COSMETIC
Revision Rhinoplasty after Open Rhinoplasty:
Lessons from 252 Cases and Analysis of Risk Factors
AQ1
AQ2
Serhat Sibar, M.D.
Kemal Findikcioglu, M.D.
Burak Pasinlioglu, M.D.
Ankara, Turkey
Background: In this study, patients who required aesthetic revision surgery after
open rhinoplasty were retrospectively screened for risk factors.
Methods: Two hundred fifty-two patients who underwent revision were included
in the study. Nasal deformities before the revision were determined for each
patient and evaluated in terms of their statistical relationship with preoperative
nasal morphology and surgical techniques used.
Results: The revision rate was found to be 10.8 percent. The three most common aesthetic reasons for revision were insufficient nasal tip rotation (37.7
percent), hanging columella (30.2 percent), and supratip deformity (28.6
percent). According to logistic regression analysis, the use of a strut increased
the risk of inadequate nasal tip rotation by 5.3-fold compared to the tonguein-groove technique, whereas inadequate nasal tip projection before surgery
increased this risk by 2-fold. Being older than 40 years increased the risk of
hanging columella by 6.8-fold, whereas the use of strut grafting instead of the
tongue-in-groove technique increased this risk by 5.9-fold. The use of strut
grafts instead of the tongue-in-groove technique increased the risk of supratip
deformity by 2.2-fold.
Conclusions: To ensure adequate nasal tip rotation after surgery in patients
with advanced age and low nasal tip projection and rotation, it will be more
appropriate to either use the tongue-in-groove technique or rotate the nasal
tip more than normal. In patients with advanced age (>40 years) and low nasolabial angle before surgery, the use of tongue-in-groove technique instead of
strut grafting may be advantageous for reducing the incidence of supratip and
hanging columella. (Plast. Reconstr. Surg. 148: 747, 2021.)
CLINICAL QUESTION/LEVEL OF EVIDENCE: Risk, III.
R
hinoplasty is a discipline with a lifelong
learning curve, and it is difficult to achieve
predictable results in the long term. In the
postoperative period, numerous changes in nasal
morphology may occur because of time, along
with many variables.1 These changes may necessitate revision surgery if they do not match the
outcome predicted by the surgeon or the patient’s
postoperative expectations. In the literature,
revision rates of rhinoplasty vary between 5 and
15 percent.2–10 Rhinoplasty operations were performed using the open technique in our clinic,
From the Department of Plastic, Reconstructive, and
Aesthetic Surgery, Gazi University Hospital.
Received for publication January 23, 2020; accepted March
15, 2021.
Presented at the 41st Congress of the Turkish Society of Plastic
Reconstructive and Aesthetic Surgery, in Samsun, Turkey,
October 26 through 30, 2019, and awarded first place in the
scientific competition of specialists, clinical studies.
Copyright © 2021 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000008318
and the patients who needed revision surgery for
aesthetic reasons were evaluated retrospectively
for various risk factors. With the results obtained,
we aimed to determine the factors that increase
risk in terms of revision, and to find solutions to
minimize revision rates.
PATIENTS AND METHODS
Patients who underwent open rhinoplasty
performed by five different surgeons in our clinic
between 2013 and 2018 were screened retrospectively. Overall, 478 of 4003 patients were excluded
because of previously undergoing rhinoplasty
at another center (secondary cases), use of the
closed technique, having cleft lip or cleft palate, or
having a history of maxillofacial trauma requiring
Disclosure: The authors have no financial interest
to declare in relation to the content of this article. No
funding was received for this article.
www.PRSJournal.com
AQ3
747
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Plastic and Reconstructive Surgery • October 2021
F1
surgery. Of the remaining 3525 patients, 2991
patients had at least 1-year follow-up and were
screened for revision rhinoplasty. Revision rhinoplasty was performed in 324 patients, and 72
patients were excluded from the study because of
lack of surgical notes or photographic documentation. The remaining 252 patients (after at least
1 year of follow-up) were included in the study for
the analysis of possible risk factors before revision
because of aesthetic concerns (Fig. 1).
In addition to the demographic characteristics of the patients, parameters such as skin
thickness, presence of external deviation and
dorsal aesthetic lines, status of the bone and
cartilage roof, nasal tip morphology, nasolabial
angle, dorsal hump size, and nasal tip projection
and rotation were evaluated based on preoperative photographs. Photographs were captured
using a Canon EOS 60D (Canon, Inc., Tokyo,
Japan) 18-135 IS lens with a fixed distance of 2
m between the camera and the patient in the
photography room inside the clinic. Adobe
Photoshop Version CC 2018 (Adobe Systems,
Inc., San Jose, Calif.) was used for photographic
analysis.
The technical details of the operation were
classified according to the patients based on the
surgical notes and the personal archives of the
surgeons. The existing deformities in the nose
before the revision were determined for each
patient through the photographs of the patients
and evaluated in terms of the statistical relationship between nose morphology before the first
operation and the techniques used during the
operation.
