Secondary Rhinoplasty: Clinical Findings and Alternative Structures for Nasal Reconstruction in Latin American Patients

Abstract

Background:

Revision rhinoplasty for patients with Latin American nasal characteristics presents a significant surgical challenge owing to complex anatomical and structural factors. A structured and systematic approach is essential for improving outcomes, and a statistical evaluation of the results and management techniques is needed to achieve optimal patient satisfaction.

Methods:

In total, 86 patients (69 women, 17 men; age range: 18–55 y) with nasal characteristics commonly associated with Latin American noses participated in this study. Each patient underwent secondary rhinoplasty using surgical techniques performed by the authors, which used costal cartilage structures for nasal reconstruction.

Results:

The most frequently observed clinical issues were excessive dorsal reduction in the upper third (37.2%), mid-vault deviation in the middle third (53.5%), and underprojection of the nasal tip (68.6%). Of the 5 structural categories used for reconstruction, type 1 was the most frequent (35.9%), whereas type 5 was the least frequent (1.3%).

Conclusions:

A successful revision rhinoplasty for patients with Latin American nasal characteristics requires an in-depth evaluation of each patient. The surgical methodology detailed in this work provides surgeons with the tools to address these complex cases effectively.

Takeaways

Question: What are the most common clinical findings and structures used in secondary rhinoplasty in Latin American noses?

Findings: The most frequently observed clinical issues were excessive dorsal reduction in the upper third (37.2%), mid-vault deviation in the middle third (53.5%), and underprojection of the nasal tip (68.6%). Structure type 1 was the most frequent (35.9%), whereas type 5 was the least frequent (1.3%).

Meaning: Knowing the most frequent clinical findings and understanding approaches in a secondary rhinoplasty can facilitate the development of tools to address complex cases, especially in Latin American noses, whose characteristics demand a high preparation by the rhinoplasty surgeons.

INTRODUCTION

Rhinoplasty ranks among the most requested surgical procedures worldwide, addressing both aesthetic concerns and functional impairments, particularly respiratory insufficiency. Surgeons performing rhinoplasty require advanced training and surgical expertise.^1–5 This expertise is particularly essential in revision procedures where patients have undergone prior surgical intervention by different practitioners. Recent advances in surgical techniques have transformed rhinoplasty practices, progressing from traditional resection-based approaches to a blend of structural and preservation techniques. Contemporary practices often combine multiple surgical strategies to optimize outcomes.^6–8

In revision rhinoplasty, where surgical correction is needed following a previous rhinoplasty procedure, distinctive challenges arise, requiring meticulous preoperative planning and consideration.⁹ Revision rates for rhinoplasty procedures range between 5% and 20%, depending on various patient-specific and surgical factors.^10–13 Neligan¹⁴ classified the main causes for revision surgery as (1) complications arising from the initial surgery, (2) unsatisfactory aesthetic or functional results, and (3) the need for further refinement or improvement.

Latin American nasal characteristics include wide nasal bones in the superior third of the nose accompanied by a low radix. Moreover, the middle nasal vault is structurally deficient with inadequate cartilaginous support, and weak lower lateral cartilage and thick skin characterize the nasal tip, which lacks structural definition.^15,16 Based on our perspective, these anatomical characteristics increase the likelihood of revision rhinoplasty among Latin American patients. Owing to these distinctive structural traits, revision rhinoplasty in this cohort is challenging. Loghmani et al⁹ observed similar challenges in Middle Eastern populations, noting that reasons for patients in these populations to seek a revision rhinoplasty include inadequate tip projection and loss of rotation at the nasal tip. These issues may arise because projection and rotation do not always remain stable over time.

Currently, studies concerning revision rhinoplasties in Latin American patients are limited, highlighting the need to establish a comprehensive guide that not only details typical clinical findings but also proposes practical solutions for this demographic. We aimed to evaluate the prevalence of common concerns or deformities in Latin American patients seeking revision rhinoplasty and establish a foundation for effective surgical approaches.

MATERIALS AND METHODS

This observational descriptive study was approved by a local ethics committee at the Continental Clinic Institution in Lima, Peru, and was conducted in accordance with the principles of the Declaration of Helsinki. All patients provided their written informed consent, including permission to use audiovisual material.

The patients were recruited from March 2022 through August 2024. All procedures were performed by the same plastic surgeon (W.P.W.) at the Continental and Higuereta Clinics in Lima, Peru. The study enrolled 86 patients seeking revision rhinoplasty through the outpatient plastic surgery service.

