A Revision Nose Job on a Patient with Nostril Stenosis, Alar Retraction, and Pollybeak Deformity
A patient presented to our clinic for treatment after developing severe nasal obstruction and various deformities following three prior rhinoplasty procedures at a different clinic. Examination of the patient revealed the following:
- Soft-tissue "pollybeak" deformity
- Left nostril stenosis and severe narrowing of the internal nasal passage
- Retracted ala (more pronounced on the left)
- Left alar collapse
- Various scars on the columella
- A depressed scar area with a protruding hair, located immediately to the left of the columella
A fourth revision rhinoplasty using an open technique was planned. A temporal fascia graft was harvested from the right side; as the patient's own nasal cartilage was sufficient, no additional rib cartilage graft was required.
The procedures performed on the patient were as follows:
- Two-level dissection and subcutaneous tissue excision in the supratip area
- Resection of stenotic tissue and placement of bilateral marginal rim grafts (with greater emphasis on the left side)
- Placement of a septal extension graft
- Placement of a cap graft
- Resection of the columellar scar area containing a protruding hair
- Covering of the nasal tip cartilages with fascia graft and placement of fascia graft in the area of the retracted left ala
- Smoothing of the nasal dorsum using a micromotor
- Placement of a fascia graft over the nasal dorsum
The PDS sutures visible on the patient's nasal tip and dorsum are the sutures securing the basket grafts. Removal of these sutures was planned for one week post-operatively.
Our patient, who had previously undergone rhinoplasty three times at another clinic, presented to us due to severe nasal obstruction, narrowing of the nostril, alar retraction, alar collapse, and a pollybeak deformity that had developed over time. A detailed examination revealed marked stenosis, particularly in the left nostril, and severe narrowing of the internal nasal passage. This clinical picture necessitated complex reconstructive surgery aimed not only at aesthetic revision but also at restoring proper nasal airflow.
The patient exhibited a soft-tissue-related pollybeak appearance, more pronounced alar retraction on the left side, collapse in the left alar region, and various areas of scarring on the columella resulting from previous surgeries. Additionally, there was a depressed, irregular scar area just to the left of the columella, featuring a hair shaft protruding outwards. Consequently, it was determined that the planned surgery required a comprehensive assessment addressing scar tissue, nostril aperture, alar support, and the nasal airway, rather than simply altering the shape of the nose.
Before-and-after images of the procedure are provided below:
Risks and Surgical Challenges of the Complex Revision Rhinoplasty Performed on the Patient
- Since repeated surgeries involve progressively altered anatomy and the formation of additional scar tissue, tissue dissection during the operation is significantly more difficult.
- To minimize the risk of circulatory impairment and infection post-operatively, surgical trauma must be kept to an absolute minimum.
- The patient's skin is quite irregular and altered. There is a risk of skin perforation and infection in areas affected by previous scarring or infection.
- Had there been insufficient cartilaginous support, it might have been necessary to harvest a graft from the patient's own rib.
- Nostril stenosis—resulting in the near-total closure of the left nasal airway—is a recurrent condition that is difficult to treat. Prolonged use of internal silicone nasal splints post-operatively may be beneficial.
- The patient presents with a "pollybeak" deformity in the supratip region due to thick subcutaneous tissue. To prevent excessive soft tissue regrowth post-operatively, the patient may need to perform nasal taping and use medication—such as Zoretanin tablets—that inhibits fibro-adipose tissue formation.
- In general, the recovery period following revision rhinoplasty is longer.
- After placing grafts in the retracted alar region, the skin incision could not be closed directly; instead, the cartilage grafts were covered with fascia. Suturing is difficult when grafts are placed in retraction zones characterized by already tight and scarred tissue.
Why Is Fourth-Stage Revision Rhinoplasty More Challenging?
While a surgeon typically works with previously undisturbed anatomical structures during primary rhinoplasty, the situation is quite different in fourth-stage revision rhinoplasty. Three prior surgeries may have altered cartilage shapes, weakened certain supporting structures, caused scar tissue formation, and disrupted normal tissue planes.
Consequently, in fourth-stage revision rhinoplasty, the surgeon must first "rediscover the existing anatomy." During the operation, a detailed assessment is made regarding which cartilages remain intact, the location of scar tissue, the cause of nostril narrowing, and the extent to which existing tissues can be reused.
What Is Nostril Stenosis?
Nostril stenosis refers to an excessive narrowing of the nasal vestibule—or the nasal opening—that restricts airflow. It can occur, particularly following previous rhinoplasty surgeries, as a result of wound healing processes, scar contraction, loss of alar support, or excessive tissue removal.
In this patient, the pronounced stenosis in the left nostril was a major cause of nasal obstruction. Although narrowing at the nasal opening may appear to be a minor anatomical change, it can significantly impact airflow. Therefore, correcting vestibular stenosis is a key functional objective of revision surgery.
