Revision Rhinoplasty Operation For "Under Projected Nose, Retracted Ala and Left Alar Pinch Deformity"

Revision Nose Job for Functional and Cosmetic Reasons

Following a septorhinoplasty operation performed at a different clinic a year ago, the patient presented with complaints of a hole-shaped discharge-filled sunken area on the left nostril, a feeling of narrowing and congestion in the left nostril, a collapse in the left nostril, adhesion in the right nostril, and a sagging nasal tip. The patient's examination revealed the following:

- under-projected nose tip

- scar and partial stenosis under the wing of the left nostril

- left alar pinch

- synechiae in the inner part of the right nostril

- synechiae between the septum and inferior turbinate in the right nasal cavity

- retracted ala, more pronounced on the left

- septal deviation to the right

We performed a revision rhinoplasty using rib cartilage temporal fascia, synechiae excision, and the procedures we will explain in detail below.

In the image above, in the pre-operative nasal photograph taken from below, the left partial nostril stenosis area (outer legs of the alar cartilage have fallen below the incision level and a scar has developed) is seen with the red arrows, and the notching on the left nasal wing is seen with the green arrow.

The image above was taken from the front of the nose before the operation, and in the area indicated by the blue arrow, a few mm of indentation can be seen in the area (the patient has never had a nose piercing, there was an infection in this area, the patient said that although there was no indentation in this area during the first surgery, there was redness and this indentation later on), the green arrow shows the indentation on the left wing of the nose.

The image above is a preoperative nasal photograph. The concave area on the patient's left nasal wing is shown with a blue arrow. The notching and alar retraction area on the patient's left nasal wing is shown with a green arrow.

The patient underwent open technique septorhinoplasty and synechia excision operations under general anesthesia. Temporal fascia graft was taken from the patient's left temporal region and rib cartilage was used.

Intraoperative findings: The hollow area on the patient's left nasal wing, which looked like a piercing, was quite adherent to the inside of the nose. It was thought that there may have been a past infection or suture reaction in this area. The patient's left nasal wing was notched, and the outer leg of the alar cartilage was sagging downwards in the area of ​​the previous marginal rim incision inside the nose. There was intense scar tissue in this area. At the entrance of the left nostril, synechiae were seen between the upper part of the nasal septum and the inner part of the nasal wing. It was seen that the nasal septum was deviated to the right and there were synechiae between the nasal septum and the inferior turbinate.

Operation note: An incision was made in the same way from the previous step incision scar area on the columella. The skin of the tip of the nose was lifted and elevated. A very delicate dissection was performed, as it was seen that there was a very dense scar on the left nasal wing and that the tissue between the skin and the inside of the nose was very thin. It was seen that the nasal dorsum was quite irregular. (Due to the thick skin characteristics, nasal bridge irregularities had naturally formed a maufle). Septoplasty was performed, synechiae areas between the right inferior turbinate and septum were cut, and bleeding control was performed with radiofrequency. Triangular tissue was removed from the synechiae area area on the upper inner part of the right nasal wing, and radiofrequency was applied. The cartilage in the caudal septum area was shaved, and two layers of cap grafts were placed on the alar cartilage dome point. The nasal bone was drilled with a micromotor. Lateral osteotomy was performed. Soft tissue was shaved from the supratip area, and this tissue was placed as a basket graft in the form of a graft in the hollow area on the left nasal wing with a 5/0 PDS fixation suture from the subcutaneous side. Left marginal rim graft, cartilage graft was placed on the lateral crus of the alar cartilage. Fascia graft was laid on these grafts and on the left alar cartilage. Bleeding control was performed. Internal nasal silicone splint was placed on both sides. The nose was bandaged and the operation was concluded by placing an external thermoplastic nasal seplint.

The small, protruding sutures you see in this photo are securing the camouflage grafts placed underneath. After one week, these sutures will be cut close to the skin.

In the photos of the nose taken from the side, the nose tip projection is increased, while the photo above shows an underprojected nose image. The stitch on the side, the one closest to the eye, is a skin stitch placed in the lateral osteotomy area. The stitch on the nose is a temporal fascia fixation stitch placed on the bridge of the nose. These stitches will be cut and removed at the follow-up examination 1 week later.

Under Projected Nose (Insufficient Nasal Projection)

Insufficient nasal projection is a condition where the tip of the nose does not extend far enough forward compared to the rest of the face. This appearance can make the nose appear short, flat, or sunken, especially in profile. While it is present from birth in some patients, it may develop in others after previous rhinoplasty surgeries.

Insufficient nasal tip projection is not just an aesthetic problem. If the cartilage structures supporting the nasal tip are weak, the nasal airway can also be affected. In modern rhinoplasty techniques, septal extension grafts, the tongue-in-groove technique, or various support grafts can be used to both increase nasal tip projection and provide long-term stability.

Retracted Alar (Alar Retraction)

Alar retraction is when the nasal wing is positioned higher than normal, resulting in the nostrils and internal nasal structures becoming more visible than normal. The increased distance between the nasal wing and the upper lip is particularly noticeable when viewed from the front and side.

This condition can be congenital or develop after previous rhinoplasty surgeries. Excessive cartilage removal, scar tissue formation, or loss of support are among the most common causes of alar retraction. Treatment aims to bring the nasal wing into a more natural position using alar rim grafts, composite grafts, or lateral crural repositioning techniques.

Alar Pinch Deformity

Alar pinch deformity is the inward collapse and compression of the nasal wing due to insufficient cartilage support on the outer part of the nasal wing. When seen on the left side, it is called "Left Alar Pinch Deformity". This deformity can both impair aesthetic appearance and negatively affect breathing function.

This problem, which can occur especially after excessive thinning or removal of the lateral crural in older rhinoplasty techniques, may become more pronounced over time. Patients often complain of unilateral nasal congestion, nasal valve narrowing, or an asymmetrical nasal appearance.

Treatment may involve lateral crural strut grafts, alar batten grafts, or lateral crural reconstruction techniques. The goal is not only to correct the shape of the nasal wing but also to improve airflow by restoring structural support to the external nasal valve region. This allows for a more balanced outcome in terms of both aesthetics and function.

Search result link where you can find articles prepared by Dr. Murat Enöz about revision rhinoplasty and published on this website (you can also reach previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=revision+rhinoplasty

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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