Abstract
Background:
Aesthetic and functional concerns, especially after multiple revision rhinoplasties, continue to provide a challenge even for the experienced surgeon.
Objective:
This study aimed to report the results in terms of “secondary rhinoplasty,” performed by the senior author after previous rhinoplasty.
Methods:
This descriptive prospective study was carried on 150 patients with surgical indication of secondary rhinoplasty and they were asked to fill out the questionnaire divided into 3 parts: overall epidemiological questions, questions of patients’ aesthetic and functional complaints, and objective evaluation by the surgeon. The nasal problems in the upper and middle regions were divided into high or low, broad or narrow, crooked, irregularity of nasal bridge, or other alterations. The patients included in the study had surgical programming of secondary rhinoplasty, with mandatory aesthetic and optional functional purposes, having previous rhinoplasty with the same or different surgeon.
Results:
There were 136 females and 14 males with the mean age of 31.52 (6.36) years. The most common complaints were related to the nose tip with 123 cases included deviated tip and pinched (bilateral) with 25.3%, 30.7%, and 25.3%, middle nose with 78 cases included mid vault deviation, inverted V, and polly beak with 31.3%, 18%, and 9.3%, and upper nasal region with 69 cases included dorsum irregularity and wide dorsum with the rates of 22.7% and 16.7%, respectively; respiratory problem was reported in 13 cases.
Conclusion:
Unilateral or bilateral twisting at the nasal tip had the highest percentages, and the lowest incidence was in relation to the complaints of the upper nasal part.
Keywords: secondary rhinoplasty, outcomes, aesthetic, functional
Abstract
Historique:
Les problèmes esthétiques et fonctionnels, surtout après de multiples rhinoplasties de révision, continuent de poser problème, même chez le chirurgien expérimenté.
Objectif:
La présente étude vise à rendre compte des résultats des « rhinoplasties secondaires » effectuées par l’auteur principal après une rhinoplastie antérieure.
Méthodologie:
Les chercheurs ont réalisé la présente étude prospective descriptive sur 150 patients ayant une indication chirurgicale de rhinoplastie secondaire à qui ils ont demandé de remplir un questionnaire divisé en trois parties : questions épidémiologiques globales, questions sur les doléances esthétiques et fonctionnelles et évaluation objective du chirurgien. Ils ont divisé les problèmes nasaux des zones supérieure et médiane : haut ou bas, large ou étroit, croche, irrégularité de la fosse nasale ou autres altérations. Les patients participants devaient subir une rhinoplastie secondaire planifiée pour des fins esthétiques obligatoires et fonctionnelles optionnelles, et avaient déjà subi une rhinoplastie exécutée par le même chirurgien ou par un autre.
Résultats:
Au total, 136 femmes et 14 hommes d’un âge moyen de 31.52 ± 6.36 ans ont participé à l’étude. Les doléances les plus courantes étaient liées à la pointe du nez, soit 123 cas comportant une déviation et un pincement (bilatéral) de la pointe dans 25,3 %, 30,7 % et 25,3 % des cas. La zone moyenne du nez était touchée dans 78 cas, dont une déviation de la voûte nasale moyenne, un V inversé et un bec-de-perroquet dans 31,3 %, 18 % et 9,3 % des cas. La région supérieure du nez était en cause dans 69 cas, y compris une irrégularité du dos du nez et un dos large dans 22,7 % et 16,7 % des cas. Enfin, un problème respiratoire a été déclaré dans 13 cas.
Conclusion:
Une torsion unilatérale ou bilatérale de la pointe nasale présentait le plus grand nombre de problèmes, et l’incidence la plus basse était liée aux doléances de la partie supérieure du nez.
Introduction
Secondary rhinoplasty is reoperation of a nose previously operated. Some authors distinguish this from “revision,” which is reoperation by the same surgeon on their own patient. Usually the term “secondary rhinoplasty” refers to more extensive surgery than revision.” Some also refer to secondary rhinoplasty as “revision rhinoplasty.” The incidence of secondary rhinoplasty is far from negligible, with a mean of 5% to 15% of the primary cases operated, with some articles showing incidence of more than 21%. There are 3 reasons for secondary and revision rhinoplasty that include: (1) complications of surgery, (2) unsatisfactory or untoward result, and (3) the need for further improvement.1
To optimize patient satisfaction from revision rhinoplasty, the surgeon must be keenly aware of the functional and cosmetic deficiencies that the patient considers most problematic, so several studies discuss about most common aesthetic and functional abnormalities in multiply revised noses. Successful secondary rhinoplasty requires familiarity with commonly reported concerns after primary rhinoplasty as well as the identification and correction of underlying problems.2,3 Surgeons performing secondary rhinoplasty should be aware of problems commonly seen after primary procedures and should have the technical skills to address them.4
So in this study, we reviewed secondary and revisional rhinoplasties performed by the senior author. We report our results in terms of “secondary rhinoplasty,” defined as rhinoplasty performed by him after previous rhinoplasty by a different surgeon, or “revisional rhinoplasty,” defined as rhinoplasty in which he performed the primary and secondary operations.
