To begin with this nose was primarily a very difficult ethnic rhinoplasty case of andine or latin american blood features, like poor tip support, short septum, flaring nostrils, undefined tip, upturned tip, etc; it was a case for a complex open structure ethnic rhinoplasty in which advanced techniques had to be applied, including multiple grafting supply.
However the case received a very poor quality and standard rhinoplasty with very poor execution, judgment errors, wrong indications and technical mistakes which aggravated her congenital issues or created new ones; the most remarkable problems of this revision were a mixture of ethnic features and iatrogenic or medically caused deformities, among which were an open roof deformity, missing portions of the nasal bones at the walls of the nasal pyramid, inverted V deformity plus pinched middle vault, multiple visible irregularities at the dorsum, persisting hump, tip collapse, supratip prominence or polly beak deformity, null tip definition, nasal pinching and nasal valve collapse with breathing difficulties, alar rim retraction and notching, alar rim collapse, piggy nose and upturned nasal tip, untreated flaring nostrils, etc; all in a context of very thin skin which made worse both the deformities and the difficulty of their correction.
Open approach rhinoplasty was mandatory to begin with a comprehensive visualization of structures, damages and a meticulous surgical cleansing of fibrosis and debridement of unstable tissues and damaged anatomical elements; it was found the lateral cruras of the lower lateral cartilages had been accidentally severed and damaged, they were congenitally filmy and the medial cruras were weak and unsupportive; the caudal septum had been trimmed and its shortness aggravated.
Once the problems were identified and the host tissues prepared it was harvested grafting from the deep nasal septum and both ear concha cartilages; the portions of cartilage were distributed, prepared, tailored to fit the planned anatomy and sutured in place.
Grafting was used to perform an L shaped septocolumellar grafting acting at the same time as caudal extension graft, spreader or spacer graft and columellar strut, all in one, thus providing nasal length, derotating the tip, supporting the tip and correcting the inverted V and middle vault pinching; nasal bones osteotomies were performed to infracture the nasal walls and close the open roof.
Then lateral cruras batten grafts were applied to reinforce them, smoothen their damaged contour and correct the alar contour irregularities and its retraction.
With the help of a pair of mini tip extension grafts the domes of the alar cartilages were positioned and secured by tongue in groove maneuver to them and the newly extended caudal septum, with suitable plasties and plications on them.
Finally, and due to the missing fragments of nasal bones and the transparent features of the dorsal skin it was deemed necessary adding a camouflage layer like the superficial temporalis fascia graft, harvested for such purpose and placed all over the dorsum and nasal walls, leading to a great postoperative success in its role of smoothening the visible contour of the nose.
At the end of the procedures the alar flare was corrected by means of alar wedge resections in an asymmetrical fashion to improve the symmetry.
The final outcome visible in the images is totally successful, showing a brand new nose free of ethnicities, with a good length, horizontal columella and well located and derotated tip, good tip projection and shape, no collapse of alar rims, nostrils or nasal valve, good breathing, all the deformities at the dorsum and pyramid corrected and no irregularities are visible.
It is remarkable how, in spite it was extracted the maximum available amount of cartilage from both ears, the postoperative look of the auricle is perfect and no signs of such extraction nor deformities are present, no anterior scars, no droopiness, all the natural ear creases are respected and no rupture of contour; harvesting ear cartilage in rhinoplasty is not a trivial maneuver and in case it is not properly executed may lead to additional deformities requiring repair or even complex reconstruction.
This case's difficulty scenario is top among the revision rhinoplasties, requiring the maximum degree in skills, experience, excellence, creativity and meticulousness.
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