Statistical Analysis
Data analysis was performed using SPSS
Version 17.0 (SPSS, Inc., Chicago, Ill.). Normality
of continuous variables was determined using the
Kolmogorov-Smirnov test. Descriptive statistics
for continuous variables were expressed as mean
± standard deviation (range), whereas number
and percentages were used for categorical data.
Differences between groups in continuous and
sequential data were compared using the MannWhitney U test. When comparing categorical variables, Fisher’s exact test was used in cases where
one or more of the cells in a 2 × 2 probability table
had an expected frequency of less than or equal
Fig. 1. Study population and sample.
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Volume 148, Number 4 • Risk Factors for Revision Rhinoplasty
to 5, and Pearson chi-square test was used in cases
where one or more of the cells had an expected
frequency of greater than 5. Determination of
the best predictor(s) (hanging columella, supratip deformity, and insufficient nasal tip rotation)
affecting certain deformities was assessed by multiple logistic regression analyses after adjustment
for all possible confounding factors. Variables
with a univariate test result of p < 0.20 were considered candidates for the multivariate model
together with all variables of known clinical significance. Odds ratio and 95 percent confidence
interval were calculated for each independent
variable. Values of p < 0.05 were considered statistically significant.
RESULTS
T1
T2
The revision rate was 10.8 percent, and no
statistically significant difference was found
between surgeons in terms of their revision rates
(especially for the three most common complications). When the demographic and clinical
characteristics of the patients were examined,
the mean age was 31.9 years (range, 18 to 56
years). When the demographic and clinical characteristics of the patients were examined, the
mean age was 31.9 years (range, 18 to 56 years)
30 (11.9 percent) patients were male, and 222
patients (88.1 percent) were female. For skin
thickness analysis, the classification system previously described in the literature by Daniel was
used (thick skin, N + 1, N + 2, N + 3; thin skin,
N − 1, N − 2, N − 3; N, normal).11 Because of
the low number of patients with thin skin [n = 17
(6.7 percent)], they were included in the same
group comprising patients with normal skin
thickness during statistical evaluation. Because
the Turkish population has characteristics similar to the Middle Eastern population, the majority of patients who underwent revision surgery [n
= 209 (82.9 percent)] had thick skin. A total of 62
patients (24.6 percent) had a history of previous
nasal trauma, and 92 patients (36.5 percent) had
preoperative external deviation; 179 patients (71
percent) had irregular dorsal aesthetic lines, 146
patients (57.9 percent) had a wide bone roof, 159
patients (63.1 percent) had a wide cartilage roof,
and 163 patients (64.7 percent) had broad tip
morphology (Table 1). The three most common
nasal tip features in preoperative morphologic
analysis were nasal tip asymmetry [n = 73 (29 percent)], tip fullness [n = 52 (20.6 percent)], and
droopy tip [n = 40 (15.9 percent)], respectively
(Table 2).
Table 1. Demographic and Clinical Characteristics of
the Patients
Characteristic
No. of patients
Age, yr
Mean ± SD
Range
Age groups
<30 yr
30–40 yr
>40 yr
Sex
Male
Female
Skin thickness
Normal or thin
Thick
Previous nasal trauma
Preoperative external deviation
Dorsal aesthetic lines
Regular
Irregular
Bone roof
Wide
Normal
Cartilage roof
Narrow
Wide
Normal
Tip
Narrow
Broad
Normal
Value (%)
252
31.96 ± 8.98
18–56
123 (48.8)
88 (34.9)
41 (16.3)
30 (11.9)
222 (88.1)
43 (17.1)
209 (82.9)
62 (24.6)
92 (36.5)
73 (29.0)
179 (71.0)
146 (57.9)
106 (42.1)
63 (25.0)
159 (63.1)
30 (11.9)
13 (5.2)
163 (64.7)
76 (30.2)
The mean preoperative nasolabial angle was
91.2 degrees (range, 73 to 110 degrees). The
mean size of dorsal hump was 4.04 mm (range,
1 to 9 mm). Insufficient nasal tip rotation was
detected in 172 patients (68.3 percent). For nasal
ridge reconstruction, spreader flap technique
Table 2. Frequency Distribution of Patients in Terms
of Preoperative Nasal Tip Morphology
Characteristic
No. (%)
No. of patients
Normal
Asymmetric
Bulbous
Alar flare
Hanging columella
Footplate flare
Tip fullness
Unitip
Droopy tip
ANS hypertrophy
Bifidity
Nostril asymmetry
Cephalic orientation
Alar retraction
Lateral crural concavity
Intercrural groove
Short medial crus
Long medial crus
Broad tip
Other
252
13 (5.2)
73 (29.0)
30 (11.9)
24 (9.5)
35 (13.9)
22 (8.7)
52 (20.6)
12 (4.8)
40 (15.9)
9 (3.6)
13 (5.2)
7 (2.8)
7 (2.8)
6 (2.4)
10 (4.0)
4 (1.6)
4 (1.6)
7 (2.8)
2 (0.8)
6 (2.4)
ANS, anterior nasal spine.