Methods
This descriptive study was prospectively carried out in a private office from January 2015 to December 2017. After receiving information about the research and giving their authorization by signing the free and informed consent form, 150 patients with surgical indication of secondary rhinoplasty were submitted to an interview prior to the surgery by the main investigator to fill out the questionnaire.
During the questionnaire development, it was divided into 3 parts: overall epidemiological questions, questions about the patients’ aesthetic and functional complaints, and objective evaluation by the surgeon. The first part consisted of questions about the number of previous surgeries, the time intervals of the last surgery, and also the surgeon who performed the last surgery. This part was completed by the both patients and surgeon.
The second part consisted of questions about the patient (epidemiological issues, patient’s functional and aesthetic concerns) that was filled by the patients. The third part was exclusively used for information collection of requested factors from the surgeon (aesthetic–functional objective evaluation of the nose).2
Regarding the patient aesthetic complaints and to better understanding as well as the adequate filling out of the questionnaire, the nose was divided into upper, middle, and lower thirds or regions (tip and nasal base). The nasal problems in the upper and middle regions were divided into high or low, broad or narrow, crooked, irregularity of nasal bridge, or other alterations mentioned by the interviewees. Concerning those regions, some problems of the lower third are nose bulbous tip, narrow/pinched tip, upturned/raised (in the case of an excessive nasolabial angle), downturned (in the case of a nasolabial angle less than normal), prominent/protruding tip, asymmetrical, lacking appropriate tip definition, with collapse during inspiration and other changes mentioned by those interviewed about that region. In the nasal base region, complaints are broad or narrow such as short or long columella, retracted or unsightly scar, and visible graft and other alterations mentioned by the interviewees that could not be related to the upper, middle, and nasal tip regions.
The third part of the questionnaire was then applied by the main investigator to the surgeon responsible for the surgery, preoperatively. The patients included in the study had surgical programming of secondary rhinoplasty, with mandatory aesthetic and optional functional purposes, having previously undergone rhinoplasty with the same or another surgeon.
Finally, collected data entered into SPSS, version 20. Qualitative data in the forms of frequency and frequency percentage and quantitative data in the forms of mean and standard deviation have been demonstrated. As inferential statistics, respectively, Fisher exact test and χ2 test have been applied to compare frequency distribution of qualitative data, while independent t test has been used to compare the percentage of complaints.
Results
From 150 cases with rhinoplasty, 136 (90.7%) were female and 14 (9.3%) were male with the mean age of 31.52 (6.36) years. The frequency of previous rhinoplasty in these patients ranged from 1 to 4 times, so that more than 80% of them were exposed to rhinoplasty for the second time.
In addition, among the reported complaints leading to current rhinoplasty, the most common complaints were related to the nose tip with 123 (82%) cases, middle nose with 78 (52%) cases, and ultimately from the upper nasal region with 69 (46%) cases. Also, the respiratory problem was reported in 13 (8.7%) cases.
On the other hand, in the upper nasal region, the most common complaints were of dorsum irregularity and wide dorsum with the rates of 22.7% and 16.7%, respectively. Also, the mid vault deviation, inverted V, and polly beak were the most common complaints of middle nose with 31.3%, 18%, and 9.3%, respectively. Finally, from the complaints of nose tip, overprojection, deviated tip, and pinched (bilateral) were reported with 25.3%, 30.7%, and 25.3%, respectively (Figure 1). Evaluation of the reporting complaints from the nose (upper part, middle, and tip) based on gender, age, and frequency of previous rhinoplasty showed that reported complaints from the nose were not different in both gender (P value > .05), but reported complaints from the nose were higher at older ages (P value < .05) . The reported complaints from the upper and middle parts of the nose were also more frequent in those who had 2 previous rhinoplasty (P < .05). However, in the complaints of nasal tip, the percentage of reports was not significantly different between the number of rhinoplasties (P > 0.05; Table 1).
Figure 1.
Frequency of reported complaints of the patients.
