Dr. Alejandro Nogueira's Case #3CX6RKZ6

The preoperative findings were quite obvious and typical in revision cases, in spite all her nasal skin is sebaceous and thick, thus concealing and minimizing her deformities.

Essentially she had, unexplainably, a persistent dorsal hump nobody tried to fully remove but barely rasped partially, the mandatory osteotomies were never performed and therefore she suffered from open roof deformity, inverted V deformity and a pinched middle vault.

Additionally her tip and alae showed some bossae of uncertain diagnosis and causes difficult to tell, likely post surgical or iatrogenic; the caudal septum was nonexistent, the tip poorly supported and prone to collapse, lacking the tip the desirable projection; the patient expressly requested a supratip break effect whenever it would be possible during the revision surgery; the nostrils had been previously trimmed and it was deemed unsuitable and dangerous a secondary trim.

An open approach was applied to access and visualize structures, in order to perform a detailed diagnosis of the skeletal damages after three previous rhinoplasties and design a reconstructive strategy; the first finding was a massive amount of fibrosis, calcified and entangled with the cartilaginous remains; the first stage was performing a meticulous debridement of the fibrotic masses preserving the essential anatomical elements forming the nose, cartilages, bones, mucosa and skin.

The intraoperative visual findings confirmed and augmented the severity of the preoperative diagnosis; indeed the caudal septum was over resected, but more that it was suspected, being unfeasible using it as donor site of grafting due the minimal portion left in the depth of the nasal fossa; the lateral cruras of the lower lateral or alar cartilages and the domes of the tip were over resected and literally grinded, shattered in small portions and evidencing random cuts likely arisen after the failed attempts of revision via closed approach, therefore the lateral cruras, the domes of the tip and the tip itself was judged irreparable and a reconstruction plan o them decided; the other issues were confirmed, like non performed osteotomies on the nasal bones, open roof deformity, inverted V deformity with collapse of the soft nasal walls, more severe at the right side as can be seen in the photos of the case, and a pinched middle vault.

Fortunately the concha bowls of both ears were large enough to donate sufficient cartilage to rebuild and repair the damaged parts, otherwise the rib would have been used as donor.

Firstly a septal reconstruction was carried ahead by means of a pair septocolumelar grafts of double support, two on one design and L shaped, anchored to the upper lateral or triangular cartilages and to the remain of the deep septum; these septocolumelar grafts acted as key stand structure to provide spacer grafts to treat the inverted V and the pinched middle vault, tongue in groove support and strut to the medial cruras and tip projection support.

Then two handmade and customized lateral cruras were tailored to replace the irreparable original ones, and secured in place to the angle of the septocolumellar grafts; a shield graft to replace the tip, fully customized and also handmade was applied to reposition, reshape and rebuild the nasal tip on top of L shaped nasal lengthening structure, with care to create the supratip effect sought by the patient.

Finally the mandatory osteotomies were performed to realign the nasal pyramid and close the open roof deformity.

The final result is a very nicely and feminine nose, with a neat and smooth dorsum, very triangular in shape, good tip shape, support and length, an improved nasolabial angle and a nice supratip break; all the preoperative issues have been eradicated and the nose shows no stigmata of the previous damage, in spite the bad internal situation forced to a more reconstructive than repairing or revision procedure.

It is remarkable how, in spite it was extracted the maximum available amount of cartilage from both ears, the postoperative look of the auricle is perfect and no signs of such extraction nor deformities are present, no anterior scars, no droopiness, all the natural ear creases are respected and no rupture of contour; harvesting ear cartilage in rhinoplasty is not a trivial maneuver and in case it is not properly executed may lead to additional deformities requiring repair or even complex reconstruction.