Are Nostril Stenosis and Nasal Valve Narrowing the Same Thing?
While nostril stenosis and nasal valve narrowing are related, they are not the same anatomical problem. In cases of nostril stenosis, significant narrowing may occur, particularly at the entrance of the nasal vestibule. Narrowing in the nasal valve region, however, can affect airflow in a deeper anatomical area.
In complex revision rhinoplasty, it is important to evaluate these areas separately, as merely widening the nostril may not resolve a deeper nasal valve issue. The surgical plan must be tailored to the actual anatomical source of the obstruction.
What Causes Alar Retraction?
Alar retraction is the upward displacement of the nasal wing (ala) from its normal position, making the nostril more visible. Factors such as excessive reduction of alar cartilages during previous rhinoplasties, loss of structural support, scar contracture, or a deficiency of skin and soft tissue can contribute to alar retraction.
Alar retraction is not merely an aesthetic issue; in severe cases, it can alter the geometry of the nasal entrance and affect airflow. Therefore, a reconstructive approach becomes particularly important when alar retraction, nostril stenosis, and alar collapse coexist.
How Can Left Alar Collapse Affect Nasal Congestion?
Weakening of the cartilaginous support in the alar region can cause the nasal wing to move inward during inspiration. This can contribute to narrowing of the nasal vestibule and reduced airflow, particularly during breathing.
When alar collapse is identified during revision rhinoplasty, the treatment plan should address not only the correction of external appearance but also the restoration of support to the alar framework. For this purpose, lateral crural strut grafts, alar batten grafts, or other structural cartilage grafts may be used in suitable patients.
What Is Pollybeak Deformity?
Pollybeak deformity is a nasal deformity characterized by prominence in the supratip region located immediately behind the nasal tip when viewed in profile. Soft tissue thickness, alterations in cartilaginous structures, or a failure to properly balance dorsal structures during prior surgery can lead to various forms of pollybeak deformity.
Since soft tissue is a significant component of the pollybeak appearance in this case, the surgical plan should not focus solely on reducing cartilaginous or bony tissue. Careful assessment is required, as excessive dorsal resection could result in a new depression or profile irregularity.
Why Does Soft-Tissue-Induced Pollybeak Require a Specialized Approach?
Not every pollybeak deformity is caused by excess cartilage or bone. In some patients, the thickness of the skin and soft tissue in the supratip region, scar tissue, or healing-related changes can play a significant role.
Therefore, in revision surgery, it is essential to first determine whether the deformity is caused by soft tissue, cartilage, bone, or a combination thereof. Performing unnecessary cartilage resection in a deformity primarily driven by soft tissue can lead to a loss of dorsal support and result in a different type of deformity.
Why Might the Open Technique Be Preferred for a Fourth Revision Rhinoplasty?
In complex revisions, the open rhinoplasty technique allows the surgeon to directly assess the anatomical structures of the nasal tip and columella. A detailed view of these anatomical structures can facilitate surgical planning, particularly in cases involving a combination of asymmetry, alar retraction, vestibular stenosis, and multiple areas of scarring.
However, the open approach itself carries the risk of creating a new surgical incision and scar. Consequently, incision planning and the preservation of soft-tissue blood supply are particularly critical in patients who already have multiple scars on the columella.
Why Might a Temporal Fascia Graft Be Used in a Fourth Revision Rhinoplasty?
In this case, a temporal fascia graft harvested from the right temporal region may be considered, particularly for supporting the soft-tissue contour and if necessary covering irregular surfaces to create a more natural transition.
As it is derived from the patient's own body, temporal fascia is an autologous material. Its thin and malleable nature can help soften the contours over cartilage grafts in certain revision cases. However, temporal fascia alone cannot replace strong structural cartilage support; its intended use must be determined based on the nature of the deformity.
Why Was Rib Cartilage Not Used?
Rib cartilage can serve as a significant alternative graft source in multiple revision rhinoplasty cases where the amount of septal cartilage is insufficient. However, the use of rib cartilage is not required in every complex revision case.
In this patient, there was no need for an additional rib cartilage graft because the existing nasal cartilage was sufficient. Utilizing existing autologous cartilage as effectively as possible rather than unnecessarily creating a new graft source is a key principle of the surgery.
Difference Between Alar Batten Graft and Lateral Crural Strut Graft
Various cartilage graft techniques can be employed to treat alar collapse and nasal vestibular narrowing. An alar batten graft may be considered specifically to support the lateral nasal wall and reduce inward collapse during inspiration.
A lateral crural strut graft, on the other hand, can be used to enhance the structural support of the lower lateral cartilages and stabilize the shape of the alar cartilages. The choice of technique depends on the anatomical source of the deformity and the available cartilage tissue.