Table 1.
Comparison of Reported Complaints of Nasal Condition Regarding Some of the Patient’s Basic Characteristics.
| Characteristics | Upper | Middle | Tip | |||
|---|---|---|---|---|---|---|
| Yes (n = 69) | No (n = 81) | Yes (n = 78) | No (n = 72) | Yes (n = 123) | No (n = 27) | |
| Sex | ||||||
| Female | 64 (92.8%) | 72 (88.9%) | 71 (91%) | 65 (90.3%) | 111 (90.2%) | 25 (92.6%) |
| Male | 5 (7.2%) | 9 (11.1%) | 7 (9%) | 7 (9.7%) | 12 (9.8%) | 2 (7.4%) |
| P value | .575 | .875 | .704 | |||
| Age, years | 32.71 (6.31) | 30.52 (6.26) | 32.62 (6.52) | 30.31 (5.99) | 31.63 (6.33) | 31.00 (6.56) |
| P value | .036 | .027 | .642 | |||
| Number of previous rhinoplasties | ||||||
| 1 | 53 (76.8%) | 75 (92.6%) | 61 (78.2%) | 67 (93.1%) | 105 (85.4%) | 3 (85.2%) |
| 2 | 15 (21.7%) | 2 (2.5%) | 14 (17.9%) | 3 (4.2%) | 13 (10.6%) | 4 (14.8%) |
| 3 | 0 (0%) | 2 (2.5%) | 2 (2.6%) | 0 (0%) | 2 (1.6%) | 0 (0%) |
| 4 | 1 (1.4%) | 2 (2.5%) | 1 (1.3%) | 2 (2.8%) | 3 (2.4%) | 0 (0%) |
| P value | .002 | .023 | .694 | |||
Discussion
Approximately 5% to 15% of patients submitted to rhinoplasty operations undergo secondary surgery with different functional and aesthetic complaints that needed a detailed assessment including all the expectations of patient from secondary procedure.1 Rhinoplasty is one of the most frequently used surgeries with its own complications like other surgical procedures and it is important to be aware of them by the surgeon and patient to reduce the incidence of these complications through appropriate measures.
This study aimed to outline the main aesthetic–functional complaints reported by patients submitted to secondary rhinoplasty. The results of this study showed that among 150 cases of rhinoplasty, there were 90.7% women and only 9.3% male with the mean age of 31.22 years. Therefore, in this assessment, the prevalence of rhinoplasty in women was obviously higher than the men, and the tendency for such surgical procedures is begun from the young age.
Unfortunately, in this study, 14.6% of performed rhinoplasties was for the second, third, or fourth time and patients have complained of problems in the upper and middle parts of their nose and also nasal tip, or respiratory problems, as the most common complaints of nasal tip problems were reported with 82%.
The complaints of crooked nasal tip, especially the unilateral crooked nasal tip, have shown the highest percentage of complaints received by patients leading to the first, second, third, or fourth rhinoplasty. After that, the problems of overprojection and deviated tip have been most reported. Subsequently, nose problems such as overrotation, drooping tip, and wide tip were the most common complaints of nasal tip deformity. Other nasal deformities have had a nearly the same distributions.
In a prospective study, Daniel4 determined 5 primary reasons of motivating Middle Eastern women to seek secondary rhinoplasty: (1) to achieve a smaller, more refined nose with a slight dorsal curve and a more defined tip with no attention to an acceptable, natural appearing result; (2) for correction of a deformity that was insufficiently corrected during the primary operation; (3) to eliminate visible stigmata of rhinoplasty; (4) to address major secondary deformities (ie, a persistent primary abnormality and surgical stigmata plus functional limitations); and (5) for aesthetic reconstruction after multiple aggressive procedures.
Loghmani et al in a retrospective study compared the patients who were scheduled for primary rhinoplasty based on their age and gender in 2 time periods (2005 and 2015). They reported that most of the patients were female with similar ratio to male in the 2 periods, but it seems that rhinoplasty is more requested in older age in recent years,5 but in the current study, we have concluded the rate of 77% for the primary and 90.7% for the secondary rhinoplasty in 2 studied periods. The different results can be due to the changes in aesthetic criteria or more sensitivity of women about their appearances and also the cultural issues.
