Augmentation Male Revision Rhinoplasty

Third Revision Masculinizing Rhinoplasty for Nasal Dorsum Collapse and Nasal Deformity

The patient, who had previously undergone rhinoplasty twice at a different clinic, presented to our clinic complaining of nasal dorsum collapse, asymmetry, and difficulty breathing through the nose. Examination revealed the following findings:

- Deviation of the nasal axis to the right

- Excessively curved nasal profile due to over-reduction of the nasal hump

- "Polly-beak" deformity

- Drooping nasal tip

- Asymmetry between the nostrils

- Collapse of the left nostril during inspiration

We performed an open-technique augmentation revision rhinoplasty.

Operative note: Following a columellar incision, the nasal tip skin was elevated. Caudal septoplasty was performed. The dome points of the alar cartilages were repositioned. Nasal tip cartilage support was enhanced by placing a septal extension graft using the "tongue-in-groove" technique. A left marginal rim graft and a cap graft were placed. Irregularities on the nasal dorsum were corrected using a micromotor with a tungsten burr. Bilateral low-to-high osteotomies were performed using an ultrasonic device. A left spreader graft was placed. A fascia graft harvested from the right temporal region was placed—in a butterfly shape—over the pre-marked areas to augment the nasal dorsum. The skin was redraped and sutured. Bilateral internal silicone splints were inserted, and the nose was taped. Additional note: The patient presented with a nose shape that appeared feminine. He reported significant wrinkling on the nasal dorsum when smiling (due to excess skin resulting from over-reduction of the nasal hump), a downward drooping of the nasal tip during smiling, and a curved profile that was disproportionate to his face. The procedure aimed to restore a masculine appearance and normalize the nasal shape by augmenting the nasal hump and enhancing tip support to return the nasal tip to characteristics typical of a male nose. A comparison of the patient's pre- and post-operative images reveals that the nasal shape has become natural and more symmetrical.

This case serves as a typical example of natural male revision rhinoplasty.

Advantages of Using Fascia Grafts in Augmentation Revision Rhinoplasty

In cases where the nasal hump has been excessively reduced, we aim to use a graft that can naturally restore volume to the nasal dorsum. The characteristics of an ideal graft include:

- being a viable (living) graft that does not increase the risk of infection or necrosis in an area where surgical dissection has previously occurred and blood supply is compromised

- the ability to smooth out irregularities on the nasal dorsum

- not causing protrusions or sharp, asymmetrical edges on the nasal dorsum after the resolution of edema

- ease of harvesting

- ease of fixation within the surgical site without shifting. Considering these factors, "fascia" grafts—derived from the connective tissue covering muscles—can be easily harvested and utilized in revision rhinoplasty operations, serving both for augmentation purposes and as a camouflage layer beneath the skin. When block cartilage, diced cartilage, and other cartilage grafts are placed on the nasal dorsum, they may result in surface irregularities or an asymmetrical appearance after healing. On this website, you can find images of various complications arising from the placement of synthetic industrial products on the nasal bridge.

The patient's silicone splints were removed after one week, and the nose was re-taped.

The development of nasal dorsum collapse, irregularities along the nasal bridge, and general nasal deformity in a patient who has previously undergone two rhinoplasty procedures can render a third revision rhinoplasty a highly complex surgery. In such cases, the objective is not merely to augment the nasal bridge but also to reconstruct the collapsed nasal framework, correct the nasal contour, establish a dorsal structure consistent with masculine facial characteristics, and create a support system that is as robust as possible.

Particularly in male patients, a nasal bridge that appears completely flat or excessively scooped can result in an outcome that is out of harmony with the face's overall proportions. Therefore, in masculinizing rhinoplasty, the height, width, and straightness of the nasal dorsum, as well as the nasofrontal transition, must be evaluated in conjunction. Achieving these aesthetic goals during a third revision surgery requires more extensive technical planning than a primary rhinoplasty, due to the presence of scar tissue and the fact that cartilage has already been removed or reshaped.

What Causes Nasal Dorsum Collapse?

Nasal dorsum collapse can occur, particularly following previous rhinoplasty procedures, as a result of excessive reduction or inadequate support of the cartilaginous and bony structures along the nasal bridge. Excessive removal of the structural components of the septum can also compromise the stability of the nasal framework.

