There are many reasons to undergo a rhinoplasty. You may desire a more youthful, contoured cosmetic appearance of the nose; or you may just be interested in a functional improvement in breathing. In either case, a rhinoplasty can help recontour the nose to make it more aesthetically harmonious with the rest of your face. A rhinoplasty can address the nasal bridge, the nasal radix, the nostrils, ala, columella, the external nasal valve, and the internal nasal valve. Dr. Raffy Karamanoukian is a double board certified plastic surgeon and holds special expertise in cosmetic and functional rhinoplasty.
A revision rhinoplasty is a nose surgery that is performed on someone who has previously undergone a rhinoplasty in the past. A secondary rhinoplasty means that someone is undergoing a rhinoplasty for the second time; whereas a tertiary rhinoplasty a third time, and quaternary a fourth time; and so on. You may not have thought that you would ever be a candidate for a secondary or tertiary rhinoplasty, but many people are. Revision rhinoplasty is reserved for those patients who wish to correct a rhinoplasty that has resulted in a cosmetic or functional problem.
ASYMMETRIC NASAL TIP: The nasal tip defines an important cosmetic part of the nose and face. The patients who have had previous rhinoplasty may have asymmetries between the right and left nostrils and nasal tip that can be visualized from afar. In these patients, corrective revision rhinoplasty can help remodel the nasal tip in order to make it more proportional and balanced between the right and left side. The majority of asymmetric nasal tips resulting from a previous rhinoplasty results from cartilage grafts that are displaced, over or under resection or nasal tip cartilage, scar tissue that has formed from open rhinoplasty, or trauma. The evaluation of an asymmetric nasal tip begins with oblique photographs taken which can objectively identify discrete asymmetries between the right and left side. The nasal tip when visualized from a frontal view, should be an identical match between either sides. Correction of the asymmetric nasal tip begins with an evaluation of the intrinsic cartilage within the nose. If the asymmetry is as a result of over resection, cartilage grafts are used to correct the imbalance of the nasal shape. If the asymmetry is caused by scar contracture, trauma, or displaced cartilage graft ,the correction entails removal of the scar tissue or displaced cartilage and repositioning of the native tip cartilage. The external examination and consultation will also include a functional breathing examination to determine whether the internal scar tissue is impairing your ability to breath. If there is any sign of breathing obstruction, these will be addressed during your revision rhinoplasty with board certified plastic surgeon Dr. Raffy Karamanoukian.
CENTRAL NOSE COLLAPSE WITH INVERTED-V DEFORMITY: The central portion of the nasal dorsum is an area that is internally supported by two pieces of buttressing cartilage known as the upper lateral cartilage. These structural cartilages derive from the central septum and fan out to provide functional airway support for breathing. When they are over-resected, the end result is an abnormal appearance of the dorsal nose coupled with breathing problems. A central nose collapse can usually be associated with previous fracture or damage to the nose, and patients who have had previous nasal fractures are certainly more at risk for this problem. Correction of a middle nose collapse, central nose collapse, or inverted-V deformity can benefit from a revision rhinoplasty with spreader graft placement.
COLLAPSED NOSTRILS: Although we tend not to think very much about the nostrils, a problem with the nostrils with one or both nostrils after rhinoplasty can cause significant embarrassment as well as social anxiety. The nostrils form the structural opening of the nose and play a critical role in both the cosmetic appearance of the nose as well as a functional role in helping the process of nasal breathing. The patients who have previously undergone rhinoplasty may have had an excessive amount of cartilage removed from the nostrils, causing either nostril retraction, nostril collapse, or excessive nostril show. All these three of these conditions can cause significant problem from a cosmetic prospective. The balanced appearance of the nose can often be distorted by an exaggerated nostril or an excessively retracted nostril that is too small for the nose. These problems with the nostril can be further compounded by problems with breathing caused by nostril collapsed or nostril scarring. The first step in evaluating the nostrils is to perform an external nasal examination in which the nostrils are measured and evaluated and comparison to the rest of the nose. If the nostrils appear too small or too large, the balance of the nose may be distorted causing an abnormal appearance to the lower part of the nose relative to the upper part of the nose. An external examination can also gage the structure of the nostril cartilage in order to determine how well it can perform under normal breathing conditions. If the structural support of the nostrils is destroyed, the nostril will tend to collapse and close shut with inspiration. Dr. Raffy Karamanoukian is a board certified plastic surgeon and an expert in revision rhinoplasty surgery in Los Angeles. Her performs nostril corrective surgery during revision rhinoplasty and can evaluate your nose and determine which surgical option is appropriate to correct the cosmetic or functional problem with the nostrils. The nostrils will be examined relative to the rest of the nose, including the nasal tip, columella, bridge, and septum. If the nostrils are excessively large or small, they can be balanced in accord with the rest of the nose. Functional obstruction of the nostrils can also be achieved with careful planning and placement of compounded graft or cartilage grafts within the nose.
