Assesment of Tissue Circulation / Perfusion Before The Revision Rhinoplasty

Inadequate tissue perfusion risk in revision nose job surgeries 

Revision Rhinoplasty -  Tissue Circulation / Perfusion Before 

Especially in patients with recurrent rhinoplasty surgeries, tissue perfusion problems may occur, even if it is a rare condition, the risk of circulatory problems should not be ignored in patients undergoing revision rhinoplasty surgery. Inadequate tissue perfusion can cause unwanted infection and tissue loss in revision rhinoplasty operations.

Inadequate blood circulation may cause subcutaneous and cartilage necrosis. Although revision rhinoplasty is the basis for the evaluation of perfusion in patients undergoing clinical examination, ischemic problems may not always be predictable.

In a recent scientific study entitled "Unique Uses of SPY: Revision Rhinoplasty", it was shown that the SPY Elite laser angiographic system, which is widely used to analyze preoperative perfusion, can objectively evaluate tissue perfusion. We present a case of revised rhinoplasty with hypoperfusion of the nasal tip after placement of the structural grafts at the nasal tip, and angiography was used to correct whether only topical nitroglycerin would correct the hypoperfusion of the nasal tip prior to removal of the grafts. An SPY angiography was performed to evaluate hypoperfusion to the nasal tip, followed by re-imaging only after treatment with topical nitroglycerin. The perfusion of the nasal tip was restored and confirmed by the SPY angiography system. Objective findings obtained from SPY angiography allowed grafts to remain in place and resulted in optimal cosmetic results. In this scientific article, it was emphasized that it may be appropriate to use technology when evaluating reconstructive cases that may be difficult to remove tissue viability from clinical examination due to critical SPY angiography.

Tissue perfusion is vital to provide aesthetically pleasing and functional reconstructive surgery. Loss of skin flap can lead to undesirable cosmetic results, especially in the head and neck area. Early recognition of ischemic areas without delay is critical in correcting compromised perfusion. Clinical examination remains the most widely used method to evaluate tissue perfusion. Although widely acceptable, perfusion in difficult cases is often difficult to assess and also depends on the experience of a surgeon.

In addition, topical vasodilator agents have recently been used to manage ischemic conditions because of their efficacy and convenience. In this case, nitroglycerin paste was also used to restore perfusion in a high-risk graft against ischemia.

Patients with recurrent rhinoplasty may have a higher risk of nasal ischemia!

Especially in patients who have undergone 2 or more nasal esthetic surgeries and various cartilage grafts, the skin and subcutaneous blood circulation in the nose may be considerably weaker than normal. Since it will not be easy to evaluate the blood circulation preoperatively, necrosis of cartilage and other grafts that can be used during revision nasal aesthetic surgery or infection in the tissue can easily occur.

The information presented in this scientific study is that "cases involving multiple revision nasal surgery may benefit from SPY angiography to assess tissue perfusion in real time". The use of SPY angiography can help surgeons in preoperative, postoperative and postoperative planning and minimize complications and risks.

Why can a reduction in blood circulation be seen in recurrent revision nasal aesthetic surgeries?

Tissue dissections, skin cuts and bone interventions during rhinoplasty operations are more or less damaging to all vascular structures. However, bleeding control by cauterization during operation may also adversely affect blood circulation. It is inevitable that blood circulation will gradually decrease in recurrent nose surgeries.

I have seen a friend who is a plastic surgery specialist for half and assistance, I have seen in the revision rhinoplasty peration (the patient had already undergone 3 revision rhinoplasty operations), there was no bleeding at the end of the nose during skin dissection (such as cutting a thick cardboard). The lack of circulatory support required for feeding the living tissues to be placed can bring the risk of infection, tissue loss and abscess at the tip of the nose after surgery. Two years after the operation, the columellar strut graft was placed in this patient and I was able to understand that almost all of it was melted by hand palpation of the coumella. Some physicians recommend performing PRP (Platelet Rich Plasma) on the nose in patients who have undergone repeated rhinoplasty operations. It is always the best approach to perform the least possible surgical trauma in revision nasal aesthetic surgery.

Perhaps in the future, a simple device such as a temperature meter or a saturation meter can be used to make it easier for us to understand whether there is sufficient blood circulation in the office conditions before surgery in patients who require revision rhinoplasty. In patients without adequate blood circulation, it may be appropriate to provide information about the risks of revision rhinoplasty operation and, if necessary, not to perform the operation.

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

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