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AQ4
Plastic and Reconstructive Surgery • October 2021
T3
F2, F3,
T4
was preferred in 116 patients (65.9 percent), and
spreader grafts were preferred in 86 patients (34.1
percent). For nasal tip support, strut grafting was
used in 184 patients (73 percent), and tongue-ingroove technique was used in 68 patients (27 percent). The mean number of cartilage grafts used
in the nose was 1.0 (range, zero to three), and the
mean number of sutures used in the nasal tip was
2.81 (range, zero to seven) (Table 3). The preferred suture material for midvault and tip reconstruction in all patients was 5-0 round (16 mm)
polydioxanone suture.
The most common aesthetic reasons for revision were insufficient nasal tip rotation [n = 95
(37.7 percent)], hanging columella [n = 76 (30.2
percent)], and supratip deformity [n = 72 (28.6
percent)] (Figs. 2 and 3 and Table 4). Patients
with large bone roof and thick skin structure
before the first operation were more prone to
Table 3. Other Clinical Findings of Patients
Value (%)
AQ5
No. of patients
Preoperative NL angle, deg
Mean ± SD
Range
Preoperative dorsal hump, mm
Mean ± SD
Range
Nasal tip projection
Droopy
Normal
Elevated
Nasal tip rotation
Insufficient
Normal
Excessive
Basal tip morphology
Triangular
Trapezoidal
Boxy
Preoperative radix
Droopy
Normal
Elevated
Spreader flap vs. spreader graft
Spreader flap
Spreader graft
Tongue-in-groove vs. strut
Tongue-in-groove
Strut
No. of cartilage grafts used
Mean ± SD
Range
Cartilage grafts used
Dorsal onlay
Radix onlay
Spreader
Spreader and strut
Strut
No. of sutures used on nasal tip
Mean ± SD
Range
NL, nasolabial.
252
91.29 ± 6.00
73–110
4.04 ± 1.00
1–9
95 (37.7)
156 (61.9)
1 (0.4)
172 (68.3)
79 (31.3)
1 (0.4)
189 (75.0)
31 (12.3)
32 (12.7)
33 (13.1)
207 (82.1)
12 (4.8)
116 (65.9)
86 (34.1)
68 (27.0)
184 (73.0)
1.0 ± 0.4
0–3
2 (0.8)
1 (0.4)
28 (11.1)
44 (17.5)
135 (53.6)
2.81 ± 0.89
0–7
wide dorsum deformity at postoperative follow-up
(p < 0.005) (Table 5).
Analysis of possible risk factors for dorsal
hump deformity showed that thick skin and
spreader grafts significantly increased the risk
compared with other skin types and spreader
flaps, respectively. In addition, it was found that
risk was positively correlated with the size of the
dorsal hump before the first operation (p < 0.005)
(Table 6). It was found that factors such as previous nasal trauma, preoperative deviation, preoperative irregular dorsal aesthetic lines, and the use
of spreader flaps instead of spreader grafts could
be effective in the emergence of external deviation deformity (p < 0.005) (Table 7).
In addition to irregular dorsal aesthetic line
and asymmetric nasal tip morphology before the
first surgery, factors such as higher number of
sutures used at the nasal tip increased the risk
of postoperative nasal tip asymmetry (p < 0.005)
(Table 8). It was observed that full and bulbous
nasal tip morphologies and thick skin caused a
fuller appearance at the tip after the operation
(p < 0.005) (Table 9).
Risk factor analysis for inverted-V deformity
showed that wide bone roof before first operation was a risk-increasing factor (p < 0.005).
However, dorsal hump amount, skin thickness
and spreader flap or spreader grafts used in nasal
ridge reconstruction had no effect (Table 10).
It was found that the use of tongue-in-groove
technique instead of strut graft significantly
increased the risk of retracted columella deformity (p < 0.005) (Table 11). The most significant
determinants of hanging columella deformity
were age older than 40 years and the use of strut
grafts instead of tongue-in-groove technique
(Table 12).
The most significant determinants of supratip deformity were age older than 40 years, using
strut graft instead of tongue-in-groove technique,
and having low nasolabial angle before surgery
(Table 13). Advanced age, low nasolabial angle
before operation, insufficient nose tip rotation
or projection, and the use of strut graft instead of
tongue-in-groove technique were among the factors causing insufficient nasal tip rotation deformity (Table 14).
Logistic regression analysis was performed to
evaluate all risk factors that may have an effect on
the three most common complications (i.e., insufficient nasal tip rotation, hanging columella, and
supratip deformity). Accordingly, for insufficient
nasal tip rotation, use of strut graft instead of
tongue-in-groove technique increased the risk by
T5
T6
T7
T8
T9
T10
T11
T12
T13
T14
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Volume 148, Number 4 • Risk Factors for Revision Rhinoplasty
Fig. 2. Preoperative photograph of the patient (left); supratip deformity is observed after surgery (center), and 14 months
after revision (right).