Patients of Latin American ethnicity who had undergone prior rhinoplasty performed by a different surgeon were included. Patients with poorly controlled comorbidities or risk assessments by an anesthesiologist indicating potential postoperative complications incompatible with safe recovery were excluded.

For analyzing the present study, frequency and percentage measurements were used to establish the distribution of clinical findings according to sex and findings.

Surgical Technique

1. Cartilage harvest: Under general anesthesia, the seventh costal cartilage was harvested through a 3- to 4-cm incision in the anterior thoracic region at the inframammary fold. After excision, the cartilage was cut obliquely, forming a lamina approximately 3.5 cm long and 2 mm thick or less.¹⁷

2. Nasal exploration and incision: Access was achieved through an “inverted-V” or “M-shaped” transcolumellar incision, followed by meticulous layer-by-layer dissection. The most appropriate structural technique from 5 standardized alternatives was selected based on intraoperative findings.

Type 1 Structure

This structure consists of bilateral spreader grafts¹⁸ customized to each patient’s anatomy, each measuring approximately 6–8 mm in width, 1–2 mm in thickness, and 3–4 cm in length. These grafts are secured with 5-0 nylon or polydioxanone (PDS) U-sutures to stabilize the middle nasal vault and prevent mid-vault septal deviation.

In addition, the caudal septum is reconstructed using a septal extension graft (SEG) as needed. A subtotal septal replacement is often required, in which case thin inferior wafer grafts (1.2 cm long × 5 mm wide) are added, following the method described by Toriumi et al.¹⁹ The wafers are anchored to the nasal spine with perforations using 4-0 nylon sutures.

After placing the wafers, the SEG was secured to the nasal spine using 5-0 nylon sutures, with a small wedge resection in the inferior nasal area to ensure the stability of the SEG (Fig. 1). Note that before placing the wafers, a spinoplasty is necessary. We strongly recommend using the ultrasound to create a flat spine on both sides.

Fig. 1.

Type 1 structure: bilateral spreader grafts (in orange) with cartilage wafers anchored to the anterior nasal spine inferiorly. The additional tip graft (in green) provides enhanced definition.

Type 2 Structure

This structure consists of 2 bilateral septal extenders placed in a biconvex configuration. These extenders feature a rectangular base and tapered tips to avoid raising the supratip, which could otherwise dominate the nasal tip. Additionally, a Peck or Sheen onlay graft could be applied to the nasal tip to anchor the alar cartilages.^20,21 The grafts are then sutured with 5-0 nylon or PDS suture.

The extender lamellae thickness should be 1.5 mm or less to avoid airway obstruction or columellar thickening. A 3- to 4-mm length is recommended to ensure adequate contact with the nasal septum while allowing for the desired projection (Fig. 2). This kind of double structure anchored to the septum is referred to as the “taco graft” by Kosins, whereas Cordero adds a Sheen-type graft, calling it the SEG 593.

Fig. 2.

Type 2 structure: bilateral septal extenders (in orange) with a tip graft (in green).

Type 3 Structure

In patients with a wide nasal spine, ultrasound guidance can create a channel within the bony nasal spine for precise SEG placement. In addition, a triangular incision at the SEG base aids fixation to the nasal spine. As with the type 1 approach, a full-length perforation is made through the nasal spine, allowing secure anchoring with nonabsorbable 4-0 nylon sutures (Fig. 3).

Fig. 3.

Type 3 structure: bilateral spreader grafts sutured using nonabsorbable 5-0 nylon (in orange). The septal extender (light yellow) is secured to the nasal spine using a 4-0 nylon suture.

Type 4 Structure

This adaptable structure allows for asymmetrical configurations tailored to individual patient anatomy. For example, 2 septal extenders may be placed unilaterally, with a single extender on the contralateral side connected through a spreader graft. This structure is determined on a case-by-case basis following a comprehensive intraoperative assessment. (See Video 1 [online], which displays type 4 asymmetrical structural reconstruction for high septal deviation.)

Video 1. Type 4 asymmetric septal reconstruction addresses severe, uneven nasal septum deviations. It involves extensive cartilage removal, grafting to rebuild the septum symmetrically, and advanced techniques to restore proper nasal airflow.

Download video file ^{(39.1MB, mp4)}

Type 5 Structure

This structure combines cephalic and caudal elements. In the cephalic area, 2 spreader grafts are anchored to the bony dorsum through osseous perforations using 4-0 nylon sutures. Two wafer grafts are secured to the nasal spine in the caudal area, with 1 or 2 SEGs placed between the wafers.

