Dr. Alejandro Nogueira's Case #Z4HRN8N2

The last three sets of images are extraordinarily meaningful since they depict, on the left frame, the naturally born nasal situation prior to the bad initial rhinoplasty, the middle frame shows the disastrous result of such bad nose job just before the revision rhinoplasty applied, and the right end frame is the post revision outcome.

The naturally born nose was already a case of high difficulty, showing hanging columella, alar rim retraction due to poor support, over projected tip, too sharp tip and a very difficult dorsal rhombus with an almost humpless dorsum which, otherwise, has a minimal excess and visible side dorsum ridges; the case would have required highly skilled open structure rhinoplasty to perform an aggressive deprojection of the tip, smoothening and rounding of tip shape, resupporting the alae and treat the retraction of their rims; the dorsum needed very slight lowering by shaving however the dorsal rhombus required custom paramedial resection of the cartilaginous middle vault plus resection of a bony wedge at the osseous synostosis of the upper half of the nasal pyramid; finally internal osteotomies or infractures should have been applied to close the roof, which is a maneuver always lowering about one or two millimeters the dorsum; spreader grafts would have been necessary because of the excessively narrow or pinched middle vault or supratip, placed between the upper lateral cartilages and the cartilaginous septum in order to provide stability to the middle vault and a right width according the upper vault; tongue in groove maneuver was indicated to correct the over exposed columellar show or hanging columella.

That would have been an ideal procedure; unfortunately things were managed in a very different manner.

The surgeon attempted to get rid of the dorsal rhombus by scooping the dorsum and removing a nonexistent hump, which lead to a severely sunken saddle nose deformity due to over resection of the dorsum; failed to perform the mandatory osteotomies to close the roof, which produced open roof deformity, broad osseous dorsum and the always associated to open roof deformity in inverted V and subsequent pinched middle vault, needless to say the spacer or spreader grafts were not used; the surgeon trimmed the caudal septum with no logic to do so, ending in a upturned or piggy nose, the tip was not deprojected, neither was the tip shape modified which lead to a tombstone deformity due to over definition of the tip, the lateral cruras were trimmed which aggravated the alar rim retraction and the hanging columella; in brief, no open structure rhinoplasty techniques were employed, no grafting applied plus a non judicious planning and execution lead to a sever deformity.

The revision began with meticulous access, debridement or removal of unsuitable tissues and non viable elements, visual diagnosis and intraoperative planning of the strategy; it was clearly stated the septum was over resected at its lower or caudal portion, so first step was applying septal lengthening by one on one method with a graft harvested from the deep septum; grafting was also harvested from both ears concha bowls; then the lateral cruras were regularized and made even, the tip modified and worked on; deprojection of the tip pillars was also done; then two spacer grafts applied at the middle vault to correct the pinching and the inverted V deformities; osteotomies performed to close the roof at the dorsum and obtain stability; tongue in groove maneuver was used to secure the middle cruras to the newly lengthened and grafted septum, thus correcting the hanging columella; caudal extension grafts of the lateral cruras were used to push down the alar rims and correct the poor alar support.

Finally, once the nose was fully stabilized and all the issues corrected, the dorsum had to be rebuilt and raised by an entire dorsum replacement graft from radix to tip, made of ear cartilage assembling 3 pieces with fine suturing; due to the transparency of the nasal dorsum skin a superficial temporal fascia graft was applied between the skin and the dorsal graft so that any potential tombstone visibility would be prevented.

The final result is a perfectly triangular profile, well supported, shaped and positioned tip, the columella and the alae have been corrected and the brand new dorsum is undetectable, there are no traced of the open roof deformity, the inverted V deformity, the saddle nose deformity, the pinched middle vault or the piggy nose, leading to a brilliant and feminine outcome after a very long time consuming and highly skills demanding revision rhinoplasty.