Fig. 3. Preoperative photograph of the patient (left); hanging columella is seen 1 year after surgery (center), and after revision (right).
T15
5.3-fold, insufficient nasal tip projection increased
the risk by 2-fold, and preoperative low nasolabial
angle increased the risk by 0.8-fold.
For hanging columella, age older than 40 years
increased the risk by 6.8-fold, and using strut graft
instead of tongue-in-groove technique increased
the risk by 5.9-fold. The use of strut grafts instead
of tongue-in-groove technique increased the risk
for supratip deformity by 2.2-fold (Table 15).
DISCUSSION
Revision rates are gradually increasing in rhinoplasty because of increasing patient demands
and unrealistic expectations. Because of several
features such as disruption of natural anatomy
and more difficult dissection by extension, revision surgery poses a greater difficulty than the
initial operation. To minimize revision rates,
potential risks should be predicted in advance,
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Plastic and Reconstructive Surgery • October 2021
Table 4. Frequency Distributions of Patients in
Terms of Prerevision Deformities
No. (%)
Insufficient nasal tip rotation
Hanging columella
Supratip deformity (pollybeak)
Dorsal hump
Broad dorsum
External deviation
Nasal tip asymmetry
Tip fullness
Nostril asymmetry
Dorsal asymmetry
Inverted-V
Alar retraction
Alar flare
Retracted columella
Dorsal deviation
Depression at facet polygon
Nasal ridge asymmetry
Dorsal irregularity
Insufficient nasal tip projection
External valve failure
Supraalar notching
More than normal rotation
95 (37.7)
76 (30.2)
72 (28.6)
50 (19.8)
44 (17.5)
41 (16.3)
37 (14.7)
20 (7.9)
15 (6.0)
15 (6.0)
14 (5.6)
13 (5.2)
7 (2.8)
7 (2.8)
4 (1.6)
4 (1.6)
3 (1.2)
2 (0.8)
1 (0.4)
1 (0.4)
1 (0.4)
1 (0.4)
Table 5. Comparison of Various Risk Factors in
Groups with and without Wide Dorsum Deformity
before Revision
No (%)
No.
Risk factor
Spreader flap vs.
spreader graft
Spreader flap
Spreader graft
Bone roof
Wide
Normal
Skin thickness
Normal or thin
Thick
Preoperative dorsal
hump, mm
Mean ± SD
Range
208
Yes (%)
0.996*
29 (65.9)
15 (34.1)
111 (53.4)
97 (46.6)
35(79.5)
9 (20.5)
40 (19.2)
168 (80.8)
3 (6.8)
41 (93.2)
4.04 ± 1.03
1–9
4.07 ± 0.89
3–6
No.
Risk factor
Spreader flap vs.
spreader graft
Spreader flap
Spreader graft
Preoperative radix
Droopy
Normal
Elevated
Skin thickness
Normal or thin
Thick
Preoperative dorsal
hump, mm
Mean ± SD
Range
0.001*
0.047*
0.856†
*Pearson χ2 test.
†Mann-Whitney U test.
and appropriate measures should be taken
accordingly. The revision rates in the present
study were similar to those reported in the literature. Literature data indicate that revision of
patients with thick skin is more difficult than that
of those with other skin types.12,13 In the present
study, the majority of patients (82.9 percent)
had thick skin. Although skin thickness alone
did not increase revision risk for the three most
common complications (i.e., inadequate nasal
tip rotation, hanging columella, and supratip
deformity), if accompanied by other risk factors
(e.g., advanced age, strut use, and massive hump
resection), it may increase revision risk because
No (%)
Yes (%)
202
50
p
0.001*
143 (70.8)
59 (29.2)
23 (46.0)
14 (54.0)
27 (13.4)
164 (81.2)
11 (5.4)
6 (12.0)
43 (86.0)
1 (2.0)
42 (20.8)
160 (79.2)
1 (2.0)
49 (98.0)
3.9 ± 0.98
1–9
4.4 ± 1.00
3–7
0.616*
0.002*‡
0.003†‡
*Pearson χ2 test.
†Mann-Whitney U test.
‡Statistically significant.
Table 7. Comparison of Various Risk Factors in
Groups with and without External Deviation
Deformity before Revision
No (%)
p
44
137 (65.9)
71 (34.1)
Table 6. Comparison of Various Risk Factors in
Groups with and without Dorsal Hump Deformity
before Revision
No.
