Technical overview of potential complications

The nationally reported revision rate for primary rhinoplasty ranges from 8% to 15% [2-9]. Sadly, there will likely never be a shortage of patients requiring revision rhinoplasty. Experienced surgeons consistently achieve a high level of satisfaction among their patients. Still, complications can occur despite technically well-performed surgery. All surgeons have complications ( Box 2 ).

Having the opportunity in practice to examine numerous revision rhinoplasty patients from across the United States and around the world, the senior author has observed a wide range of problems. The senior author has selected problems encountered in revision practice that warrant highlighting because they are problems encountered frequently or because they illustrate specific surgical techniques that may be particularly useful in the surgeon's armamentarium.

Specific problems to avoid

Overresection of lateral crura - Overresection of the lateral crus is perhaps the most common problem seen in a revision rhinoplasty practice [6,10,24-27]. Overresection of the lateral crus leads to the predictable changes of alar retraction, pinching, bossae, and tip asymmetry ( Fig. 1 ). Excision of vestibular mucosa in primary rhinoplasty also may contribute to scar contracture with alar retraction. A conservative approach to cephalic resection is warranted in rhinoplasty.

In many revision cases, the amount of lateral crus that remained seemed ample; that is, it fell within the "guideline" of 6 to 9 mm that typically is cited. In these cases, the scar contracture secondary to healing apparently overpowered the remnant cartilage. If the tip cartilages are soft and weak, and if the scar contracture is profound, undesirable changes can occur.

In some cases, this situation can be anticipated. An anatomic study of the alar base recognized that in a normal patient population, 20% of patients had a thin alar rim. This anatomic variation must be recognized, and cephalic resection probably should be avoided or minimized in these patients to minimize the risk of alar retraction or external nasal valve collapse [25]. These changes are not always predictable, however, and are not always avoidable.

Understanding that the healing forces are not completely predictable, it is important to take a conservative approach when undertaking cephalic resection. Risk cannot be eliminated, but can be reduced in this manner.

Alar batten grafts are the first-line treatment of alar retraction and nasal valve collapse ( Fig. 2 ) [10,24,26]. Batten grafts have been well described in the literature. Alar retraction may be treated by cartilage batten grafts in less severe cases (1-2 mm) [9].

Auricular composite grafts commonly are used in more severe cases ( Fig. 3 ) [27]. The skin and cartilage of the anterolateral surface, just inferior to the inferior crus, of the opposite ear (eg, left ala, right ear) provides the best donor site and the best contour. An incision several millimeters from the nostril rim is followed by careful dissection with freeing of adhesions, creating a defect and displacing the alar rim inferiorly. Volume and support must be restored to hold the nostril rim in positiondthis role is fulfilled by the composite graft. The fashioned composite graft is sutured carefully into place [27]. Typically, the senior author uses 5-0 chromic suture. A cotton ball or other light dressing is applied intranasally to apply light pressure for 1 to 3 days.

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