Secondary Rhinoplasty: Decision Making

Abstract

In a primary rhinoplasty, a great deal of decision making goes into the operative plan, which is then executed with minimal changes in 90% of cases. When modifications are required, it is usually a single step moved up or down the scale; i.e., a combined sill base excision rather than a pure nostril sill excision. In contrast, the operative plan for a secondary case is complex and a challenge to figure out. Intraoperatively, the best conceived plan serves merely as a guide, the execution of which requires constant decision making and often radical changes to its fundamental components. An example of constant decision making is elevating the skin envelope – a relatively straightforward step in a primary case, but stressful in a scarred thin secondary case. A radical change in the operative plan can be the creation of symmetrical rim strips. In a primary case, the surgeon knows that a 6 mm alar rim strip is possible, only in rare cases will the lateral crura need to be relocated (alar malposition) or flipped (severe concavity). No matter how much experience the surgeon has, no one knows for sure what the alar cartilages will be like in a secondary case and the same goes for the septum. Thus, every secondary rhinoplasty is a surprise, often bad, and one must be prepared for significant intraoperative stress. The three requirements most essential for doing secondary rhinoplasty are the following: (1) know exactly what the patient dislikes about their nose and what they want, (2) do photographic analysis and write out an operative plan, but stay flexible as major changes will be required, and (3) the more surgical techniques you have experience with the better. This chapter is an attempt to guide you through the decision-making process of secondary rhinoplasty, which will hopefully teach the reader to recognize the challenges ahead of time and deal with them intraoperatively.