211
Risk factor
Previous nasal trauma
No
177 (83.9)
Yes
34 (16.1)
External deviation
before first operation
No
157 (74.4)
Yes
54 (25.6)
Dorsal aesthetic line
Regular
73 (34.6)
Irregular
138 (65.4)
Spreader flap vs.
spreader graft
Spreader flap
132 (62.6)
Spreader graft
79 (37.4)
Yes (%)
p*
41
13 (31.7)
28 (68.3)
3 (7.3)
38 (92.7)
0 (0.0)
41 (100.0)
<0.001
<0.001
<0.001
0.012
34 (82.9)
7 (17.1)
*Pearson χ2 test.
of skin redundancy on the bone and cartilage
roof. Neaman et al. found that the full, asymmetric and wide nasal tip morphologies are more
prone to revision. Asymmetric tip and tip fullness
were two of the most common morphologic disorders observed in revision cases in the present
study, which was consistent with the literature
(Table 2).5
A higher incidence of wide dorsum deformity
in patients with wide bone roof and thick skin
was attributed to the relatively wide appearance
of thick skin on the dorsum and the potential
reopening of the bone roof in the long term, particularly in incomplete osteotomies. Because skin
thickness cannot be changed in these cases, this
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Volume 148, Number 4 • Risk Factors for Revision Rhinoplasty
Table 10. Comparison of Various Risk Factors in
Groups with and without Inverted-V Deformity
before Revision
Table 8. Comparison of Various Risk Factors in
Groups with and without Nasal Tip Asymmetry
before Revision
No.
Risk factor
Previous nasal trauma
No
Yes
External deviation
before first operation
No
Yes
Dorsal aesthetic lines
Regular
Irregular
Nasal tip morphology
before first operation
Asymmetric
Bulbous
Alar flare
Hanging columella
Footplate flare
Tip fullness
Unitip
Droopy tip
No. of sutures used
Mean ± SD
Range
No (%)
Yes (%)
215
37
163 (75.8)
52 (24.2)
27 (73.0)
10 (27.0)
139 (64.7)
76 (35.3)
21 (56.8)
16 (43.2)
70 (32.6)
145 (67.4)
3 (8.1)
34 (91.9)
36 (16.7)
26 (12.1)
22 (10.2)
28 (13.0)
21 (9.8)
46 (24.1)
10 (4.7)
38 (17.7)
37 (100)
4 (10.8)
2 (5.4)
7 (18.9)
1 (2.7)
6 (16.2)
2 (5.4)
2 (5.4)
2.7 ± 0.9
0–7
3.5 ± 0.7
3–5
p
0.711*
0.357*
0.002*
<0.001*
>0.999†
0.546†
0.338*
0.216†
0.472*
0.691†
0.059*
<0.001‡
*Pearson χ2 test.
†Fisher’s exact test.
‡Mann-Whitney U test.
problem can be prevented by fully mobilizing the
bones with osteotomies or performing a doublerow osteotomy.
A higher incidence of dorsal hump deformity in patients with thick skin, high hump,
and spreader grafts was attributed to the thickness of the skin on the dorsum or the upward
displacement of the graft resulting from insufficient fixation of the cranial portion of spreader
Table 9. Comparison of Various Risk Factors in
Groups with and without Nasal Tip Fullness before
Revision
No (%)
No.
232
Risk factor
Nasal tip morphology
Asymmetric
68 (29.3)
Bulbous
24 (10.3)
Alar flare
22 (9.5)
Hanging columella 32 (13.8)
Footplate flare
19 (8.2)
Tip fullness
40 (17.2)
Unitip
11 (4.7)
Droopy tip
38 (16.4)
Skin thickness
Normal or thin
43 (18.5)
Thick
189 (81.5)
AQ6
*Pearson χ2 test.
†Fisher’s exact test.
‡Statistically significant.
Yes (%)
p
20
5 (25.0)
0.683*
6 (30.0)
0.020†‡
2 (10.0) >0.999†
3 (15.0)
0.746†
3 (15.0)
0.369†
12 (60.0) <0.001†‡
1 (5.0)
>0.999†
2 (10.0)
0.749†
0.030†‡
0 (0.0)
20 (100.0)
No.
Risk factor
Spreader flap vs.
spreader graft
Spreader flap
Spreader graft
Bone roof
Wide
Normal
Skin thickness
Normal or thin
Thick
Dorsal hump
before first
operation, mm
Mean ± SD
Range
No (%)
Yes (%)
238
14
p
0.393*
155 (65.1)
85 (34.9)
11 (78.6)
3 (21.4)
134 (56.3)
104 (43.7)
12 (85.7)
2 (14.3)
40 (16.8)
198 (83.2)
3 (21.4)
11 (78.6)
4.05 ± 1.01
1–9
3.93 ± 0.83
3–6
0.030†
0.713*
0.533‡
*Fisher’s exact test.
†Pearson χ2 test.
‡Mann-Whitney U test.
grafts. Because skin thickness cannot be changed
in these patients either, it may be preferable to
use spreader flaps instead of spreader grafts. If
spreader grafts are to be used, special attention
should be paid to the fixation of the cranial portion of the graft in the keystone area.
A higher incidence of external deviation
deformity in patients with previous nasal trauma
and deviated and irregular dorsal aesthetic lines
before the operation may be attributable to intrinsic memory of cartilage or bone roof asymmetry.
