What to Know Before Revision Rhinoplasty Surgery

If you peruse the internet and social media searching for plastic surgery testimonials, you will find a plethora of inquiries regarding revision rhinoplasty.

Patients frequently upload photos of themselves demonstrating their displeasing results from their rhinoplasty operation seeking opinions about what can be done to remedy their concerns.

Although revision rhinoplasty surgery is a difficult procedure, it is a very common patient consult that we see in our clinic and we are very comfortable performing this procedure.

However, even though revision rhinoplasty is an option, it is much more favorable to have a rhinoplasty done correctly the first time. This emphasizes the importance of meeting with an experienced, board-certified facial plastic surgeon during your initial consultation.

Why Do Patients Seek Revision Rhinoplasty?

The primary goals of rhinoplasty are appearance and functionality — a nose that looks good and a nose that works well (in terms of breathing).

Patients are typically seeking help with one or both of these two issues.

There are many surgeons that are primarily concerned with how the nose appears, and breathing is a secondary concern.

We acknowledge that appearance is a vital concept to a rhinoplasty but creating or inadequately addressing nasal obstruction leads to less than ideal outcomes that can be bothersome to the patient.

As for the appearance of the nose, there are a variety of reasons that a patient’s initial rhinoplasty can have shortcomings. One of the most important components of a consultation with a patient is to mutually agree upon the ideal appearance of the nose.

If there is a misunderstanding in communication between the patient and their surgeon regarding the goal of the nasal appearance, it is difficult to meet the patient’s expectations. We perform computer modeling on all our rhinoplasty patients so that we mutually agree upon a surgical plan.

However, what is even more important is providing our patients with a model that is surgically obtainable.

Depending on a patient’s nasal anatomy, skin thickness, surrounding anatomy, etc., some desired appearances may not be surgically feasible. This is why we aim to develop a computer-generated plan that is both aesthetically congruent with the patient’s wishes and surgically obtainable.

This point cannot be overemphasized. It is easy to make a patient’s nose look good on imaging, but having the knowledge, experience, and expertise to know if the image can be surgically executed requires an experienced surgeon.

As alluded to above, persistent or new-onset nasal obstruction is a reason that a patient may seek consultation for revision surgery. They may be happy with the appearance; however, they have functional issues with breathing and would like this corrected.

Another reason that a patient may seek a revision is that they were happy with their results initially, but the appearance or functionality of their nose changed overtime. This can be a result of trauma to their nose, inadequate cartilage support, or processes associated with aging.

What Makes Revision Rhinoplasty More Difficult?

There are various components to a previously operated nose that make the revision procedure more difficult.

During a rhinoplasty, regardless of whether an open or closed technique was performed, skin and soft tissue must, to some degree, be elevated from the underlying bony and cartilaginous structures. This makes repeat dissection of these tissues more difficult to perform.

An additional component that adds difficulty to revision surgery is not knowing how the previous surgeon operated.

There are various surgical techniques and grafting procedures available for the surgeon to use to achieve desired outcomes. However, it is difficult to determine which maneuvers were previously performed in the initial rhinoplasty surgery.

This leads to a distortion of normal nasal anatomy that can be initially misleading during surgery and requires an experienced eye to identify deviations to normal anatomy.

The lack of cartilage from prior surgeries adds another level of difficulty to revision rhinoplasty. Recently, rhinoplasty surgeons have started to perform cartilage preserving procedures because we recognize the importance of the cartilaginous framework of the nose to provide adequate support.

We are careful to remove the minimal amount of cartilage necessary when performing surgery.

A very common source of cartilage that we use during surgery is the cartilaginous septum. This is the structure that makes up the front part of the middle of the nose, or the nasal septum.

Frequently, we remove a portion of this structure during rhinoplasty — primarily for two reasons.

The first reason is to remove deviated portions to facilitate improved nasal breathing. When we remove portions of this cartilage, we leave enough cartilage to provide enough support so that the nose does not collapse.