The cephalic and caudal components maintain structural continuity without direct fixation, allowing each structure to maintain functional independence; therefore, we coined the name TUMI (tip upright midline independence) graft. Free-diced cartilage is placed along the reconstructed braced cantilever, acting as an integrative matrix between the components.²² (See Video 2 [online], which displays type 5 structural reconstruction: independent dorsal and tip components with a free-diced cartilage interface.)

Video 2. Type 5 structural rhinoplasty involves separate reconstruction of the nasal dorsum and tip. These components are then seamlessly joined using a precisely sculpted, free-standing cartilage graft interface, demanding high surgical precision and artistry for optimal aesthetic and functional outcomes.

Download video file ^{(68.7MB, mp4)}

RESULTS

In total, 86 patients were recruited for this study, comprising 69 women and 17 men (age range: 18–55 y). The most common clinical findings were observed in 3 nasal regions: in the upper third, excessive dorsal reduction (37.2%); in the middle third, dorsal deviation (53.5%); and at the nasal tip, inadequate projection (68.6%) (Fig. 4). Among the 5 structural classification types, type 1 was the most frequently observed (35.9%), whereas type 5 was the least common (1.3%) (Fig. 5).

Fig. 4.

Distribution of structural reconstruction types (percentages).

Fig. 5.

Clinical findings according to each third and sex.

No significant complications, such as bleeding, nasal tip necrosis, or infections, occurred. Postoperative pain was managed with basic analgesics such as non-steroidal anti-inflammatory drugs and acetaminophen. During 6-month follow-ups, no deformities or structural complications associated with the surgical scheme were found.

DISCUSSION

Revision rhinoplasty presents significant challenges, even for the most experienced surgeons. Unlike primary rhinoplasty, where both structural and preservation techniques may be applied, revision rhinoplasty typically requires exclusively structural approaches, owing to its reconstructive nature. This complexity is heightened by limited preoperative planning capabilities and frequent intraoperative discoveries, making revision rhinoplasty a highly dynamic procedure.

In this type of surgery, it is common to encounter altered anatomical structures, compromised vascularity, and excessive scarring. The combination of scar tissue and reduced blood supply often results in a less pliable soft tissue envelope (STE), especially in the nasal tip. Consequently, patient outcomes in this type of surgery can be difficult to predict.²³

Moreover, many patients often have unrealistic expectations that may not align with their anatomical limitations, particularly following previous rhinoplasties. Postsurgical noses frequently present with asymmetries and variations that influence outcomes, often diverging from the patient’s desired aesthetic goals.

Given the substantial complexity of revision rhinoplasties, we present 5 fundamental principles for the comprehensive management of revision rhinoplasty patients: the “initial 5 principles for secondary rhinoplasty.”

First Principle: Patient Communication

Patients need to understand that each rhinoplasty case is different and unique. Clear communication concerning the complexity of the procedure and realistic treatment possibilities based on tangible results and patient expectations is crucial. In our practice, we assess case suitability based on the criteria proposed by Marcus,²³ which include evaluating whether a patient’s expectations are reasonable, if their goals are achievable, if they are emotionally prepared for revision surgery, and if they are a good fit for our practice style and approach to care.

When all responses to these considerations are satisfactory, surgery can be performed so that each patient has a clear, realistic understanding of potential improvements and physical limitations. Ultimately, the surgeon bears responsibility in deciding whether to undertake each complex case.²³

Second Principle: Identify Appropriate Reconstruction Materials

Given the characteristically weak cartilage structure in Latin American noses, we recommend harvesting cartilage from the sixth or seventh rib. Although auricular cartilage can be valuable in other scenarios, it is generally inadequate for revision rhinoplasty in Latin American patients. Many experts consider costal cartilage the optimal source for revision procedures, particularly when addressing nasal dorsal augmentation, tip projection, and mid-vault stabilization.^17,24–26

However, we recommend evaluating the costal cartilage, especially in patients older than 35 years of age, owing to potential calcifications that may complicate harvesting. Therefore, we recommend performing computed tomography (CT) scans with 3-dimensional reconstruction, particularly in female patients with an increased likelihood of cartilage calcification.^24,25 If available, an ultrasound scan performed by a trained operator can also provide a valuable, nonradiative, and cost-effective alternative for this assessment.²⁷

Third Principle: Case Analysis

Before revision rhinoplasty, each patient must undergo a thorough preoperative evaluation, particularly using imaging techniques such as CT or cone beam CT, as recommended by Robotti et al.²⁸ Additionally, a preoperative endoscopic assessment is essential to evaluate potential damage to the nasal mucosa, bone tissue, and any turbinate pathologies. Airway assessment is critical, as functional breathing issues are common in revision rhinoplasty cases.²⁹ Nassab and Matti³⁰ reported that approximately 25% of patients who underwent revision rhinoplasty experienced functional respiratory problems. We consider routine examinations essential; patients should be informed of these assessments.

