What is Revision, Secondary (Secondary), Septorhinoplasty?

Even in the open technique, it can sometimes be difficult to separate the scar tissue from the cartilage tissue despite direct vision.

The situation that patients often want to improve in secondary surgeries; These are the complaints of nasal obstruction that developed or existed after previous surgeries but did not go away after surgery. In this group of patients, excessive reduction, collapse and weakening of the nasal support mechanisms may have occurred due to previous surgical interventions. The most important causes of postoperative obstruction are; collapse in the side wall of the nose, collapse in the middle dome region, insufficient correction of the middle section curvature.

Certain external cosmetic defects often indicate and accompany the internal defect. Narrow middle dome area, reverse V deformity at the bone-cartilage junction of the nasal ridge, and pinch deformity, which appears to be compressed with two fingers, can be counted among these. Avoiding excessive removal of the nasal tip lateral cartilages (lower lateral), reinforcing the alar base and tip (nose base and tip) region, and recreating the middle dome area are the key approaches necessary to avoid the above-mentioned negative consequences.

The most important difficulty in secondary surgeries is that the septal cartilage (cartilage of the middle part of the nose) is not sufficient to take a piece. In mid-section surgeries, it may sometimes be necessary to leave only the amount of cartilage that must remain there in the first surgeries (L-strut). In such cases, cartilage pieces should be taken from other areas. These areas are ear or rib cartilage. With an incision made behind or in front of the ear, a piece of cartilage is taken from the ear canal. However, the cartilage taken from the ear is limited in quantity and may sometimes not be suitable in terms of shape. In these cases, rib cartilage is a good option. Rib cartilage is both sufficient in quantity and can be shaped as desired. Rib cartilage is taken from the cartilage of the 7th, 8th and 9th ribs. A 3-5 cm incision is made on the skin above the rib to be removed. It is taken from the ribs on the right side. Rib cartilage is cut to the desired size, fineness and shape with various techniques and used according to need.

Problem areas in secondary surgeries are usually the nasal tip (nose tip), nasal upper cartilages and the middle vault of the nasal ridge. If the base of the nose is not adequately supported in the first surgery, weakness may occur at the tip of the nose. This situation can be manifested by a drop in the tip of the nose, low nasal tip projection, and a low angle between the nose and the upper lip. In some cases, it may also occur as a result of the removal of a piece from the anterior end of the middle chamber and the retraction of the nasal tip as a result of scarring in the lateral cartilages, and the tip of the nose being lifted more than normal. In these cases, the corrective technique is planned according to the condition of the remaining cartilage. In general, the lower lateral cartilages of the nasal tip are weakened and lost their tension. In cases where the lower tip of the middle part of the nose is shortened more than necessary in previous surgeries, it is possible to both strengthen the base of the nose and correct the drooping of the nasal tip by placing extension grafts (pieces) in this area. In cases with more advanced nasal tip drooping, the columellar strut (the graft that acts as a pillar placed between the cartilages at the far end of the middle section) with pieces taken from the rib cartilage can be placed, both for drooping and increasing the projection.

The size, shape and position of the intermediate and medial legs of the lower lateral cartilage of the nose determine the shape of the tip of the nose. Asymmetries, pits, bulbosity and other deformities may occur due to previous surgery. Often the cartilages are damaged and the reshaped cartilages do not provide nasal tip support. In patients with thick skin, a strong nasal tip skeleton should be created so that its reflection on the skin through the soft tissue can be clear. In this case, a shield graft suitable for the desired augmentation and shape can be used. With a cap or butress graft to be placed on the upper end border of the shield graft, the transition between the two grafts can be softened, and the desired shape can be achieved in the angle between the tip of the nose and the nasal ridge from the outside. If there is weakness, collapse and cupping, a lateral crural graft can be placed on the cartilage section that forms the side wall of the lower tip of the nose.

Excessive removal of the cartilage on the side wall of the nose in previous surgeries is one of the main causes of stenosis and collapse in this section. This complication is more common in patients with long, narrow noses and in patients with a preexisting supraalar region. This may show as collapse of the side wings of the nose in deep breathing. Alar batten graft is used to correct this situation. This negativity is eliminated with the piece placed on the side wall where there is the greatest weakness and collapse. Sometimes it may be necessary to suture the lateral lateral cartilage so that this piece does not adversely affect the width of the nostril and does not slip out of place. Depending on the shape and amount of weakness on the side wall of the nose tip, this graft (piece) is placed and fixed in the appropriate position and shape. In the post-operative period, intranasal stents (apparatus in various sizes, made of soft material in the form of a nostril) can be used at various times, in order to prevent the nasal tip lateral wall from approaching the midline again and forming stenosis.

Other negative consequences (lower border of the lateral wall of the tip of the nose) may occur due to excessive removal or weakening of the cartilages in adverse situations. Excessive cephalic trim (removal of a piece from the upper part of the nasal tip lateral cartilage) may cause retraction at the alarm rim border or increase the columellar show of the middle part of the nose. Again, the weakening of this region may cause indentation, collapse and deterioration of the triangular structure of the nose seen when viewed from below. The grafts placed at the alar rim border are narrow 2-3×5-8 mm cartilage pieces. They are placed in the created pocket. If necessary, the shield is fixed to the graft or soft tissue with sutures. This bottom view adds to the triangular look. In advanced alar retractions, lengthening of the alar rim area can be achieved with composite (consisting of cartilage and skin) grafts.

The collapse of the lower end of the upper lateral cartilage and the internal valve, the ridge of the nose that seems to be pinched with two fingers, reverse V deformity occurs as a result of the deterioration of the horizontal part of the middle dome. As in primary surgeries, the placement of spreader grafts is the most appropriate option in secondary surgeries to provide symmetry and support of the middle dome. Only in secondary surgeries, this piece may need to be larger and more numerous.

Asymmetry and irregularities may be observed in the bone dome section due to previous surgery. They are usually caused by uneven osteotomy and inadequate repositioning. If lateral osteotomies and flattening of the nasal ridge (hump, hump) are performed without approximation to the midline, “open roof” deformity may occur. These negativities are resolved by re-doing the osteotomies and replacing the bones. If there are irregularities on the back of the nose, however, these irregularities are corrected. If the ridge of the nose is too low, a graft (piece) is placed in this area and the radix area to try to raise it. Correcting narrowed nasal bones is a bit more difficult. In this case, osteotomies are made again and the bone structures are removed from the midline and intranasal stent (apparatus) is used to prevent them from coming back to the midline.

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