CROOKED NASAL BRIDGE: The nasal dorsum represents the structural portion of the external nasal bridge. The nasal bridge is prone to being injured as a result of normal daily activities. Falls, trauma, accidents, and previous rhinoplasty surgery can all begin to warp or curve the straight nasal septum. From the outside, the first visible sign of a crooked septum is a nasal bridge that is windy or twisting in appearance. The severity of the external curvature of the nasal bridge often corresponds to the severity of breathing obstruction.
A twisting or curved nasal bridge is often difficult to correct unless a proper analysis of the underlying deformity is not studied. The curvature of the nasal septum can occur as a result of a nasal bone fracture, septal fracture, or a displacement of the nasal base. These abnormal changes can cause breathing obstruction and a poor cosmetic appearance to the nose. This is best seen on an anterior-posterior view of the nose.
The visualization of the curvature can usually be enhanced by performing an intranasal inspection. If you have had previous rhinoplasty and still have a crooked nasal septum and nasal bridge, you may be a candidate for revision rhinoplasty to correct the abnormality. In most cases, improvement can be obtained by a simple septoplasty procedure performed under anesthesia. During a septoplasty surgery, the twisting S curvature of the nasal septum can be corrected with improvements in both breathing and cosmetic appearance. In some cases, the internal nasal obstruction or septal obstruction is compounded by a crooked septum along the bridge of the nose. This may manifest as a curvature of the nasal bridge, which is often harder to correct cosmetically. If you are considering revision rhinoplasty and are concerned about a crooked nose or a previously broken nose, please call the office of Dr. Raffy Karamanoukian, a board certified plastic surgeon and revision rhinoplasty expert.
DEVIATED NOSE: A deviated nose is problematic from a cosmetic perspective as well as a medical perspective. Deviation of the entire nose, the septum, or nostrils can cause significant breathing problems and a functional breathing obstruction upon inspiration or expiration. The most common reasons for a deviated nose include a fractured nasal bone, fractured septum, or collapsed or malformation of the nostril cartilage. These changes in the nose represent a significant problem for adolescents and adults as the cosmetic changes in the nose can make the facial appearance look unnatural and uneven. A frequent complaint among patients with deviated nose includes asymmetry of face, breathing obstruction, and a characteristic “crooked nose”. Some of the common reasons to develop a deviated or crooked nose include infracture of the nasal bone on one side or both sides, an acute or old fracture of the septum that leads to an S shaped curvature or bending of the septum and abnormal development or damage to the cartilage that makes up the nostrils and the columella. Often, patients don’t realize that they had a previous nasal injury as a child and later developed consequences of the childhood fracture.
