Why Should We Incorporate Functional Reconstruction When Managing Revisions of Nasal Surgery?

Goals/Purpose: Residual functional and aesthetic deformities following nasal surgery for cosmetic, congenital and post traumatic purposes are not uncommon and probably under reported. Many procedures/modifications have been suggested for correction of such residual nasal deformities. Surprisingly, however, the vast majority of publications focus on correction of nasal appearance, while little or no attention is given to the identification and management of coexisting airway obstruction. Yet such conditions from various anatomic and structural reasons might potentially have significant impact on patients' quality of life and well being. The objective of this communication is to stress the significance of paying equal attention to the functional and aesthetic aspects of the deformity for re operations after nasal procedures, based on 35 years of experience and suggest incorporation of such approach to various treatment protocols. Our protocols will be discussed in detail, and the rational of our approach substantiated with representative cases, as well as patients' testimonies.

Methods/Technique: From 1984 to 2019, 331 revisional procedures were performed. 228 patients (156 with cleft nasal deformities, 49 after aesthetic rhinoplasty and 23 after correction of traumatic deformities) who had undergone 1 to 3 previous procedures, had at least one year of follow up and complete pre and postoperative clinical, photographic records and patient feedback were included in this study. All procedures were individualized and performed after extensive clinical, endoscopic, imaging and functional evaluation(rhinomanometry, after 1993). A variety of nasal techniques were applied to manage each component of the deformity, achieve symmetry, aesthetic balance and to address all elements contributing to the airway obstruction.

Results/Complications: 173 patients(75.87%) had significant objective functional and aesthetic improvement. This number increased to 82.45% (188 patients) when subjective breathing data, based on patient's perception were used. 29 patients(12.71%) had good aesthetic but modest functional improvement, while 21(9.21%) required additional surgery to improve appearance.

Conclusion: Based on our long term experience, analysis of our data and positive patient feedback, who in the vast majority were alleviated from their debilitating symptoms, we would like to stress the importance and rational for incorporation of functional reconstruction in all cases of residual deformities after nasal surgery, as needed. A comprehensive preoperative evaluation, including endoscopy, detailed understanding of all anatomic and physiologic aspects of the deformity, and use of the most appropriate procedures are prerequisites for success. Understanding breathing physiology through subjective and objective evaluations could be of great assistance for the preoperative planning, while rhinomanometry when available, can offer an objective tool to further appreciate airflow and resistance and substantiate further functional results.