A and C, A woman in her mid-20s who had undergone rhinoplasty 1 year earlier and returned with a small deformity of the left nasal dorsum. B and D, The patient at 1 year after endonasal revision of her nasal deformity under local anesthesia.
A, C, and E, Preoperative photograph of a man in his early 20s who sustained trauma to his nose after a revision rhinoplasty, resulting in fracture of the nasal bones, saddling of the dorsum in its middle third, and valve collapse. B, D, and F, Photograph at 4½ months after a second revision rhinoplasty with osteotomies, spreader grafts, and an auricular cartilage onlay.
A, C, and E, A woman in her late 40s who presented to our clinic after 2 previous rhinoplasties done respectively 14 and 10 years earlier outside of the United States. B, D, and F, The patient at 9 months after a revision rhinoplasty with spreader grafts and rim grafts from septal cartilage, a columellar strut, a tip graft, and a dorsal onlay with conchal cartilage.
A, C, E, and G, A woman in her late 40s with a previous rhinoplasty done outside of the United States. B, D, F, and H, The patient after revision rhinoplasty done with irradiated rib, composite conchal cartilage grafts, and acellular dermis.
Customize your JAMA Network experience by selecting one or more topics from the list below.
Rodman R, Kridel R. A Staging System for Revision Rhinoplasty: A Review. JAMA Facial Plast Surg. 2016;18(4):305–311. doi:10.1001/jamafacial.2016.0249
Rhinoplasty is known to be one of the more technically challenging cosmetic procedures, with a revision rate of 5% to 15%. Reasons for revisions may range from minor deformities that can be treated in the office to major cosmetic and functional defects that require multiple surgical procedures to correct. The literature lacks a uniform scale that systematically evaluates the patient presenting for revision rhinoplasty. The TNM staging system for classifying malignant tumors was developed to aid the physician in planning treatment, providing some information about prognosis, assisting in evaluating the results of treatment, and facilitating the exchange of information. Although the patient presenting for a revision rhinoplasty does not have a potentially lethal disease, a classification system for such patients resembling that used for malignant tumors may provide similar benefits.
As in TNM staging, we describe 3 major components that determine the overall difficulty of surgery for revision rhinoplasty. In our PGS system, “P” represents “problem,” consisting of the specific anatomic anomaly with which the patient presents. The second component in our system is “G” for “graft,” based on the number of grafts required. The third component of this system is “S,” for “number of previous surgical procedures.” In addition, we have included a category “E,” for “patient expectations,” which is added after the stage of the patient’s condition has been determined through the PGS classification.
Conclusions and Relevance
Rather than being measured in terms of survival, as with the TNM system for malignant tumors, the prognosis in revision rhinoplasty is measured in terms of what can be achieved with surgery as opposed to what cannot. This preoperative staging system may help the patient understand the complexity of the repair required and help manage expectations. The PGS system will facilitate exchange of information between surgeons who perform revision rhinoplasty. A standardized evaluation system will allow meaningful comparisons of surgical techniques and evaluations of outcomes of rhinoplasty procedures.
Rhinoplasty is known to be one of the more technically challenging cosmetic procedures because of intricate nasal structural components, which comprise both form and function, and because of the prominent central location of the nose on the face.1 When patient satisfaction scores after rhinoplasty are compared with those of other plastic surgery procedures, they reflect a lower rate of satisfaction. The rate of revision rhinoplasty reported in the literature ranges from 5% to 15%.2,3 Even in expert hands, rhinoplasty done for cosmetic purposes requires surgical correction in 5% to 10% of patients.4 The decision to perform a revision rhinoplasty is often based on the patient’s and physician’s acceptance of the outcome, which is largely subjective. Many revision rhinoplasties are done for minor deformities, such as asymmetries of cartilaginous components or underresection of a hump. However, some patients require major repairs of iatrogenic cosmetic and/or functional defects. Quiz Ref IDSeveral authors have grouped deformities encountered in revision rhinoplasty by their anatomical locations,5,6 some have grouped them according to the type of defect (underresection, overresection, scarring, or functional defect),7 and others have classified such deformities as “major” and “minor” deformities.8 A review of the literature fails to provide a uniform scale for systematically evaluating the nose of the patient presenting for revision rhinoplasty. Such a scale is needed to assign a qualitative value to the deformities of such patients’ noses, approximate the complexity of the needed repair, and facilitate comparisons of structure and appearance of the nose and discussions of revision rhinoplasty between rhinoplasty surgeons.