In a study in Sweden on a population with different nationalities, the male to female ratio was 1.3:1. They showed that the procedure was more prevalent among Middle Eastern patients including Iranians. Their results among Middle Eastern patients indicated that female to male ratio was higher in younger and older patients, but it was identical in middle-aged patients.6 In a study in Mashhad, Iran,79% of the studied population were female. Mean age of the studied population was 24 and 27 years in 2005 and 2015, respectively.7
The objective evaluation of the nasal aesthetics performed by the surgeons in comparison to the patients’ complaints showed a greater number of visualized alterations. Nevertheless, in the surgeons’ evaluation reports, the drooping of the nasal tip and the presence of residual nasal hump were the 2 most prevalent factors. Other alterations reported by surgeons, but the presence of abroad nasal base was less frequently reported than the previous ones, and a bulbous tip and bridge irregularities in the upper third of the nose had the same frequency of reports, followed by the raised bridge in the middle third, nasal tips with little definition, and scar retractions.8,9
According to the data from the aesthetic evaluation performed by the physicians and the aesthetic complaints of the assessed patients, drooping nasal tip and residual nasal hump were the 2 main complaints of patients confirmed by the surgeons, followed by the broad nasal base, bulbous tip, and irregularities in the upper third of the nose with the same frequency and nasal tips with little definition.10
According to the results of our study the complaints of crooked nasal tip, especially the unilateral crooked nasal tip, have shown the highest percentage of complaints received by patients leading to the first, second, third, or fourth rhinoplasty. After that, the problems of overprojection and deviated tip have been most reported. Subsequently, nose problems such as overrotation, drooping tip, and wide tip were the most common complaints of nasal tip deformity. Other nasal deformities have had a nearly the same distributions.
Such findings contrast with the results of other studies such as Pearlman and Talei, which showed the presence of an asymmetric tip was the main complaint of previously operated patients reported in the objective examination by the physicians.11
In our study, complaints of middle third of the nose deformity were common with 52% as the problem with mid vault deviation, inverted V, and polly beak had the highest percentage of reporting frequency which may be resulted from the high frequency of the secondary rhinoplasties. In contrast, problems involving overresection (too low), irregularity, and deviation have not been observed at all, which can be due to the surgeon’s expertise and also using the new methods of surgery.
In their series of 104 patients who underwent secondary rhinoplasty, Yu et al12 found a crooked middle third of the nose (33 [32%] patients) was the most frequent presenting concern after tip asymmetries. In their review study on 92 patients who underwent secondary rhinoplasty over a 9-year period, Chauhan et al13 found the crooked nose to be the most common presenting concern (35 [38.0] patients), which is in accordance with our results.
Nassab and Matti in a study on concerns and surgical management of secondary rhinoplasty reported that the basic concerns were asymmetry (36.7%), large tip (24.8%), and breathing difficulties (22.0%). The most common clinical findings were nostril asymmetry (33.9%), septal deviation (32.1%), overresection (26.6%), and tip asymmetry (26.6%).14
In a study by Vian et al, the presence of drooping tip and residual bridge hump were the patients’ main complaints, confirmed by the surgeons. It was shown that there is correlation between subjective obstructive symptoms and the intranasal evaluation performed by surgeons in 87.5% of the cases. Among the patients with respiratory symptoms, in 56.25% of the cases, the main deformity identified was residual septal deviation.15
The complaints of the upper nose in our study were in the third place with 46%, so that problems such as dorsum irregularity and wide dorsum have the highest reported incidence rates, but problems such as overresection (too low) and open roof have not been seen in cases.
Nasal airway obstruction is one of the most frequent causes of revision rhinoplasty in patients after previous rhinoplasty procedure, but fortunately, the reported complaints of respiratory problems were reported as 8.7% in the current study. However, these complaints often occur more than once in these surgeries. Goudakos et al revealed the mean number of previous septorhinoplasties as 1.33. Nasal ventilation obstruction was identified in 91.3% of the patients, which was mainly caused either by septum deviation or nasal valve dysfunction. The average preoperative Nasal Obstruction Symptom Evaluation score was 61 (15), and it improved substantially, even from 1 month later.16
It should be noted that patients present concerns ranging from minor asymmetry to major overresection and nasal collapse for secondary rhinoplasty that many of them have undergone previous operations for many times and sought consultations from various surgeons. Regarding their concerns, these patients may have very high expectations of surgical correction. The surgeons who performed primary rhinoplasty in these patients may be inexperienced and not recognize the importance of specific nasal structures. Surgeons also may neglect to perform adequate osteotomies to prevent the inverted V deformity. In primary procedures, full support of the nasal tip may be overlooked, as evidenced by the lack of columellar strut placement. It is necessary for the surgeons performing secondary rhinoplasty to be aware of problems commonly seen after primary procedures and should have the technical skills to address them. The multiply operated nose become a very different entity from the virgin nose. Despite the expertise and knowledge associated with secondary rhinoplasty, healing would be a variable beyond our control. Hence, even among the most experienced surgeons, some rate of revisional surgery should be expected.