The treatment of a deviated nose or crooked nose begins with an external and internal inspection of the nose. External inspection of the skin and cartilage and bone of the nose can determine whether there are obvious old fracture patterns and breaks or curvatures in the bone or cartilage. The examination should continue onto the nostrils and midline columella to determine the amount of asymmetry and deviation. Dr. Raffy Karamanoukian, a board certified rhinoplasty surgeon in Los Angeles, can also inspect your internal nose to determine the amount of nasal obstruction and septal deviation. Upon examination of the different parts of the nose, Dr. Karamanoukian can address specific issues in order to correct the nasal deviation. The technique depend on the amount of damage to the nose, including osteotomy to correct nasal bone asymmetry, septoplasty to correct the septal cartilage, and rhinoplasty with cartilage graft to correct asymmetry and problem with the nostrils. Your consultation for a crooked or deviated nose begins with medical history and is made complete with an external and internal nasal examination. Dr. Karamanoukian will also perform functional test to determine the level of breathing obstruction.
PINCHED OR NARROW NASAL TIP: The tip of the nose represents a key critical feature of the nose and face. Cephalometric measurements of the face and nose can identify critical ratios between the nasal tip, the mouth, and the nasal width along the bridge. If the tip is too broad or bulbous; or if the nasal tip is too narrow and pinched, there may be an associated cosmetic problem with the overall nose and facial appearance. The patients who have undergone previous rhinoplasty using a closed technique may have developed a narrow nasal tip that appears tightly packed and pinched. This is usually a result of over resection of the nasal tip cartilage or as a result of sutures and scar tissue that have contracted the nasal cartilage along the tip. The first in identifying whether you will need a nasal tip correction during a revision rhinoplasty is to undergo a careful and meticulous physical exam and external examination of the nose in order to determine whether there is enough intrinsic cartilage left in the nasal tip after your initial rhinoplasty. If there is enough cartilage, an open revision rhinoplasty can help release the scar tissue and flatten out and correct the narrow nasal tip. If there is not enough cartilage left after your initial rhinoplasty, your revision rhinoplasty will employ cartilage graft to reconstruct ala, nostrils, and nasal tip. The consultation with Dr. Raffy Karamanoukian will also entail an evaluation of your breathing relative to the nasal tip and nostrils. Some patients who have had over resection of the cartilage may have a nasal collapse on deep inspiration. This functional breathing problem can be corrected during your revision rhinoplasty with strengthening support cartilage placed along the nose. If you have questions about revision rhinoplasty or a pinched nasal tip, a consultation with pertinent examination should be made by calling 310-998-5533.
COLUMELLAR CARTILAGE GRAFT: A columellar graft is performed commonly during initial rhinoplasty surgery and during secondary and tertiary revision rhinoplasty surgeries. The goal of a columellar cartilage graft is to lend support to the columella and enhance nasal tip projection in cases where there is an absence of outward support on the nasal tip and columella. A cartilage graft for support can be a powerful tool in revision and corrective rhinoplasty and can allow Dr. Raffy Karamanoukian to correct many of the structural issues of a poorly performed primary rhinoplasty. In other words, a columellar support graft uses cartilage to correct both cosmetic concerns of the nose as well as functional concerns related to nasal tip collapse and external nasal valve collapse.
Some surgeons will refer to a columellar cartilage graft as a columellar strut, often confusing the description and leading patients to question whether these two terms represent the same entity. A columellar graft and a columellar strut is really the same thing, indicating the type of substance used (cartilage graft) and the purpose of the graft (structural support: strut).
In the majority of cases where a columellar strut is needed, a septal or conchal or alar piece of healthy cartilage usually works well as a structural support for the columella. The width of cartilage is usually around 5.0 to 6.0 mm and usually hides very well as it is sandwiched in between the right and left pieces of columellar cartilage. Stabilizing sutures are usually placed to prevent disruption of the cartilage graft and outward or inward displacement of the cartilage nasal graft. The area of placement is intracrural and is well incorporated within the nasal base upon completion of the revision rhinoplasty.
A columellar graft is a common component of revision rhinoplasty requiring structural reconstruction of the nose. Columella strut grafts can provide both cosmetic improvement during rhinoplasty, as well as structural improvement. The cartilage strut graft can provide support for the nasal tip, leading to increased projection and more natural proportions to a nose that is flat or wide. By adding projection, a flattened nasal tip can be improved dramatically. In terms of structural support, patients with vestibular stenosis, collapse of the nasal ala, or a flat pushed-in nose can benefit from a columella strut graft. The graft lends support to the columella, to the alar cartilages, and the nostril opening. Based on these features, Dr. Karamanoukian can provide a tailored columella strut graft in order to improve the function of your nose.