A complete analysis of each patient includes evaluating nasal functionality, which establishes good breathing and phonation. In this sense, direct communication with the patient and clarity about possible complications and benefits are essential.³¹ Given the subjective nature of breathing, functional tests such as active anterior rhinomanometry or acoustic rhinomanometry can provide valuable preoperative data. Ishii et al³² established a complete guideline for optimizing patient care, promoting effective diagnosis and therapy, and reducing harmful or unnecessary variations in care. However, current pre- and postsurgical preparation and follow-up protocols significantly reduce these risks. Our series did not have major complications such as neurological, ischemic, or infectious lesions.

Fourth Principle: Surgical Exploration (STE, Septum, Bone)

A detailed understanding of the nasal anatomy is essential for patients undergoing revision rhinoplasty. We recommend precise plane dissection while preserving the integrity of the STE, cartilage, mucosa, and bone structures whenever possible.

Anatomical variations, scar tissue, or foreign bodies can present challenges that may not be apparent in preoperative imaging, making careful intraoperative exploration essential. It is also important to ascertain if any injectable filler materials are present in the surgical area and whether these fillers are absorbable or nonabsorbable.

Fifth Principle: Strategic Planning

Following meticulous tissue-preservation dissection, surgeons must select an appropriate structural approach based on their intraoperative findings. The choice of structural design is fundamental to the case outcome, even influencing how the harvested cartilage should be cut. Understanding the required dimensions of cartilage grafts is crucial because surgical decisions are irreversible. Likewise, we recommend selecting 1 of the 5 structural approaches proposed here to ensure long-term nasal stability.

The 5 structural approaches share common elements, with all approaches incorporating strong anchorage to the nasal spine. Regarding nasal tip support mechanisms, Daniel and Palhazi³³ emphasized the importance of ligaments in supporting both the nasal tip and other structures. In a subsequent study, they identified ligaments and alar cartilage as primary support structures for the nasal tip, considering the nasal spine’s role as secondary.³⁴ However, in revision rhinoplasty, these ligaments and cartilages have often been previously altered or sectioned, necessitating more robust anchorage. Consequently, the nasal spine is critically important, serving as an anchor point for nonabsorbable sutures.

Anchoring to the inferior nasal spine can be achieved through several methods: wafer grafts, direct suturing, or septal cartilage fixation, all of which provide predictable long-term support. Free dice cartilage in this area acts as a stabilization matrix, resisting deformation forces over time.

In our cohort of 86 patients, nasal tip complications predominated, with inadequate tip projection being the most common (68.6%), followed by dropping and deviated tip (41.9%) (Fig. 6). Latin American patients have distinctive nasal characteristics compared with other ethnicities. Although Nassab and Matti³⁰ reported nostril asymmetry and septal deviation as primary findings in the United Kingdom, Loghmani et al⁹ found overprojection and tip ptosis to be more prevalent in Middle Eastern populations. We attribute our clinical findings to the following 2 main factors: (1) the inherent structural characteristics of cartilage in Latin American patients and (2) the historical use of aggressive tip cartilage resection techniques, often resulting in structural weakening.

Fig. 6.

Clinical findings in patients undergoing secondary rhinoplasty distribution (percentages).

Mid-vault analysis revealed a high prevalence of deviations (53.5%), followed by inverted-V deformity (33.7%),³⁵ consistent with findings reported by Loghmani et al. A primary cause of inverted-V deformity is excessive dorsal cartilage resection, which leads to detachment and weakening of the upper lateral cartilages at the osseocartilaginous junction (keystone area)³⁵ (Fig. 7). Regarding the upper third, the most frequent clinical finding was excessive dorsal reduction (37.2%), highlighting a pattern of aggressive resection techniques affecting both the dorsum and nasal tip. Correction for this issue necessitates dorsal augmentation procedures.

Fig. 7.

A woman with 2 prior rhinoplasties (the second involving costal cartilage and resulting in tip overrotation and dorsal elevation) underwent revision type 1 structural rhinoplasty. A, Preoperative frontal view. B, Preoperative lateral view. C, 1-year postoperative frontal view. D, 1-year postoperative lateral view.

