Tertiary and salvage rhinoplasties using the open rhinoplasty approach

The versatility of the open approach has made it a well accepted technique for routine rhinoplasties. However, there is less enthusiasm in applying the concept to salvage or tertiary nasal procedures. Reluctance to apply the open rhinoplasty approach for these procedures stems largely from concerns with skin viability and redraping after wide undermining. The more limited endonasal dissection is also favoured because of the need for small subcutaneous pockets, which prevent grafts from shifting. This paper reviews 26 salvage or tertiary rhinoplasties. All patients were managed with the open approach over a three-year period. The clinical considerations and preoperative planning are discussed. Potential pitfalls in skin flap elevation are examined, and the specific dissection techniques for the nasal tip, dorsum and septum are described. Four basic types of repair are recognized. In some patients, the repair is primarily a release of contracted and scarred cartilages, with or without the use of spreader grafts (1). In others, the repositioning and reshaping of displaced and misshapen cartilages is the primary focus (2). More serious problems require replacement of cartilage and bone segments that were removed in previous operations (3). Some tertiary congenital problems such as cleft lip nose require reconstruction of nasal elements that are lacking (4). While each case presented has a primary focus of repair, there is frequent overlap. A representative example of each of the four types of repair is presented.