Revision of the nasal tip

What repeats

Four findings that hold across the literature.

Tip position is the commonest reason for a second operation

A practice that reviewed 252 revisions after its own open rhinoplasties put the revision rate at 10.8 percent, and the three leading reasons were insufficient tip rotation at 37.7 percent, hanging columella at 30.2 percent and supratip deformity at 28.6 percent. All three are faults of the tip and the base it sits on.

Rests on: Sibar et al., 252 revisions · and the polly beak.

The surgeon sees more wrong than the patient does

In 100 consecutive secondary rhinoplasty patients, the commonest complaints were blocked airway at 65 percent, dorsal asymmetry at 33 percent, nostril asymmetry at 18 percent and tip asymmetry at 14 percent. On examination the surgeon recorded dorsal asymmetry in 65 percent against the patients' 33 percent, nostril asymmetry in 41 percent against 18 percent and columellar protrusion in 25 percent against 6 percent. The commonest operations performed were septoplasty at 71 percent, alar rim graft at 67 percent and dorsal graft at 63 percent.

Rests on: Lee et al., preoperative flaws and maneuvers · Pearlman and Talei, the anatomic basis · and nasal analysis.

A revision is more likely to need a further revision

Of 245 patients at one specialist clinic, 153 primary and 92 revision, another revision during follow-up occurred in 10.5 percent of the primary group and 23.9 percent of the revision group. Complex reconstruction, extracorporeal septoplasty and grafts taken from outside the nose were all used more often in the revision cases.

Rests on: Hacker et al., primary against revision · and revision rhinoplasty.

The skin over the tip behaves differently the second time

Ultrasound measurement in 36 patients found the skin and soft tissue envelope significantly thicker after revision than after primary surgery at nearly every region and every follow-up point, and the swelling settled more slowly. Skin trouble is also concentrated in revision cases: of 384 open rhinoplasties, 27, or 7 percent, had skin compromise needing unplanned treatment, and 25 of those 27, 92.6 percent, were revisions.

Rests on: Rasti et al., envelope thickness · Irvine et al., compromised nasal skin · Deot and Nassif, salvaging the envelope · and recovery.

By what has to be rebuilt

The plan follows what is left of the cartilage.

The lateral crus is scarred or thinned

A strut sutured under the remaining crus corrects notching, pinching, retraction and a collapsing valve at once. In 37 patients followed at least 12 months out of 53 secondary rhinoplasties, the mean rhinoplasty outcome score rose from 30.41 to 75.90, and the largest gain was in the group with lateral crural deformity.

Rests on: Kook et al., secondary rhinoplasty · Abdelhamid et al., repositioning in revision · and lateral crural techniques.

The lower cartilages are gone

When neither the inner nor the outer arm supports anything, a new lower lateral cartilage is carved from rib and put in. That was done in 24 patients having open surgery after multiple previous rhinoplasties, mean age 23, with follow-up between six and eighteen months and no complications attributed to the technique.

Rests on: Balikci et al., total reconstruction · and rib cartilage grafts.

The tip needs projection and contour together

A paired graft from ear cartilage, shaped as a Y and set between the inner arms, raised the tip and restored contour in 37 patients with congenital, acquired or surgical tip deformity. The nasolabial angle increased regardless of the type or the site of the deformity, and no adverse outcome was seen in the revision patients.

Rests on: Martino et al., the Y-columellar strut · and ear cartilage grafts.

There is no septum left to build on

Rib is the usual answer. In 226 revision patients given off-the-shelf fresh frozen rib grafts, mean follow-up 12.18 months, the infection rate was 2.7 percent and most of those were treated with antibiotics alone. A systematic review of 14 studies and 1358 patients put the pooled complication rate for tip-stabilising rib grafts at 4.7 percent, with resorption commoner in irradiated donor cartilage at 2.4 percent and warping commoner in the patient's own at 1.7 percent.

Rests on: Rohrich et al., fresh frozen rib · Kowalski et al., systematic review · and rib cartilage grafts.

The valves have to be rebuilt with the tip

Revision of the tip and reconstruction of the nasal valves are one operation, not two, because the same cartilages hold the sidewall open and shape the tip.

