Rhinoplasty is one of the most popular cosmetic surgeries performed in Asian countries. Although the techniques employed may be considered similar to Caucasian rhinoplasty, the procedures used for Asians have distinctions which stem from their anatomical differences as well as different aesthetic standards between the two cultures.1-3
With the increasing number of rhinoplasties being performed coupled with heightened patient expectations, the rate of revision surgery is increasing in Europe and North America.4,5. Although no formal studies have been done on the rate of revision rhinoplasties in Asian countries, the author imagines that similar trends dominate. As primary rhinoplasty among Asians includes peculiarities that distinguish the procedure from its Caucasian counterpart, instinct dictates that revision rhinoplasty among Asians occupies a distinct field in the world of rhinoplasty that poses special and unique challenges to the rhinoplasty surgeon. However, reports of revision rhinoplasties among Asians are limited in their number and content.6,7
In Asians, augmentation of the dorsum or tip is the most commonly performed procedure. Although the preferred implant material is autologous cartilage, the characteristics of the Asian nose, which includes a broad and low dorsum that usually requires substantial augmentation, exceed the amounts available from autologous cartilage. This realistic limitation has popularized the use of alloplastic implants in many Asian countries. Among various alloplastic materials, silicone in its various forms has been and remains the single most commonly used alloplastic implant in Asia.9-10 This is perhaps because they are better tolerated due to the thicker soft tissue envelope of the Oriental nose.11 However, silicone implants have also been heavily criticized for their association with complications, such as deviation, extrusion, and infection.12 The complication rate of allopastic implants used in rhinoplasty ranges from 0 to 9.7% for silicone11,13and 1.5 to 10% for Goretex.14-16 A recent meta-analysis on alloplastic implant use in rhinoplasty showed a 3.1% removal rate for both Gore-Tex and Medpor implants and a significantly higher rate of 6.5% for silicone implants.17
In this short review of revision rhinoplasty in Asian, the author introduces the common causes of revision rhinoplasty, operative techniques and general considerations for each deformity, and implications to assist in their prevention.
Most of the revisions in Asian rhinoplasty is associated with alloplastic implant related problems. Deviation, extrusion, foreign body reaction, or infection of the implant is a common problem. The major reasons for revision in the alloplast unrelated caese are dorsa and tip problems which include dorsal deviation or irregularity, residual hump, inadequate or loss of tip projection, upturned or over-rotated tip, visible graft, and tip deviation.
A retrospective review of my 623 cases of rhinoplasty between 2005 and 2008 revealed a 68 revision rhinoplasties.18Among them, 52 patients who had complete medical records and a follow up of at least one year were analyzed and the etiologies are shown in the table below.
Main etiology for revision rhinoplasty (N=52)
|Alloplast related (N = 33)||33 (63%)|
|Contracture (Short nose)||3|
|Alloplast unrelated (N= 19)||19|
|Mainly upper two-thirds problem||(N= 12)|
|Residual deviation||(37 %)|
|Dorsal irregularity or depression||7|
|Mainly tip problem||(N= 7)|
|Tip underprojection (loss of projection)||12|
|Upturned, overrotated tip||2|
Operative techniques and general considerations
Open rhinoplasty with use of autologous cartilage is the mainstream approach for most of the revisions. In patients with depleted cartilage, autologous or homologous rib cartilage provides an ample supply of materials. Perichondrium of the rib, temporalis fascia, or homologous fascia is used in patients with thin or traumatized skin.
The techniques used for revision rhinoplasty varies according to the etiology of the revision. In the implant related group, these are treated first by removal of the implant through an open approach, correction of underlying deviation if present, symmetric dissection and creation of a new subperiosteal pocket, and further augmentation of the dorsum or tip as needed. In cases with infection of the alloplastic implant, removal of the implant and revision surgery is performed concurrently using autologous grafting material.
For the revision of non-implant related patients, diverse techniques are used that include septal reconstruction, osteotomy, onlay and camouflage grafts, and various tip grafts used to control rotation and projection of the tip. Combined complaints of nasal obstruction are due to inadequate correction of septal deviation and turbinate problems. Proper management of the septum combined with conservative submucosal resection of the inferior turbinate is sufficient in maintaining patent nasal airways.
Deviation of implant
Deviation is the most common alloplastic implant related problem (fig. 1) followed by foreign body reaction, extrusion, and infection. Deviation of the implant is often the result of careless insertion of the implant after asymmetric dissection of the implant pocket, which is usually performed endonasally. Other reasons may include too large a pocket size for the implant or failure to recognize preexisting deviations. Often, patients can have preexisting deviations which are inconspicuous due to the low height of their dorsum but can become apparent after the nose is augmented. When performing revision surgery for a deviated implant, the first step is to ensure that the underlying nose is straight. If the nose is deviated, correction of the deviated nose must be performed before further augmentation can take place. Most cases of silicone implants include surrounding capsules that are deviated as well. Leaving them in situ can lead to persistent deviation. Therefore, the capsule is removed as much as possible, taking care to avoid damaging the skin soft tissue envelope (fig. 2). Careful symmetric dissection of the subperiosteal pocket, which is appropriate in size and that is large enough to accommodate the implant’s snug fit into the pocket, can minimize the chances of displacement.