The second reason is that we repurpose this cartilage to serve as grafts.

We will take the excised portion of the cartilage and place it on a sterile table and shape it into different configurations that will allow for correcting deformities, providing support, and camouflaging imperfections.

Obviously, when we perform a revision rhinoplasty, this cartilage is oftentimes absent from the patient and we must utilize other sources of cartilage away from the nose to perform the necessary augmentations.

Meeting Patient Expectations

One of the underrecognized difficulties with revision rhinoplasty is the overall feeling of the patient.

We recognize that the patient utilized their resources, sacrificed time, and put their trust in the hands of a surgeon during the initial procedure. We understand that having to do that again is an anxiety-provoking and frustrating situation for the patient.

An experienced, board-certified facial plastic surgeon is certainly capable of correcting the patient’s concerns. However, we do understand the amount of frustration and disappointment the patient may have with their less than desirable results from their initial operation.

This is something that we do not take lightly.

It may be difficult for a patient to put their trust in another surgeon to correct their concerns after an initial undesirable outcome — which is why we strive to not only meet but exceed our patients’ expectations.

So, What Can Be Done?

At your consultation, we will review your nasal concerns regarding the appearance, functionality or a combination of these two components.

We will review your imaging and mutually agree upon a realistic surgical result using computed imaging. Again, we only develop plans that we feel are surgically obtainable.

The next component is planning how to execute the plan during surgery. This varies from patient to patient; however, we will frequently need to harvest cartilage from another source.

We are typically able to assess how much cartilaginous septum is present during your physical exam, but often we will ask your permission to obtain alternative sources of cartilage.

The two primary sources of accessory cartilage are from the ear or the cartilaginous portion of the front of one of the ribs.

The ear cartilage can be accessed through a small incision in the skin of your ear through which we remove a portion of the conchal bowl.

Removing this cartilage does not change the appearance or your ear and the scar is essentially invisible once it has healed. This cartilage is less effective than septal cartilage in most cases, however there are certain types grafts that can be successfully executed from this cartilage depending on a patient’s individual needs.

The other potential site to acquire cartilage from is the rib.

We can make this an inconspicuous incision in females by placing the incision at the bottom of the breast, within an inframammary crease.

In males, there are alternative locations that we can place the incision depending on the patient’s anatomy. This cartilage serves as a plentiful and robust graft option.

As expected, there is some expected postoperative discomfort associated with this technique given that the rib cage is subjected to frequent moving with breathing, moving, laughing, etc., however, once the patient has recovered from surgery there should not be persistent discomfort or obviously visible deformity associated with the rib graft harvest.

There is also the option to utilize “donated” rib which is typically obtained from cadavers.

The cartilaginous rib tissue is appropriately treated so there is not a risk of transmitted diseases or rejection. There is long-standing, on-going debate regarding which source of rib cartilage is best to use.

The decision is ultimately best made upon discussion with the patient and their consulting surgeon.

Deciding to Have Revision Rhinoplasty

We recognize that revision rhinoplasty is a large decision for a patient, especially after undergoing a previous procedure and not being pleased with the outcome.

We are dedicated to serving our patients seeking a revision and are adequately prepared by years of experience and training to address their concerns.

This can be one of our most gratifying procedures because we know the patient’s expectations are high and we are here to meet and exceed them.

It is extremely important to derive a plan during the consultation so that our patient’s desires are expressed, confirmed, and adequately addressed.

A revision rhinoplasty is one of the more difficult procedures associated with our profession. Countless patients have trusted our expertise in addressing their concerns and we will continue to serve our patients to the best of our ability.

If you are considering a revision rhinoplasty, or an initial rhinoplasty for that matter, please seek a consultation with an experienced, board-certified facial plastic surgeon to best achieve your desired results.

Revision surgery is certainly an option; however, we prefer to achieve the desired outcome on the first attempt.

Please give us a call if you would like to discuss a rhinoplasty (revision or primary) at 518-768-7000.