홍진주성형외과

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Nose reoperation

  • 홈으로
  • Rhinoplasty
  • Nose reoperation
[ Nose reoperation ]
Preoperative Evaluation & Measure the nasal bone, implants

Usually, the skeletal frameworks of the nose can be easily identified due to its thin skin and soft tissue covering. However, in the revision case, the thick scar and capsules beneath the skin envelope hide the inner structure silhouette invisible. The unpredictability can be overcome with the 3 Dimensional CT scan, which provides volume and location of the implants and foreign body as well. More accurate information about inner framework can be much beneficial to the result of the surgery.
When should be done?
Generally, the revision could be done after the resolution of the capillary proliferation in the scar site( 6Month postop).

Generally, the revision could be done after the resolution of the capillary proliferation in the scar site( 6Month postop).

As a glue for wound healing, the scar formation comes with the capillary proliferation to supply tissue component rapidly. After wound healing, the scar maturation progresses with the capillary resolution. Before enough maturation, the tissue with rich capillaries is a poor candidate for surgical procedure due to the capillary bleeding which can be controlled hardly with electrocoagulation.
In some case, should be done immediately.

Implant or grafts distorts the neighboring cartilage
- Deviated implant or cartilage graft(onlay or strut form) malposition can distort the neighboring cartilages frameworks permanently. The long-neglected alar cartilage and nostril deformities are hard to be corrected adequately.

Infection
- The implant should be removed in the case of definite infection. After 4~8 weeks the replacement surgery can be done.

Most common Causes of the Revision
  1. Implant visibility
    The implant can be seen through the skin due to inappropriate implant size or malposition.
  2. Capsular contracture
    Infection around the implant causes capsular contracture to shorten the nasal bridge and nasap tip deformity.
    *Capsular contracture is a response of the immune system to foreign materials in the human body. The occurrence of capsular contraction follows the formation of capsules of tightly-woven collagen fibers, created by the immune response to the presence of foreign objects surgically installed to the human body
  3. Nasal deformity distorted by the implant malposition.
    The implant can be seen through the skin or extruded due to inappropriate implant size or malposition. Deviated implant or cartilage graft(onlay or strut form) malposition can distort the neighboring cartilages frameworks permanently. The long-neglected alar cartilage and nostril deformities are hard to be corrected adequately. In this case, the reoperation should be done immediately even before 6 months after primary surgery. Thin skin coverage should be reinforced with the dermal graft.
  4. Nostril scar
    The nostril is the opening of the nasal cavity. The vestibule which is the entrance of the nose has the concave wall. The violation of the wall concavity can be seen from outside. Nostril deformity can be corrected by restoring concavity of the vestibule and continuity of the columella.
  5. Unnatural Ratio

    Prominent nasal bridge with blunt tip
    The upper part of the nasal bridge can be augmented easily because the underlying skeleton is rigid bone. However, the nasal tip is hard due to the soft cartilage. Ratio of bridge and tip can be unnatural.


    Blunt tip
    The tip is the most protruding part of the nose. However, if the augmentation is done not exatly at the tip (slightly upper than the tip), the tip become blunt more than before.


    Short nose
    The ratio of the projection to the length of the nose should be 1 to 1.5~1.7. The tip might be rotated upward too much by the previous surgery (cephalic rotation) to become a short nose.


    Pinched tip deformity, too prominent tip
    The tip can be narrower too much or onlay graft visible through the thin skin, pinched alar cartilage should be separated adequately with interposition cartilage graft and the skin thickness augmented with dermal graft.


    The Wide nose
    코The nasal width can be reduced for a natural sooth sidewall with bone shaving or cutting the junction of nasal bone. This procedure can be done very precise osteotome not under general anesthesia, but with a local anesthesia. Usually, no nasal packing is needed.
Cause of an infection and contracture
While an implant located on the upper part of the nasal bridge (nasal bone) is stable, that on the lower is relatively unstable and mobile to irritate the surrounding tissue. Generally, an L-shape implant is more vulnerable to the infection due to disproportion of the volume.

