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The principles of nasal pyramid correction in secondary rhinoplasties are identical to the ones in primary rhinoplasties.

Although saddle-nose deformities are present in approximately 20 % of all rhinoplasties, the extent of saddle collapse varies widely. Hence, a wide variety of techniques are necessary to correct saddle noses. Because all saddle-nose defects arise from skeletal deficiency, augmentation is the primary means of surgical treatment. We prefer to use autologous augmentation materials for this purpose, with one exception: Tutogen (allogenic) fascia lata (Tutoplast® Inc., Neunkirchen am Brand, Germany). Tutoplast fascia lata is a gamma radiation processed human allograft which we have used successfully in over 3000 patients during the past 8 years (Fig. 7.1). Soaking the graft in antibiotic solution is necessary to rehydrate the graft and reduce infection risk. In addition to the avoidance of a donor site scar, fascia lata offers an ideal structure and stiffness for use in augmentation rhinoplasty. Conversely, autologous fascia lata lacks adequate stiffness, necessitating the use of percutaneous stay sutures to guide graft positioning and to prevent graft displacement.

Naturally occurring malformations of the lower lateral cartilages (LLCs) are common, and the use of the open rhinoplasty approach makes the recognition and characterization of tip malformations far more reliable and precise. Likewise, many unsuccessful rhinoplasties result from the inability to properly recognize and treat congenital LLC malformations because of poor surgical exposure using the closed approach. Malformations of the nasal tip may occur unilaterally or bilaterally with variations in both type and magnitude. Virtually any segment of the LLC can be affected by congenital anomalies, including the medial crural footpods, the medial crura themselves, or the nasal domes. However, the most common site for naturally occurring tip malformations is the lateral crus, with crural concavity being the most commonly seen anomaly. Although most malformations of the LLC are associated with cosmetic disturbances, concave malformations of the lateral crura are also commonly associated with functional impairment, particularly in noses with weak lateral crura that are prone to inspiratory collapse or in noses with an adjacent septal deformity that exacerbates nasal valve obstruction. In the thin-skinned nose, concavities of the lateral crus are often visible externally, but overlying soft tissues may conceal smaller concavities, underscoring the importance of a careful endonasal examination as part of the preoperative evaluation process. While some LLC deformities are hidden by the overlying soft tissues, we prefer not to rely solely on soft-tissue camouflage for treatment. Instead, correction of all skeletal deformities is preferred in order to optimize both the functional and cosmetic results. Although Daniel feels that a slight crural concavity (coupled with convexity of the intermediate crura) will yield the best tip contour, we believe that flat and sturdy lateral crura yield not only a pleasant tip contour but also provide the structural rigidity necessary for reliable function of the nasal airway.

The septum plays an important role in most cases of revision rhinoplasty, since residual deformity is often present. The residual deformity is often caused by an insufficient analysis and subsequent inappropriate or incomplete surgical technique. If this is the case, the long-term outcome is often disappointing, with drooping of the tip, saddling of the dorsum, and/or recurrence of the septal and/or nasal deviation.

Surgical alteration of the bony pyramid is often anxiety-provoking for the prospective rhinoplasty patient. Just talking about “breaking” the bone in the middle of the face creates fear and apprehension. However, contemporary techniques, combined with sophisticated cutting instruments, intraoperative ice-water cooling, and postoperative mechanical cooling devices to minimize swelling and bruising, have greatly improved surgery of the bony vault. Yet despite technical advances, the most important factor is still a well-conceived and individualized treatment plan executed with meticulous precision and extreme care.

Alterations of nasal tip contour are perhaps the most challenging aspect of cosmetic rhinoplasty. And because tip contour must harmonize with the surrounding facial features in a natural but pleasing manner, some degree of surgical tip refinement is a goal of nearly every cosmetic rhinoplasty. However, in addition to constituting a major determinant of facial beauty, the tip is also an integral component of the human nasal airway. Hence, surgical alterations to the nasal tip framework must be circumspect in order to prevent impairment of nasal airway function. Naturally weak tip cartilages are at increased risk of collapse with surgical manipulation, and cartilage size may not always correspond to cartilage strength.

The twisted nose is the most common deformity in noses, in our practice up to 50 %, but it presents a challenge to rhinoplastic surgeons as functional problems as well as aesthetic deformities often occur. The terminology used – deviated, twisted, crooked, asymmetric, scoliotic, and deflected – is confusing.

The nose is the central aesthetic element of the face, and a failed rhinoplasty may lead to significant psychosocial stress and dysfunction. The impact of a failed rhinoplasty should prompt the surgeon to explore the cause of treatment failure and to consider attempting to salvage the outcome with secondary surgery. However, the inexperienced surgeon often exacerbates the initial treatment failure when attempting to correct his or her own work, creating an ever greater challenge for the next surgeon. In such cases, the patient is often apprehensive, skeptical, and mistrusting of further surgery, even at the hands of an accomplished revision rhinoplasty specialist. However, the embarrassment and emotional angst of a failed rhinoplasty eventually prompt further surgery despite the associated fear and anxiety. Yet, in addition to the psychological issues of the revision rhinoplasty patient, the revision surgeon must also contend with the technical challenges of a previously operated nose. Disruption of surgical navigation planes, excessive bleeding, and dense scarring typically make the dissection far more challenging. Moreover, missing, distorted, or damaged skeletal structures typically necessitate complex skeletal grafting, and graft survival is less reliable due to compromised circulation. In the worst-case scenario, vascular insufficiency can lead to graft or skin necrosis. Even when the technical aspects of surgery are successful, postoperative swelling is often increased, and the healing process is usually prolonged. For all of these reasons, a candid and explicit preoperative discussion in which the limitations, risks, and complications of revision rhinoplasty are reviewed in detail must be undertaken. Additional time must also be allotted for a complete discussion of the relevant issues.