinoplasty and Revision Rhinoplasty in conjunction with their experience in performing the type of surgery you require.  If you have had a lot of reductive nose surgery therefore requiring a lot of reconstruction surgery, then you will need an experienced revision nose surgeon who has performed many major types of reconstructive nose surgery's.  STEP 3. After researching [information websites like this blog, using internet forums, rating sites, realself.com where some surgeon's  recommend or speak highly of other surgeon's, etc..] and seeing a few surgeons who you had at the top of your list, decide which one you have the most confidence in and feel comfortable with. Your decision may come down to liking one surgeon's methods better then another's. i.e.) maybe you prefer your own cartilage rather then synthetic material in your nose, or prefer closed approach over open, or like some other technique one surgeon use's that other's don't. You need to discover what the surgeon's exact plans are for your nose surgery and be comfortable with it.

This I feel should help direct your focus in the right direction and alleviate some of your understandable fears and obsessions with  finding out or limiting yourself to, who's Numero Uno. It's really a process, a process of elimination to finding the right surgeon(s) for your specific case  (which there may be more then one, two or three surgeons) which therefore suggests there is no best revision nose surgeon for all cases. Hope that's of some help!

Note: Your list can include things you didn't like about the surgeons surgical center, after care offered, etc...