Additionally, scar tissue formation during the healing process, cartilage warping, or a gradual loss of structural support over time can lead to collapse and irregularities in the nasal bridge. While the collapse may present solely as an aesthetic issue for some patients, in other cases, it can alter the geometry of the nasal valve region and impair nasal breathing.

Why Is a Third Revision Rhinoplasty More Challenging?

In a third revision rhinoplasty, the surgeon often does not encounter standard anatomical planes. Previous surgeries may have resulted in subcutaneous fibrosis, scar tissue, and the displacement of anatomical structures. Distinguishing normal cartilage boundaries can become difficult, requiring greater caution during dissection.

Furthermore, a significant portion of the septal cartilage may have already been utilized or removed during earlier operations. This complicates the task of sourcing the necessary material to reconstruct the dorsal structure. Consequently, preoperative planning, the assessment of available tissues, and knowledge of alternative graft options are of critical importance in revision rhinoplasty.

The Goal of Augmentation Rhinoplasty Is Not Merely to Raise the Nasal Bridge

Augmentation rhinoplasty involves reconstructing an insufficient or collapsed nasal dorsum using various graft and implant materials. However, simply elevating the nasal bridge does not always yield a natural and balanced outcome. Especially in masculinizing rhinoplasty, the straightness, width, and projection of the dorsal line—as well as its relationship with other facial anatomical structures—are just as important as the height of the nasal dorsum. Therefore, both the frontal and profile views of the nasal dorsum must be evaluated simultaneously during augmentation.

Nasal Dorsum Reconstruction with Septal Cartilage

Septal cartilage is one of the autologous graft materials frequently used in rhinoplasty. Because it is harvested from the patient's own tissue, it offers high biocompatibility and can be shaped for various purposes.

However, the fact that septal cartilage may have already been used in prior surgeries can pose a significant limitation in third-stage revision rhinoplasty. If a sufficient amount is available, septal cartilage can be utilized to provide dorsal support or to create other structural grafts. When there is insufficient cartilage, alternative sources such as ear or rib cartilage may be considered.

How Can Temporal Fascia Grafts Be Used in Revision Rhinoplasty?

Temporal fascia is an autologous tissue that can be used particularly in revision rhinoplasty to refine soft tissue contours and create smoother, more natural transitions over grafts. Thanks to its thin and malleable nature, it helps cover irregular cartilage surfaces with a softer contour.

In this case, the combined use of temporal fascia and septal cartilage can offer distinct advantages for both structural reconstruction and surface contour refinement. Temporal fascia can serve as an additional soft tissue layer, particularly in areas where a more natural appearance regarding thickness and transitions is desired.

The Advantage of Combining Temporal Fascia with Cartilage Grafts

In revision rhinoplasty, the use of a rigid cartilage graft alone can sometimes lead to visible graft edges or surface irregularities, particularly in patients with thin skin.

Temporal fascia can be used to soften the transition between the cartilage graft and the overlying skin. This approach aims to minimize sharp transitions in the dorsal structure and achieve a more uniform contour. However, fascia alone cannot substitute for structural support; when necessary, the primary load-bearing structure must be created using cartilage or another structural graft.

How Is the Nasal Dorsum Planned in Masculinizing Rhinoplasty?

In male rhinoplasty, the goal is not to create an excessively concave or diminutive nose, which are often considered feminine traits. Instead, the aim is to establish a stronger, balanced nasal contour that harmonizes with the patient's facial structure.

Therefore, in masculinizing rhinoplasty involving augmentation, it is crucial to avoid over-refining the dorsal line and instead create a nasal bridge with appropriate width and sufficient projection. The relationship of the nasal bridge to the forehead and the nasal tip must also be evaluated.

What Are the Different Grafting Techniques for a Third Revision?

The technique employed for nasal dorsum reconstruction depends on the patient's existing anatomy. If a sufficient amount of septal cartilage is available, various structural grafts can be prepared. Rib cartilage may be considered when greater volume and support are required. In addition, diced cartilage grafts, crushed cartilage grafts, cartilage wrapped in fascia, and various dorsal support techniques may be employed in specific cases. Ready-made implant materials may also be an option for some patients; however, in revision cases, material selection requires careful consideration due to potential complications such as infection, extrusion, displacement, and skin contour irregularities.

