Alloplasts

The senior author's experience with alloplasts has been to remove them. The author has removed alloplasts because they cause pain, because they caused an unacceptable cosmetic result, because they became infected, and because of extrusion into the nose and through the skin. There is disagreement among rhinoplasty surgeons regarding the use of alloplasts. The nose fulfills few of the requirements for use of alloplastic materials. If the alloplast extrudes through the skin, the skin-soft tissue envelope is permanently and irreparably damaged. The senior author discourages the use of alloplasts in primary and revision rhinoplasty.

Inverted V-middle vault collapse

In inverted V-middle vault collapse deformity, the caudal edge of the nasal bones are visible in broad relief. Inadequate support of the upper lateral cartilages after dorsal hump removal can lead to inferomedial collapse of the upper lateral cartilages and an inverted V deformity [35]. Inadequate infracture of the nasal bones is another significant cause of inverted V deformity. The anatomic cause of inverted V deformity must be recognized. Osteotomies with infracture of the nasal bones, spreader grafts, or both should be performed when appropriate.

Twisted nosednewly or persistently twisted

Persisting deviation after rhinoplasty may occur at the upper third, middle third, or tip of the nose or may occur postoperatively in a previously straight nose. Preoperative anatomic diagnosis is a crucial component of successful treatment. Persisting deviation of the nasal bones may occur because of greenstick fractures or other problems with osteotomies [36,37]. Inherent deviations in the cartilage of the middle nasal vault may prove especially challenging [37]. Also, hump removal may uncover asymmetries that result in postoperative deviation where none existed previously. Tip asymmetry may be overlooked preoperatively, or it may due to asymmetric excision of lateral crura, asymmetric placement of a columellar strut, placement of an overlong columellar strut, or other causes. Numerous surgical maneuvers are available to address the deviated nose [36,37].

Skin-soft tissue envelope

In the unoperated nose, the skin-soft tissue envelope has well-defined tissue planes in which avascular dissection may be undertaken. Vascular supply and lymphatics are found superficial to the nasal musculature [38,39]. Dissection in the proper tissue planes (areolar tissue plane, ie, submusculoaponeurotic) preserves nasal blood supply and minimizes postoperative edema. Operating in the more superficial planes not only leads to a bloody surgical field, but also risks damage to the vascular supply with potential damage to the skin. When the skin-soft tissue envelope is damaged, it can never be restored fully. The damaged skin creates an esthetically displeasing appearance [38,39].

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