The TNM staging system for classifying malignant tumors was developed by Pierre Denoix between 1943 and 1952, and the Union for International Cancer Control subsequently established a Special Committee on Clinical State Classification under his chairmanship. The TNM classification system describes the anatomic extent of the cancerous tumor, based on the fact that the choice of treatment and prognosis are related to the size/extent of the tumor (T), the involvement of regional lymph nodes (N), and any evidence of metastasis (M).9 The purpose of such a system is to aid the physician in planning treatment for the cancer, providing information about its prognosis, assisting in evaluating the results of its treatment, and facilitating the exchange of information.10
Although the patient undergoing revision rhinoplasty does not present with a potentially lethal disease, a standardized classification system like the TNM staging system may bring similar benefits of planning, prognosis, evaluation of results, and exchange of information. Patients presenting for revision rhinoplasty will be evaluated according to a standardized scale, and the resulting score will be categorized into stages based on the complexity of the required repair. Unlike the diseases for which the TNM system is used, the prognosis in rhinoplasty is not measured in terms of survival but by what may be possible surgically. This preoperative staging system may help the patient to understand the complexity of the required repair and help in managing the patient’s expectations. Similarly, it will help the surgeon with treatment planning. A revision with a low stage of complexity might be adequately repaired by most surgeons who choose to perform rhinoplasty, whereas a revision with a high stage of complexity may best be referred to a surgeon experienced in revision rhinoplasty. The preoperative staging system for revision rhinoplasty will also facilitate the exchange of information among surgeons performing revision rhinoplasty. A standardized evaluation system will allow meaningful comparisons of surgical techniques and evaluation of outcomes.
This article describes a staging system for revision rhinoplasty toward the goals of establishing a standardized method for evaluating patients who present for revision rhinoplasty and assisting with its planning, the prognosis for a particular patient, evaluating the results of the patient’s procedure, and exchanging information between surgeons and their patients.
Like the TNM staging system, the staging system for revision rhinoplasty has 3 major components that determine the overall difficulty of the surgery needed for revision. Depending on the severity of any of the 3 components, the nose is given a final stage, I-IV, to assign a complexity as in the TNM system.
In this system, “P” represents “problem,” the specific anatomic anomaly with which the patient presents. This problem component is subgrouped, stratified by level of difficulty involved in the repair, into 4 levels of complexity and assigned a number (1-4) (Table 1).
The second component of the staging system is “G,” for “graft” (Table 2). If a graft is required to achieve a satisfactory result, the complexity of the surgery is increased and therefore the level is also increased. In the event that multiple grafts are needed, the complexity increases to a higher level. The classification described here is based on the number of grafts needed to meet the required needs of the patient. Quiz Ref IDBilateral grafts count as 1 graft. For example, if the patient requires a harvesting of septal cartilage to create spreader grafts and a columellar strut, this counts as 2 grafts and the patient’s graft is classified as a G1 graft. The use of acellular dermis, a graft of the temporalis muscle fascia, or any other soft-tissue graft is also included toward the staging. If, for example, the patient requires a columellar strut, spreader grafts, a tip graft, and a graft of acellular dermis, the columellar strut would count as 1 graft, the spreader grafts as a second graft, the tip graft as a third graft, and the graft of acellular dermis as a fourth graft. Four grafts represent a graft category of G2. In the event that no regional graft material is available for harvest, either from the nasal septum or conchal bowl, and the patient requires rib cartilage (cadaveric or autograft), the case is automatically upstaged to a category of G3. Any patient who requires 2 or more grafts from nonnasal sites is described as being in graft category G4 and will ultimately be defined as requiring a stage 4 revision rhinoplasty. Thus, the graft category of a patient who requires conchal cartilage and a temporalis fascia graft, conchal cartilage and rib cartilage, or 2 rib grafts is G4.
The third component of the staging system is “S,” representing the number of previous surgical procedures (Table 3). All patients who qualify for the staging system will have had at least 1 previous rhinoplasty procedure. However, the history of multiple previous rhinoplasty procedures increases the level of technical difficulty and the patient’s level is increased accordingly. In addition to anticipated scarring, patients who have had a previous rhinoplasty have altered anatomy, and the surgeon performing a revision rhinoplasty must proceed with great caution and attempt to discover what has been previously resected, grafted, or otherwise modified.