Dorsal Onlay Grafts and Spreader Grafts Are Not the Same

The purposes of the grafts used in nasal dorsum reconstruction differ. While dorsal onlay grafts are primarily used to augment the height and contour of the nasal dorsum, spreader grafts are generally utilized to support the middle vault and adjust the geometry of the nasal valve region.

In complex revision cases, a combination of these techniques may be required for a single patient. However, applying the same graft combination to every patient is not appropriate. The surgical plan must be determined based on the underlying anatomical deformity and the reconstruction goals.

Why Is Warping a Concern with Cartilage Grafts?

Warping the bending or twisting of the graft over time can be a significant issue, particularly with thicker or shaped cartilage grafts. The graft's inherent elastic properties and the direction of the cut can influence shape changes that may occur during the healing process.

Therefore, the preparation, orientation, and proper fixation of the cartilage graft are crucial in revision rhinoplasty. Warping of the dorsal graft over time can lead to new asymmetry or irregularities in the nasal dorsum, even if it initially appeared smooth.

How Does Scar Tissue Affect Surgery in Revision Rhinoplasty?

In a nose that has undergone surgery twice before, scar tissue can alter surgical plans. The normal mobility of the skin and soft tissues may be reduced, and identifying the natural anatomical boundaries of the tissues during dissection can become more difficult.

Furthermore, dense fibrosis can make it challenging to assess the resulting contour. Therefore, in a third revision rhinoplasty, it is crucial to perform surgical dissection in a controlled manner and avoid unnecessary tissue trauma.

What Are the Major Risks in Nasal Dorsum Reconstruction?

As with any surgical procedure, complications such as infection, bleeding, edema, and wound healing issues can occur in complex revision rhinoplasty. Additionally, more specific problems—such as graft displacement, warping, resorption, contour irregularities, and asymmetry—may arise.

Particularly in patients undergoing augmentation, the graft may become visible or palpable beneath the skin, or irregularities along the dorsal line or excessive, unwanted projection may develop. In patients who have undergone multiple prior surgeries, the predictability of outcomes may be more limited compared to primary rhinoplasty due to existing scar tissue and changes in tissue quality.

Infection and Graft-Related Issues in Revision Rhinoplasty

While the use of autologous cartilage and fascia—favoring the patient's own tissues—is a significant option, it does not entirely eliminate the risk of complications. Issues such as surgical site infection, fluid accumulation around the graft, or wound healing problems may occur. Especially in reconstructive procedures involving large structural grafts, it is crucial to properly prepare the graft, surround it with well-vascularized tissue, and position it stably within the surgical site.

How Can a Natural Appearance Be Preserved in Tertiary Revision Rhinoplasty?

Over-augmenting the nasal dorsum during the procedure can create an appearance that is disproportionate to other facial features. Therefore, surgical planning must consider not only the degree of augmentation but also which specific areas are to be augmented and how the dorsal transitions will be shaped.

Using soft tissue grafts such as temporal fascia in suitable patients can help soften the contours of rigid grafts. However, the foundation of a natural appearance lies in the correct choice of graft, appropriate shaping, stabilization, and a surgical plan tailored to the patient's existing anatomy.

Personalized Planning for Success in Tertiary Augmentation Rhinoplasty

Performing a third revision rhinoplasty on a nose that has undergone two previous surgeries and presents with nasal dorsum collapse and significant deformity requires a highly personalized surgical approach. In such cases, it is essential to evaluate available autologous tissues (such as septal cartilage), support soft tissue contours with temporal fascia when necessary, and plan for alternative graft sources if required.

The primary goal of such a surgery is not merely to elevate a collapsed nasal dorsum. Key objectives that must be addressed simultaneously include re-supporting the nasal framework, refining the dorsal contour, creating a nose that harmonizes with male facial anatomy, correcting deformities caused by previous surgeries, and achieving the most stable result possible. Unlike primary rhinoplasty, tertiary revision rhinoplasty is a complex surgery that requires the preservation and reconstruction of existing anatomical structures. Therefore, preoperative assessment, the determination of suitable graft materials, and a realistic evaluation of the patient's expectations are crucial components of the surgical plan.

You can read articles related to "augmentation revision 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=augmentation+revision+rhinoplasty

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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