Infection is the invasion of an human body by disease-causing bacteria or virus, inflammation is part of the complex biological response of body tissues to harmful stimuli, such as pathogens, bacteria etc, and is a protective response involving immune cells, blood vessels, and molecular mediators. The function of inflammation is to eliminate the initial cause of cell injury, clear out necrotic cells and tissues damaged from the original insult and the inflammatory process, and initiate tissue repair.
Bacteria are killed effectively by the immune system, but there are shelters for them nearby implant where the blood supply reach hardly. That’s why the implant should be removed immediately. Implant removal can subside the infection/inflammation within 1~2days. Neglected infection can cause capsular contracture distorting neighboring tissue and structures. It is important to cure the infection to prevent contracture deformity.
JJ PS Revision Rhinoplasty knowhow
Autogenous graft
Autogenous dermis
Inappropriate implant position deteriorates the normal thickness of the overlying skin. The skin thickness over the nasal tip should be compensated by dermal graft from tailbone area. The skin over the tailbone is the thickest of the human body.

Dermis is the second layer just beneath the epidermis layer mainly consisting of collagen. Donor site scar is about 1.5CM and hidden at the crest between two buttocks. We use dermal graft only for the nasal tip unlike some surgeons use for a whole length of nasal bridge. A dermal graft for a whole length nasal bridge might make nose too blunt and donor site scar noticeable.

Instead of dermis, temporal fascia or skin allograft donated by a human cadaver could be used for the rhinoplasty. But fascia is too thin and an allograft not that safe as an autogenous graft.
Autogenous cartilage
conchal cartilage septal cartilage costal cartilage
Unlike the stable upper nasal bridge, the nasal tip is mobile. Tip-plasty needs autogenous cartilage graft to reduce the ratio of artificial prosthesis.

For rhinoplasty, ear conchal cartilage, septal cartilage, and costal cartilage is used according to their elasticity, strength and texture. Autogenous cartilage graft forms its own blood supply and no physical stress is applied to over the covering skin. Some surgeons use the allograft cartilage donated by the human cadaver. But an allograft cartilage could be absorbed in their volume and vulnerable to infection.

JJ do not use the allograft for revision rhinoplasty.

references
1. Toriumi DM1. Choosing Autologous vs Irradiated Homograft Rib Costal Cartilage for Grafting in Rhinoplasty. JAMA Facial Plast Surg. 2017 Mar 23
2. Wee JH, Mun SJ, Na WS3, Kim H, Park JH, Kim DK, Jin HR. Autologous vs Irradiated Homologous Costal Cartilage as Graft Material in Rhinoplasty. JAMA Facial Plast Surg. 2017 Mar 23.
JJ Plastic Surgery is Different and Special, Because
  1. Zero medical accident for 16 years from the beginning with 1:1 privatized surgery
    1 : 1 tailored operation from the beginning and the after care of operation Renowned for Specialized clinic in reoperation after thousands of cases of reoperation.
    3D-CT –assisted preoperative measurement & preoperative medical check-up Collaboration system by the specialty ; Full-time residing Anesthesiologist ; Poor availability with Emergent medication of Dantrolene, Bridion etc. Aftercare program according to each surgery
    preoperative stage Operation planning and performing stage Postoperative care stage
  2. Allumni medical clinic of SEOUL NATIONAL UNIVERSITY HOSPITAL & Selected Plastic clinic for the “Let Me IN” for the medical support.
    Allumni medical clinic of
    SEOUL NATIONAL UNIVERSITY HOSPITAL
    Selected Plastic clinic for the
    “Let Me IN” for the medical support.
  3. Full availability of High-tech Equipment for the safety.
    · Measuring in delicacy using 3D-CT
    3D-CT helps analyzing minute shape difference of bone indiscernable in naked eye, shape of nasal septum, general status of skin including shape, size and asymmetry in 3 dimensions. It highly elevates the possibility of operational success.
    It is important for the clinic to be equipped with 3D-CT to avoid another re-operation.


    · Acuvein, the high-tech equipment, not only minimizes swelling and bruising but also elevates the degree of safety
    · Quick recovery after operation with help of “Hyperbaric Oxygen Therapy”
    · Provision to possible medical accident by preoperative ‘One-Stop Safe medical check-up’
    · Anesthesiologist resides all the time for safety
    · Equipped with medication (Dantrolene) for malignant hyperthermia, which is only accessible in large scale hospital.
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