Among the 5 structural approaches proposed, type 1 was the most frequently used, followed by types 2, 4, and 5. Type 1, the most straightforward structural approach to implement, provides reliable support and stability to both the superior and inferior structures, making it ideal in highly complex cases. In patients without severe high septal deviations or those requiring minimal septal correction, anterior fixation using wafer grafts is recommended to enhance support and stability. For cases with insufficient tip projection, wafer grafts are recommended to provide tip stability and predictability. However, subtotal resection is often necessary for deviation correction (Fig. 8).

Fig. 8.

A woman with a nasal hump, inverted-V deformity, and poorly defined nasal tip underwent type 2 structural rhinoplasty. A, Preoperative frontal view. B, Preoperative lateral view. C, 1-year postoperative frontal view. D, 1-year postoperative lateral view.

The type 2 structure, the second most selected approach, is typically used when an intact, surgically uncompromised septum allows bilateral extender placement. Because structural misalignment may occur, this approach is contraindicated in cases with weak cartilages or significant septal deviations. Spreader grafts can address minor deviations; however, an alternative structural approach is warranted if deviation persists.

The type 3 structure is recommended in conditions similar to those of type 1, except when significant tip rotation and projection are not required. This technique requires an adequate nasal spine, which can be prepared with an ultrasound-guided channel for precise septal extender placement. It is important to note that the septal extender must be carefully carved to achieve an optimal fit to the nasal spine (Fig. 9).

Fig. 9.

A female patient presented with dorsal overresection, mid-vault deviation, an inverted-V deformity, and an inadequate nasal tip (lacking definition, projection, and rotation with alar retraction) following primary rhinoplasty. Type 3 structural rhinoplasty was performed. A, Preoperative frontal view. B, Preoperative lateral view. C, 1-year postoperative frontal view. D, 1-year postoperative lateral view.

Type 1 and type 3 structures are similar; however, the main difference is the focus on the nasal spine as a new structural support in relation to the rotation and projection of the desired nasal tip. We strongly suggest evaluating the rotation in relation to the nasal spine. If the rotation is in the desired position, the type 3 structure may be used. On the other hand, if adjustment of rotation is needed, either to increase or reduce it, we strongly suggest using “wafers” to control it and make it more predictable in the long term.

In revision rhinoplasty cases with severe septal deviation affecting the perpendicular ethmoid plate, leading to deviations of the internal nasal valve, as well as the nasal tip, we recommend a type 4 structural approach, involving subtotal replacement with asymmetrical reconstruction. This approach is tailored on a case-by-case basis, as there is no fixed design; instead, the structure is adjusted according to the extent of the deviation.

The type 5 structure is characterized by the lack of a direct union between the dorsum and the middle-third structure with that of the nasal tip. Specifically, the dorsal and nasal spine components remain separate without suture fixation, typically used when cartilage grafts cannot achieve appropriate union without risking deviation. However, adequate rotation and projection are maintained through nasal spine fixation, with diced cartilage providing structural support (Fig. 10).

Fig. 10.

Summary of indications and characteristics of the 5 structural reconstruction techniques used in the study.

Final Considerations

We aimed to provide a general framework for the management of revision rhinoplasty. However, individual variations may exist beyond those addressed here. Surgeons must tailor these principles according to intraoperative findings. Revision cases frequently present with partially compromised or damaged septal cartilage; therefore, the structural diagrams serve as reference points rather than absolute templates.

Cartilages tend to warp in some cases. We recommend suturing 2 laminated cartilage grafts biconcavely using 5-0 nylon sutures to achieve balanced forces. This composite graft can then serve as a main structure, secured either directly to the nasal spine or with wafer grafts (Fig. 11).

Fig. 11.

Biconcave fixation of laminated costal cartilage grafts using 5-0 nylon or PDS sutures.

Finally, although the nasal spine provides crucial support, cases with compromised structural integrity may benefit from bone suture fixation in conjunction with spreader grafts to enhance overall support.

One of the main limitations of our study is the follow-up time. However, the initial results demonstrated are satisfactory; longer follow-up periods can help corroborate these concepts. This study served as a foundational reference for future analytic research on aesthetic outcomes and satisfaction results.

CONCLUSIONS

The predominant clinical findings in Latin American patients presenting for revision rhinoplasty include inadequate tip projection, tip ptosis and deviation, and upper third deformities (including high radix and saddle nose deformity). In these cases, type 1 structural grafting was most frequently used for reconstruction, whereas type 5 was the least used. Based on our findings, we strongly recommend that surgeons conduct a comprehensive preoperative evaluation in revision rhinoplasty cases, especially in patients with Latin American nasal characteristics.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

PATIENT CONSENT

Patients provided written consent for the use of their images.