In such cases, the use of spreader grafts instead
of spreader flaps or the use of additional batten
grafts or asymmetric osteotomies may be advantageous for the removal of deviation.
Asymmetric nasal tip morphology and increase
in the number of sutures used at the nasal tip were
directly associated with the risk of nasal tip asymmetry. This was attributed to the intrinsic memory
of the nasal tip cartilage and the foreign body reaction caused by the increased number of sutures.
Increasing the number of sutures also increases
the number of independent variables effective on
Table 11. Risk Comparison According to the Technique
Used at the Nasal Tip in Groups with and without
Retracted Columella Deformity before Revision
No (%)
No.
245
Risk factor
Tongue-in-groove vs. strut
Strut
183 (74.7)
Tongue-in-groove
62 (25.3)
Yes (%)
p
7
1 (14.3)
6 (85.7)
0.002*
*Fisher’s exact test.
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Plastic and Reconstructive Surgery • October 2021
Table 12. Comparison of Various Risk Factors in
Groups with and without Hanging Columella
Deformity before Revision
No.
Risk factor
Age, yr
Mean ± SD
Range
Age group
<30 yr
30–40 yr
>40 yr
Skin thickness
Normal or thin
Thick
Nasal tip projection
Normal
Insufficient
Nasal tip rotation
Normal
Insufficient
Preoperative radix
Droopy
Normal
Elevated
Tongue-in-groove vs. strut
Strut
Tongue-in-groove
Preoperative NL
angle, deg
Mean ± SD
Range
Dorsal hump before first
operation, mm
Mean ± SD
Range
No (%)
Yes (%)
176
76
30.4 ± 7.2 35.6 ± 11.5
18–54
18–56
92 (52.3)
72 (40.9)
12 (6.8)
31 (40.8)
16 (21.1)
29 (38.2)
33 (18.8)
143 (81.2)
10 (13.2)
66 (86.8)
114 (64.8)
62 (35.2)
42 (55.3)
34 (44.7)
59 (33.5)
117 (66.5)
20 (26.3)
56 (73.7)
21 (11.9)
145 (82.4)
10 (5.7)
12 (15.8)
62 (81.6)
2 (2.6)
114 (64.8)
62 (35.2)
70 (92.1)
6 (7.9)
91.1 ± 6.4
73–110
91.7 ± 5.8
78–110
4.1 ± 1.0
2–9
4.0 ± 1.1
1–7
Table 13. Comparison of Various Risk Factors in
Groups with and without Supratip Deformity
before Revision
p
0.002*
<0.001†
0.279†
0.154†
0.258†
0.439†
0.001†
0.661*
0.941*
*Mann-Whitney U test.
†Pearson χ2 test.
wound healing, thereby increasing the likelihood
of asymmetry.14 In patients with such asymmetric
morphology, asymmetric suture techniques or
nonanatomical grafts may be preferred if the surgeon has sufficient experience.
The fact that patients with thick skin and a
fuller and bulbous nasal tip are predisposed to
fuller appearance in the postoperative period was
attributed to reduction of the effect of thick skin
on nasal tip definition. In such cases, more aggressive cartilage shaping techniques or structural
nasal tip grafts may be preferred.
A higher incidence of inverted-V deformity in
patients with wide bone roofs may be attributable
to the reexpansion of the nasal bones (particularly
in incomplete osteotomies) during the recovery
period following osteotomy. Although there was
no difference between the use of spreader grafts
or spreader flaps in the middle roof in terms of
inverted-V deformity, the use of thick spreader
grafts may be a better alternative.
In cases of tongue-in-groove technique, a
retracted columella is common because of the
No.
Risk factor
Age, yr
Mean ± SD
Range
Age group
<30 yr
30–40 yr
>40 yr
Skin thickness
Normal or thin
Thick
Nasal tip projection
Normal
Insufficient
Nasal tip rotation
Normal
Insufficient
Preoperative radix
Droopy
Normal
Elevated
Tongue-in-groove vs. strut
Strut
Tongue-in-groove
Preoperative NL
angle, deg
Mean ± SD
Range
Preoperative dorsal
hump, mm
Mean ± SD
Range
No (%)
Yes (%)
180
72
31.2 ± 8.3
18–55
33.8 ± 10.4
18–56
91 (50.6)
68 (37.8)
21 (11.7)
32 (44.4)
20 (27.8)
20 (27.8)
35 (19.4)
145 (80.6)
8 (11.1)
64 (88.9)
117 (65.0)
63 (35.0)
39 (54.2)
33 (45.8)
60 (33.3)
120 (66.7)
19 (26.4)
53 (73.6)
19 (10.6)
152 (84.4)
9 (5.0)
14 (19.4)
55 (76.4)
3 (4.2)
122 (67.8)
58 (32.2)
62 (86.1)
10 (13.9)
91.9 ± 6.4
73–110
89.6 ± 5.5
73–102
4.0 ± 0.9
2–7
4.2 ± 1.2
1–9
p
0.088*
0.007†
0.112†
0.110†
0.283†
0.167†
0.003†
0.008*
0.241*
NL, nasolabial.