Rests on: Longino and Most, technique and evidence · Ramirez et al., tip deformities in revision · and nasal airway obstruction.

What to ask before a tip revision

Questions the evidence supports asking.

How long should I wait

Ask when your skin will be settled enough to judge the shape. Revision skin stays thicker for longer than primary skin on ultrasound, which is why the shape you see at three months is not the shape at a year.

Rests on: Rasti et al. · and recovery.

Where is the cartilage coming from

Ask before the day. Septum, ear and rib each have their own trade, and the graft material is decided by what previous surgery left behind.

Rests on: Hacker et al. · Kowalski et al. · Rohrich et al..

What is the chance I need another operation after this one

Higher than after a first operation. The published figure from one specialist clinic is 23.9 percent after revision against 10.5 percent after primary surgery, and it should be part of the consent conversation.

Rests on: Hacker et al. · Sibar et al..

Am I a good candidate

Two published tools address this directly. In 148 cosmetic rhinoplasty patients, those who rated their mood and self-esteem worst because of their nose had revision rates of 16.7 percent and 18.8 percent, while those who rated it lower had a revision rate of 0 percent. In 961 cosmetic patients, 18 percent of those with a psychiatric diagnosis had at least one revision against 12 percent of the rest.

Rests on: Okland et al., nasal self-esteem · Tie et al., psychiatric diagnoses · and the psychology of rhinoplasty.

Is my skin at risk

Advanced age, smoking and the number of previous nose operations were each correlated with skin compromise. Of the patients who had it, 12, or 44.4 percent, resolved completely with treatment and no further surgery, and the revision rate in that group was 22.2 percent.

Rests on: Irvine et al. · Deot and Nassif.

The terms, defined

The words used about a second operation on the tip.

• Revision rhinoplasty: any operation on a nose that has been operated on before, also called secondary rhinoplasty. [34270514]
• Skin and soft tissue envelope: the skin, fat, muscle and lining covering the nasal framework, thicker and less forgiving after surgery. [36038664]
• Supratip deformity: fullness just above the tip, one of the three commonest reasons for revision. [34550928]
• Hanging columella: the wall between the nostrils sitting below the nostril rims on the profile view. [34550928]
• Lateral crural strut graft: a cartilage strip sutured under the outer arm of the lower cartilage to rebuild the sidewall. [40920505]
• Total lower lateral cartilage reconstruction: carving and inserting a whole new lower cartilage, usually from rib. [38693403]
• Fresh frozen rib cartilage: donor rib stored frozen rather than irradiated, used when there is no septum left. [35511072]
• Skin compromise: loss of blood supply to the nasal skin after surgery, needing unplanned treatment. [33054380]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology published a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It covers counselling, documentation and what should be assessed before a further operation.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries a revision textbook and two chapters on rebuilding tip support. They are written for surgeons.

• Revision Rhinoplasty Textbook
• Supporting the Nasal Tip
• Tip Rhinoplasty: Alar Structural Support Techniques
• Rhinoplasty Long Term Effects

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy, the indications and the complication list in full text at no charge.

The societies

• American Society of Plastic Surgeons, patient information.
• American Academy of Facial Plastic and Reconstructive Surgery, patient information.
• The Rhinoplasty Society, the surgeons' body, with its member directory.

The trials in progress

Healing and counselling after rhinoplasty are under test in registered trials.

• Rhinoplasty Scar Comparison, completed, 60 participants.
• Education's Impact on Involuntary Thoughts and Healing in Rhinoplasty Patients, completed, 82 participants.

What is not settled

• No randomised trial covers any part of tip revision. The evidence is single-surgeon series and one large database query. [42091330] [41412191]
• Reported revision rates come from the practices that publish them, and a patient who goes elsewhere for the next operation is not counted. [34550928] [34270514]
• Predictors of revision are drawn from a database of 101,562 primary patients and from 115 variables tested at once, so the associations need testing before they guide selection. [41286173]
• Whether donor rib or the patient's own rib is better for a rebuilt tip is argued from pooled complication rates, not from a comparison in the same hands. [38669105] [35511072]
• How long to wait before revising a tip is stated as a rule of thumb and measured by nobody. [36038664]