SPREADER GRAFTS: A spreader graft is a small piece of cartilage that is meticulously placed between the septum and the upper lateral cartilage to correct a breathing problem or to cosmetically contour a nasal bridge that is over-resected. Correction of an internal nasal valve collapse is acheived by unilateral (one-sided) or bilateral (two-sided) spreader grafts. In our practice, we measure and custom-tailor spreader grafts to achieve the desired effect. Most spreader grafts are about 1.5 to 2.0 mm thick with a height of about 2.0 to 2.5 mm and vary in terms of their length. The ideal spreader graft for revision rhinoplasty is placed from the cephalic border of the keystone area and extends caudally. The spreader grafts can correct internal nasal valve collapse, breathing problems, asymmetric nasal dorsums, and the inverted-V deformity seen in primary rhinoplasty patients.
In the practice of Los Angeles revision rhinoplasty surgeon Dr. Raffy Karamanoukian, spreader grafts represent an ideal cartilage graft technique that enhances cosmetic results and improves the functioning of the internal nasal valve. Patients who have simultaneous difficulty breathing and an inverted-V deformity may benefit from a spreader graft. Stabilizing sutures can reinforce cartilage spreader grafts during revision rhinoplasty and can lend to longterm results with rhinoplasty correction.
Spreader grafts have a high degree of positive results and can dramatically improve contour and function in a revision rhinoplasty. Our practice custom tailors spreader graft placement to minimize complications associated with corrective nose surgery. Stabilizing sutures can reinforce the spreader graft and minimize the risk of postoperative dorsal displacement of the cartilage grafts. If you have already undergone a spreader graft in the past, you may be a candidate for stacked spreader grafts or surgical remodeling of an existing spreader graft.
Preparation for spreader graft placement begins during the initial consultation with board certified plastic surgeon and revision rhinoplasty expert Dr. Raffy Karamanoukian. During your consultation, Dr. Karamanoukian will examine the internal and external nasal valves, assess your cosmetic appearance, and perform basic cephalometric analysis of your nose and face to determine whether you are a candidate for revision rhinoplasty and cartilage grafts with spreader grafts or any of the other cartilage graft reconstructions available in our Los Angeles plastic surgery office. Please try to provide our office with as much information regarding your previous surgeries, including the availability of an operative note and any pertinent history regarding previous septoplasty procedures, rib grafts, or cartilage harvests. Dr. Karamanoukian will examine you to determine the necessity of a spreader graft and will take all necessary to prepare the recipient site for introduction and placement of a spreader cartilage graft.
Donor sites for a spreader cartilage graft during your revision rhinoplasty include the septum, the conchal cartilage from the ear or ears, alar cartilage, and rib cartilage. These options are often enough to successfully plan your revision rhinoplasty and optimize surgical uptake of the cartilage graft into its recipient site.
QUESTIONS ABOUT REVISION RHINOPLASTY:
- Can I expect improvement in breathing with a revision rhinoplasty? During your initial consultation for revision rhinoplasty with plastic surgeon Dr. Raffy Karamanoukian, you will have the opportunity to discuss your specific requests and requirements regarding your revision rhinoplasty or corrective rhinoplasty. Not everyone will have both cosmetic concerns and functional breathing concerns, so our surgeon will attempt to elicit these requests from you during your consultation. An examination will help determine whether you have any functional breathing problems, including an internal or external nasal valve collapse. Some patients may also have vestibular stenosis or narrowing of the nasal opening which may further lead to breathing problems. Dr. Karamanoukian will thus carefully evaluate your nose and plan a surgical correction that incorporates cosmetic issues, if any; and functional breathing issues, if any. There are many options to improve breathing with a rhinoplasty and our staff and surgeon can help you choose the best options for you, including revision rhinoplasty, septoplasty, and cartilage grafts.