Is a Cartilage Graft Always Sufficient for Alar Retraction?
In cases of severe alar retraction, simply increasing cartilage support may not be sufficient. If the problem stems primarily from a lack of skin or soft tissue and scar contracture, it may be necessary to release the soft tissue and, if required, add tissue.
Therefore, the treatment of alar retraction should be approached through two distinct components: cartilage support and soft tissue management. This distinction is particularly important for surgical planning in patients who have previously undergone three surgeries.
How Should a Scar on the Columella and an Outward-Protruding Hair Be Evaluated?
Scars on the columella resulting from previous surgeries can affect both the aesthetic appearance and the plans for surgical dissection. The presence of a hair protruding from a depressed scar area may be a localized issue resulting from the previous wound healing process or the displacement of a hair follicle into the scar tissue.
When evaluating such an area, one must consider not only the removal of the visible hair but also the structure of the scar tissue, any potential hair follicle beneath the skin, and the condition of the surrounding tissues. Careful tissue management is required, as unnecessarily aggressive excision could lead to the formation of a new scar.
How Does Scar Tissue Complicate Fourth-Stage Revision Rhinoplasty?
Scar tissue resulting from three previous operations can cause the loss of normal anatomical planes and reduce tissue mobility. This situation can be particularly pronounced in deformities where scar contraction plays a role, such as nostril stenosis and alar retraction.
Because the structures encountered by the surgeon differ from the anatomy found in primary rhinoplasty, dissection must be performed with greater caution. Additionally, preserving the blood supply to the skin and soft tissues is a crucial surgical principle, especially in cases involving multiple revisions.
What Are the Main Risks of Fourth-Stage Revision Rhinoplasty?
In complex revision rhinoplasty, complications such as infection, bleeding, edema, and wound healing issues may occur, alongside graft-related complications, contour irregularities, asymmetry, and the partial persistence of the deformity.
During the correction of nostril stenosis, there is a risk of excessive scar formation or recurrent contraction, the reappearance of alar retraction, or failure to sufficiently widen the nasal opening. Furthermore, the displacement, warping, or visible contouring of cartilage grafts over time are among the known risks of revision surgery.
How Is the Balance Struck Between Correcting Nasal Obstruction and Achieving Aesthetic Results?
In such complex cases, aesthetics and function cannot be considered entirely separately. An excessively narrow nostril can create problems regarding both appearance and breathing. Similarly, alar collapse can affect not only the appearance of the nasal wing but also the patency of the airway. Therefore, the goal in surgical planning is to create a natural and balanced external appearance while keeping the nasal airway as open as possible. Since excessive widening of the nostril can result in an unnatural look, functional correction must be planned in conjunction with aesthetic proportions.
The Same Technique Cannot Be Applied to Every Patient in Fourth-Revision Rhinoplasty
There is no single standard surgical technique for patients presenting with a combination of nostril stenosis, alar retraction, and pollybeak deformity. While an alar batten graft may suffice for some patients, others might require a lateral crural strut, a septal extension graft, or a different form of cartilage reconstruction.
Similarly, while temporal fascia is used solely for contour refinement in some cases, other instances may call for different soft tissue grafts. Consequently, personalizing the surgical technique to the specific deformity is crucial, particularly in third or fourth revision cases.
The Primary Goal in Fourth-Revision Rhinoplasty: Restructuring the Existing Framework Rather Than Creating a New Nose
Complications such as nostril stenosis, alar retraction, alar collapse, pollybeak deformity, and severe nasal obstruction developing after three prior rhinoplasties require a surgical approach that differs fundamentally from that of a primary rhinoplasty.
In this case, the primary objectives of the fourth-revision rhinoplasty performed using the open technique are to increase the nasal vestibule opening, restore alar support, correct existing deformities, refine soft tissue contours, and execute a structural reconstruction aimed at improving nasal airflow. It was possible to perform the reconstruction without using additional rib cartilage, as the patient's own nasal cartilages were sufficient. By also utilizing a right temporal fascia graft in appropriate areas, the aim was to make the best possible use of existing tissues in this complex revision case.
In advanced surgical procedures such as fourth-stage revision rhinoplasty, the outcome depends not merely on a single technique, but on the accurate analysis of anatomical changes resulting from previous surgeries, the preservation of existing tissues, the selection of appropriate grafts, and the integrated planning of both aesthetics and function.
You can read articles related to "nostril stenosis" prepared by Dr. Murat Enöz and published on this website via this search result link (you can see the articles by clicking on "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=nostril+stenosis
You can read articles related to "complicated rhinoplasty" prepared by Dr. Murat Enöz and published on this website via this search result link (you can see the articles by clicking on "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=complicated+rhinoplasty
Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon
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