*Mann-Whitney U test.
†Pearson χ2 test.
direct fixation of the medial crus to the septum. This complication can be avoided by using
maneuvers described by Spataro and Most to
reduce this risk.15 They suggested that the fixation suture should be placed to the more cranial
part of the medial crus or the more caudal part
of the septum to prevent retracted columella
deformity after the tongue-in-groove technique.
This method reported by Spataro and Most is an
effective recommendation for preventing columellar retrusion, in our opinion, in cases where
the medial crus craniocaudal width is insufficient, and in cases where caudal septal excess is
limited or insufficient, it is more preferable to
use strut grafts instead of the tongue-in-groove
technique or to use mucosal tongue-in-groove
technique if the tongue-in-groove technique
will be preferred to prevent retracted columella
deformity.
In the present study, the most common reasons for aesthetic revision were the events involving the lower (inadequate rotation and hanging
754
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Volume 148, Number 4 • Risk Factors for Revision Rhinoplasty
Table 14. Evaluation of Various Risk Factors in
Groups with and without Insufficient Nasal Tip
Rotation Deformity before Revision
No (%)
No.
157
Risk factor
Age, yr
Mean ± SD
30.5 ± 8.4
Range
18–56
Age group
<30 yr
86 (54.8)
30–40 yr
52 (33.1)
>40 yr
19 (12.1)
Skin thickness
Normal or thin
31 (19.7)
Thick
126 (80.3)
Nasal tip projection
Normal
116 (73.9)
Insufficient
41 (26.1)
Nasal tip rotation
Normal
67 (42.7)
Insufficient
90 (57.3)
Preoperative radix
Droopy
20 (12.7)
Normal
132 (84.1)
Elevated
5 (3.2)
Tongue-in-groove vs. strut
Strut
96 (61.1)
Tongue-in-groove
61 (38.9)
Preoperative NL
angle, deg
Mean ± SD
93.4 ± 5.9
Range
73–110
Preoperative dorsal
hump, mm
Mean ± SD
4.1 ± 1.0
Range
1–7
Yes (%)
p
95
34.4 ± 9.5
19–55
37(38.9)
36 (37.9)
22 (23.2)
0.002*
0.020†
0.146†
12 (12.6)
83 (87.4)
<0.001†
40 (42.1)
55 (57.9)
<0.001†
12 (12.6)
83 (87.4)
0.300†
13 (13.7)
75 (78.9)
7 (7.4)
<0.001†
88 (92.6)
7 (7.4)
<0.001*
87.9 ± 5.1
73–110
>0.999*
4.0 ± 1.0
2–9
NL, nasolabial.
*Mann-Whitney U test.
†Pearson χ2 test.
columella) and the middle (supratip deformity)
one-third portion of the nose. This was attributed to open technique use or nasal tip modifications in most patients. When the most commonly
revised nasal areas reported in the literature were
examined, it was found that similar results were
obtained with our study.3,6,9,16–18
When the risk factors for insufficient rotation, hanging columella, and supratip deformity
were examined, it was observed that advanced age
(>40 years) and strut graft use were common risk
factors in all these cases. Advanced age leads to
limited retraction capacity of the mucosa and skin
in the postoperative period; consequently, strut
grafts are not retracted enough and cannot carry
the skin and mucous membranes accumulating
on the nose, which may be the underlying cause
of these problems. To prevent this problem, three
different solutions can be formulated. The first
option is not to reduce the cartilage and bone roof
above the retraction capacity of the skin (more
conservative reduction). The second option is to
use more stable fixation methods at the tip of the
nose (e.g., tongue-in-groove technique and septal
extension grafts). The third option is removal of
excess mucosa remaining during surgery from the
membranous septum and excision of skin from
the columellar incision site.
Another reason increasing the risk of insufficient rotation and supratip deformity was found to
be preoperative low nasolabial angle. Compared
Table 15. Multivariate Logistic Regression Analysis of the Combined Effects of All Possible Factors That May
Be Used to Differentiate between Groups with and without Hanging Columella, Supratip Deformity, or Insufficient Nasal Rotation before Revision
95% CL
Hanging columella
Age groups (>40 yr)
Strut
Nasal tip projection
Supratip deformity
Age groups
Strut
Skin thickness
Preoperative NL angle
Preoperative radix
Nasal tip projection
Insufficient nasal tip rotation
Age groups
Preoperative NL angle
Insufficient nasal tip projection
Skin thickness
Strut
OR
Lower
Upper
6.861
5.983
1.247
3.011
2.302
0.659
15.634
15.552
2.361
<0.001*
<0.001*
0.497
—
2.276
1.261
0.953
—
1.058
—
1.035
0.524
0.905
—
0.564
—
5.004
3.038
1.004
—
1.985
0.082
0.041*
0.605
0.070
0.307
0.861
—
0.857
2.064
0.726
5.308
—
0.801
1.063
0.291
2.138
—
0.917
4.006
1.815
13.178
0.260
<0.001*
0.032*
0.494
<0.001*
p
CL, confidence limit; NL, nasolabial.