Quiz Ref IDAfter a revision rhinoplasty has been assigned the 3 classifications of P1-4 for problems, G1-4 for graft, and S1-4 for previous surgical procedures, its stage is determined by the highest classification. Thus, for example, a rhinoplasty classified as P3G2S1 is a stage III rhinoplasty, and a rhinoplasty classified as P2G2S4 is a stage IV rhinoplasty.
Although patient expectation does not change the technical aspects of the surgery for a revision rhinoplasty, unrealistic expectations on the part of a patient add difficulty to case management and require greater effort on the part of the surgeon to manage the patient in the preoperative and postoperative periods (Table 4). For this reason, we have also added a category “E,” for “patient expectations,” which is added after the stage of a revision procedure has been determined according to the PGS classification. Although the patient expectation rating does not change the stage of the repair, it provides additional information about the challenges the surgeon faces in a particular case and about the advisability of proceeding with any revision. Quiz Ref IDThe E classification can be jointly decided by the patient and the surgeon because patient expectations should be discussed preoperatively.
Figure 1 (stage I) shows a white woman in her 20s who underwent septoplasty and rhinoplasty 5 months previously, with septal resection and re-skeletonization, a tongue-in-groove maneuver, dorsal hump reduction, medial and lateral osteotomies, bilateral spreader grafts, a crushed cartilage onlay graft to the left lateral nasal wall, cephalic trim, and single and double dome sutures. The patient did well postoperatively but developed a small bony irregularity on her left dorsum, which has persisted.
Using the classification scales in Tables 1 through 4, we develop the case staging as follows:
Problem classification: P1
Small bony irregularity on the left dorsum (1)
Graft classification: G0
No grafts needed
Surgical classification: S1
One previous rhinoplasty
Expectation classification: EA
Patient recognizes limitations and is willing to accept improvement
Final classification: Stage I P1G0S1EA or stage I EA
Figure 2 shows a Hispanic man in his early 20s who underwent a revision septorhinoplasty 3 years previously, with good results. Unfortunately, he sustained a trauma to the nose resulting in deviation of the nasal bones and septum. Since this trauma he has had nasal obstruction, particularly when he develops a cold.
Problem classification: P2
Persistent deviated septum (1)
Need for revision osteotomies (1)
Internal valve collapse (2)
Graft classification: G1
Spreader graft (graft 1)
From conchal cartilage
Right middle vault onlay (graft 2)
Surgical classification: S2
Two previous rhinoplasties
Final classification: Stage II P2G1S2EA or stage II EA
Figure 3 shows a woman in her early 40s who presented to discuss revision rhinoplasty. She had a primary rhinoplasty done 14 years previously in Mexico, and a revision rhinoplasty 10 years ago. At the time of presentation, she reported difficulty in breathing through her nose and concern about the appearance of her nose, which she described as “small and doesn’t look natural.” Quiz Ref IDUsing the classification scales in Tables 1 through 4, we develop the case staging as follows:
Problem classification: P3
Persistent septal deviation (1)
Dorsal saddling (2)
Inverted V (2)
Overresected caudal septum (3)
Graft classification: G2
Spreader grafts (graft 1)
Rim grafts (graft 2)
Columellar strut (graft 3)
Tip graft (graft 4)
Dorsal onlay (graft 5)
Expectation classification: EB
The patient is displeased with her surgery elsewhere and with the fact that she must undergo another procedure, but is willing to accept improvement
Final classification: Stage III P3G2S2EB or stage III EB
Figure 4 shows a woman who presented after a previous rhinoplasty done several years earlier outside the United States. She reported disliking the shape and contour of her nose.
Problem classification: P4
Droopy tip (3)
Septal perforation (3)
Alar notching (4)
Asymmetric alar base (4)
Graft classification: G4
Composite conchal skin and cartilage
Willing to accept improvement
Final classification: Stage IV P4G4S2EA or stage IV EA
At present, to our knowledge, there is no common system for sharing information about revision rhinoplasty. The purpose of developing such a system is to aid the physician in planning treatment, providing information about the prognosis, assisting in evaluating the results of treatment, and facilitating the exchange of information with the patient and with other physicians.
The staging system described in this article may greatly help the surgeon with preoperative planning for revision rhinoplasty. We suggest using the staging form when assessing all patients who present for this procedure. In addition to helping the surgeon assess the patient and organize a surgical strategy, the system may be used to help determine operative surgical and facility costs. A facility and surgeon that perform revision rhinoplasty may choose to set up a pricing system according to the P, G, and S classification components of the staging system. Providing a quantitative and qualitative measure of what the patient is expected to require during surgery, as the system does, may help the patient to understand the breakdown of costs for a revision rhinoplasty procedure.