Conclusion
According to the results of this study, rhinoplasty was mostly prevalent in women and in adolescence to middle age. Based on anatomy and nasal appearances, complaints of nasal tip problems, especially unilateral or bilateral twisting at the nasal tip, had the highest percentages, and the lowest incidence was in relation to the complaints of the upper nasal part.
Footnotes
Level of Evidence: Level 4, Therapeutic
Authors’ Note: Loghmani S. contributed to literature search, data collection, data interpretation, and the manuscript writing and revision. Loghmani A. contributed to literature search and data collection. Maraki F. contributed to project idea, study design, and editing of the manuscript.
Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
References
- 1. Neligan PC. Plastic Surgery E-Book: 6-Volume Set: Expert Consult-Online. Amsterdam: Elsevier Health Sciences; 2012. [Google Scholar]
- 2. Cochran CS, Landecker A. Prevention and management of rhinoplasty complications. Plast Reconstr Surg. 2008;122(2): 60e–67e. [DOI] [PubMed] [Google Scholar]
- 3. Ballert JA, Park SS. Functional considerations in revision rhinoplasty. Facial Plast Surg. 2008;24(03):348–357. [DOI] [PubMed] [Google Scholar]
- 4. Daniel RK. Middle Eastern rhinoplasty in the United States: part II. Secondary rhinoplasty. Plast Reconstr Surg. 2009;124(5):1640–1648. [DOI] [PubMed] [Google Scholar]
- 5. Loghmani S, Loghmani S, Baghi H, Hoghoughi MA, Dalvi F. Demographic characteristics of patients undergoing rhinoplasty: a single center two-time-period comparison. World J Plast Surg. 2017;6(3):275–279. [PMC free article] [PubMed] [Google Scholar]
- 6. Kalantar Motamedi MH, Ebrahimi A, Shams A, Nejadsarvari N. Health and social problems of rhinoplasty in Iran. World J Plast Surg. 2016;5(1):75–76. [PMC free article] [PubMed] [Google Scholar]
- 7. Mertler V. Advanced and Multivariate Statistical Methods. 5th ed Los Angeles, CA: Pyrczak Publishing; 2015. [Google Scholar]
- 8. Cuzalina A. Revision rhinoplasty. Oral Maxillofac Surg Clin North Am. 2012;24(1):119–130. [DOI] [PubMed] [Google Scholar]
- 9. Fattahi T. Considerations in revision rhinoplasty: lessons learned. Oral Maxillofac Surg Clin North Am. 2011;23(1):101–108. [DOI] [PubMed] [Google Scholar]
- 10. Berger CAS, da Silva Freitas R, Malafaia O. et al. Coleta de dados eletrônicos para análise das manobras cirúrgicas em pacientes submetidos a rinoplastia. Int Arch Otorhinolaryngol. 2012;16(4):497–501. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11. Pearlman SJ, Talei BA. An anatomic basis for revision rhinoplasty. Facial Plast Surg. 2012;28(4):390–397. [DOI] [PubMed] [Google Scholar]
- 12. Yu K, Kim A, Pearlman SJ. Functional and aesthetic concerns of patients seeking revision rhinoplasty. Arch Facial Plast Surg. 2010;12(5):291–297. [DOI] [PubMed] [Google Scholar]
- 13. Chauhan N, Alexander AJ, Sepehr A, Adamson PA. Patient complaints with primary versus revision rhinoplasty: analysis and practice implications. Aesthet Surg J. 2011;31(7):775–780. [DOI] [PubMed] [Google Scholar]
- 14. Nassab R, Matti B. Presenting concerns and surgical management of secondary rhinoplasty. Aesthet Surg J. 2015;35(2):137–144. [DOI] [PubMed] [Google Scholar]
- 15. Vian HN, Berger CA, Barra DC, Perin AP. Revision rhinoplasty: physician-patient esthetic and functional evaluation. Braz J Otorhinolaryngol. 2018;84(6):736–743. doi:10.1016/j.bjorl.2017.08.011. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Goudakos JK, Daskalakis D, Patel K. Revision rhinoplasty: retrospective chart review analysis of deformities and surgical maneuvers in patients with nasal airway obstruction—five years of experience. Facial Plast Surg. 2017;33(03):334–338. [DOI] [PubMed] [Google Scholar]