*Statistically significant.
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Plastic and Reconstructive Surgery • October 2021
Table 16. Possible Complications and Solution Recommendations
Preoperative Finding
•
•
•
•
•
•
•
•
Technique Used
Wide bone roof
Thick skin
Thick skin
Spreader graft
Dorsal hump
Previous nasal trauma
Deviated nose
Irregular dorsal aesthetic line
Asymmetric nasal tip
Large number of sutures
used on the nasal tip
• Thick skin
• Full and bulbous nasal tip
• Wide bone roof
•
Advanced age (>40 yr)
•
Low NL angle
Possible Complications
• Complete or double row osteotomy
Dorsal hump
•
•
•
•
•
•
•
•
•
•
•
•
External deviation
Nasal tip
asymmetry
Tip fullness
Tongue-in-groove
Strut graft
Recommendation
Wide dorsum
Inverted-V
Retracted
columella
Insufficient
rotation
Hanging columella
Supratip deformity
Insufficient rotation
Supratip deformity
Spreader flap
Good fixation of the spreader cranial
Spreader graft instead of spreader flap
Septal batten graft
Asymmetric osteotomy
Asymmetric suturing techniques
Nonanatomical nasal tip grafts
Minimum suture use
Aggressive nasal tip modification
Structural nasal tip grafts
Complete osteotomy
Modified maneuvers*
• Conservative bone-cartilage roof reduction
• More stable nasal tip fixation methods
(TIG, septal extension grafts)
• Mucosa or skin excision
• Overrotation
• More stable nasal tip fixation methods
(TIG, septal extension grafts)
NL, nasolabial; TIG, tongue-in-groove.
*Spataro EA, Most SP. Tongue-in-groove technique for rhinoplasty: Technical refinements and considerations. Facial Plast Surg. 2018;34:529–538.
with patients with normal nasolabial angles, more
load is placed on the tip of the nose during surgery, and the tip of the nose may droop over time
because of this load in patients with lower nasolabial angles. Insufficient rotation and supratip
deformity were believed to be caused by drooping
of the tip of the nose.
We believe that by analyzing all the risk factors
mentioned above, rhinoplasty will be better understood and revision rates can be reduced by taking
appropriate precautions during surgery. Health
care costs can be reduced, and higher patient satisfaction can be achieved by decreasing the revision rates. The present study is important because
it involves a high number of patients treated
with similar surgical rhinoplasty procedures.
Additional prospective studies and evaluation of
patient photographs with three-dimensional modeling systems will increase both the quality and
reliability of the study. Further studies have been
planned for this purpose.
CONCLUSIONS
T16
For better clarity, the results of risk factor analysis can be summarized as follows (Table 16):
1. We believe that the use of spreader flaps
instead of spreader grafts in middle roof
reconstruction in patients with thick skin
and a high dorsal hump before the operation would be appropriate to reduce the
risk of dorsal hump deformity.
2. Patients with a history of nasal trauma, preoperative external deviation, or irregular
dorsal aesthetic lines were found to be more
prone to external deviation in the postoperative period. In these patients, spreader
grafts should be preferred primarily over
spreader flaps.
3. In patients with preoperative asymmetric
nasal tip morphology, the risk of nasal tip
asymmetry can be reduced by trying to provide nasal tip symmetry with the lowest possible number of sutures.
4. The use of more aggressive nasal tip modifications is required in patients with thick
skin and preoperative bulbous or full nasal
tip morphology.
5. In patients with advanced age (>40 years),
the tongue-in groove technique may be preferred instead of strut graft to reduce the
incidence of hanging columella.
6. In patients with advanced age (>40 years)
and preoperative low nasolabial angle, the
tongue-in-groove technique may be preferred instead of strut graft to reduce the
incidence of supratip deformity.
7. Similarly, in patients with advanced age and
insufficient nasal tip projection and rotation, it is appropriate to use the tongue-ingroove technique instead of strut graft or
to rotate the nasal tip more than normal
(overcorrection) to reduce the incidence
of insufficient nasal tip rotation after
surgery.
756
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Volume 148, Number 4 • Risk Factors for Revision Rhinoplasty
8. If the tongue-in-groove technique is planned
in selected patients, it may be necessary to
consider the risk of retracted columella and to
plan solutions for this problem during surgery.
AQ7
Serhat Sibar, M.D.
Department of Plastic, Reconstructive, and
Aesthetic Surgery
Gazi University Hospital
14th Floor
Besevler, Ankara, Turkey
serhatsibar@hotmail.com
Twitter: @SerhatSibar
PATIENT CONSENT
Before the study, written consent was obtained from
all patients for scientific use of clinical photographs and
data in accordance with the ethical principles of the
Declaration of Helsinki.
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