Extrusion of implant
Most extrusion occurs when the implants extends to the nasal tip (fig. 3). The implant causes thinning of the tip skin with resultant extrusion through the membranous septum or even through the tip skin. In rare occasion, the implant extrudes through radix skin (fig. 4). Adequate management of the damaged skin is important in these patients. Autologous fascia or allogenic acellular dermal matrix (Alloderm) is useful in camouflaging the damaged skin. To avoid extrusion, the implant must be designed to avoid overaugmentation and fashioned to augment only the dorsum. Usually, the implant should not exceed caudally the anterior septal angle. The tip is augmented only with autologous tissue.
Infection of implant
Infection occurs early or late even after years after the surgery (fig. 5). In cases of infection, I usually remove the implant along with any surrounding necrotic tissue, irrigate the nose with antibiotics, and concurrently perform revision surgery with autologous grafting material (fig. 6). It is my opinion that it is more prudent to remove the implant at an earlier stage than to wait for infection control with medical treatment since antibiotics can rarely resolve the situation and the events are prone to recur.16 To avoid infection when using alloplastic implants, I take extra precautions that include preparing the nose with cotton balls soaked in betadine solution, frequent irrigation of the nose with antibiotic solution, and careful handling of the implant. The implant is designed aseptically with new gloves and inserted after being soaked in antibiotic solution. Postoperative broad-spectrum antibiotics are given for two weeks. Insertion in the proper subperiosteal plane is also important since the periosteum can serve as a natural barrier.
The unnatural operated look is caused primarily by two reasons. One is the very conspicuous indication of the implant, causing the so-called “toothbrush handle look” in the frontal view (fig. 7a) while the other is too high radix (fig. 7b) from the frontal and lateral views. Revision in this case is performed with attention to the starting point of the nose in the radix. To avoid this unnatural look, it is worthwhile to refrain from using hard alloplastic implants such as silicone in thin-skinned Asian patients. Over-augmentation should also be avoided since it can cause skin thinning over time. The implant should be designed carefully to ensure that the nasal starting point is near the midpupillary line.
Contracted, short nose
The contracted nose associated with alloplastic implants presents a major challenge (fig. 8).19 It frequently develops after removal of longstanding alloplastic implants (especially silicone or Gore-Tex) due to scar contracture caused by the secondary structural changes in the bone and cartilage beneath the implant as well as in the SSTE superficial to them. Wide release of the contracted skin and lower lateral cartilage, building a firm foundation with autologous grafting material that can counteract the contractile forces of the SSTE, and additional graft on the tip and dorsum are key maneuvers for lengthening the contracted nose; therefore, rib cartilage is used in most cases (fig. 9). Unfortunately, the only way to avoid contracture associated with alloplastic implants is by not using them.
Doral and tip problems
Frequent problems of the upper two-thirds of the nose are residual deviation or dorsal irregularities (fig. 10). As tip surgery is more commonly performed recently, tip problems such as asymmetry, polly beak deformity, under-projection, or over-rotation are also increasing. While dorsal problems are more common than tip problems in Asian, Caucasians tend to have more problems on the tip.20,21 Thicker tip skin concealing minor irregularities and a frequent need for dorsal augmentation in Asian can be an explanation for this phenomenon.
Revision techniques in this group are chosen depending on the etiology. Septal reconstruction, complete osteotomies, onlay, and camouflage grafts are used to correct the upper two-thirds. Extended spreader grafts, septal extension grafts, and onlay grafts are used to control the rotation and projection of the tip with additional alar batten, rim grafts, composite grafts, and alar base resection for further refinement of the tip (fig. 11).
Main etiologies of functional problems in Asian rhinoplasty are missed or incomplete correction of septal deformity, untreated allergy or turbinate dysfunction. On the other hand, a considerable portion of functional problems are derived from nasal valve dysfunction in Caucasian rhinoplasty.23, 24 This is because most Asian rhinoplasty includes augmentation while reduction or resection, which can be a potential source of functional problems, is relatively more frequent in Caucasian rhinoplasty.
Majority of revision rhinoplasties in Asians are associated with alloplastic implants or dorsal problems. Recent increase in tip revision reflects the increase of open rhinoplasty techniques. Proper management of these problems of revision Asian rhinoplasty needs thorough understanding of Asian nasal anatomy, proper consultation based on the Asian cultures and heritage, mastering of techniques unique to Asian rhinoplasty, and proper use of graft materials including rib cartilage. Experiences in handling problems unique to Asian revision rhinoplasty need a continuous exposure to various cases with cultural and technical assimilation.
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