Most important, the staging system we describe may help in tempering patient expectations. Although there is no life and death prognosis, the patient must understand what is possible and what is not with the planned procedure. Although patients may not understand the intricacies of TNM staging, many do have a relative or acquaintance who has been affected by cancer, and have some understanding of what stage 1, 2, 3, and most important, stage 4 means for prognosis. On this basis, a stage 4 revision rhinoplasty may help many patients toward understanding the complexity of the task ahead and may modify their expectations.
At the time of the revision surgery itself, the staging of a rhinoplasty may change, as nuances of many deformities cannot be fully appreciated until the nose is opened in the operating room. This parallels the distinction made in the TNM staging system, in which a tumor is often upstaged from the “clinical stage” to the “pathological stage” after surgery. This will always be discussed with the patient preoperatively in continued attempts to manage expectations.
Surgeons frequently keep records of the number of patients who require revision rhinoplasty. In the age of the Internet, patients often choose physicians on the basis of statistics, one of which is the rate of rhinoplasty revisions performed by the surgeon. There is a considerable difference between a surgeon with a revision rhinoplasty rate of 15% involving small finishes done under local anesthesia and a surgeon with a rate of 10% involving major repairs, including grafts and osteotomies. The mere number of revisions is not a meaningful statistic without a qualitative scale for assessing the complexity of a revision. The staging system described in this article will assist in evaluating the results of rhinoplasty and provide a qualitative assessment of the need for further treatment. Quiz Ref IDIt is difficult for surgeons to be entirely accurate in assessing their own rates of revision, as it has been shown that although patients will return for minor revisions to the same surgeon with whom they had a primary rhinoplasty, a patient who is very dissatisfied and requires a major revision will often seek a new surgeon.8 In some cases, the number of revisions a patient undergoes may also be a product of patient selection and may not reflect the technical skill of the surgeon. A certain subset of patients will never be content with the outcome of their surgery and will seek revision for small and insignificant traits.7 Although there is no way to guarantee complete accuracy in the statistics the surgeon keeps, the staging system that we describe gives organization and stratification to data that previously had neither of these.
The staging system does not take into account the number of variables beyond the surgeon’s control, such as patient comorbidities, patient noncompliance with postoperative instructions, a lack of skin elasticity that prevents augmentation, and poor quality graft material. In addition, there is inherent subjectivity in the system in that the individual surgeon classifies the problem stage of a revision procedure. No system can include every nuance and variation of rhinoplasty, but the goal of this staging system is to provide some framework and basis of classification for the surgeon’s use in approaching the patient who is to undergo a revision rhinoplasty. In addition, the staging system may undergo future revision and modification as it becomes adopted into practice. The TNM staging system has gone through several revisions, and continues to be modified as more is learned about the nature and pathophysiologic features of cancer. The same may be true of the Kridel-Rodman staging system for revision rhinoplasty, with modifications being required as the system is adopted and used by surgeons engaged in rhinoplasty.
Rhinoplasty is a difficult procedure with a relatively high rate of revision as compared with other cosmetic surgical procedures. At present, physicians lack a system for evaluating the patient who presents for revision rhinoplasty. We propose a system similar to the TNM staging system for cancer. It is called the PGS staging system and has 3 components for the classification of revision rhinoplasties, including the problem for which the revision is needed, the type of graft used in the revision procedure, and the number of previous surgical procedures done on the patient’s nose. The system also has a classification for patient expectation and attitude. It will serve the purpose of treatment planning, discussing treatment options with patients and managing their expectations, evaluating the results of revision rhinoplasty, and exchanging qualitative information with other physicians as well as with the public. It will also permit surgeons to evaluate themselves on the basis of how often they need to change the staging of a revision rhinoplasty from the clinical staging determined preoperatively to the surgical staging determined in the operating room after a patient’s nose has been opened. An experienced surgeon will be able to accurately predict how many grafts will be needed in the surgical staging of a revision rhinoplasty and its level of complexity, and will therefore be able to manage patient expectations accordingly.
Accepted for Publication: September 1, 2015.
Corresponding Author: Russell Kridel, MD, Facial Plastic Surgery Associates, 6655 Travis St, Ste 900, Houston, TX 77030 (email@example.com).
Published Online: May 5, 2016. doi:10.1001/jamafacial.2016.0249.
Conflict of Interest Disclosures: None reported.
Additional Contributions: We thank the patients for granting permission to publish this information.
Create a personal account or sign in to: