Revision Rhinoplasty
“I had a bad nose job! I’m scared to get another operation! Is there anything else that can be done?!”
Most surgeons consider rhinoplasty to be one of the most complex and difficult procedures to perform well. The rhinoplasty surgeon must have a unique combination of technical prowess and aesthetic artistry in order to achieve consistently excellent results. His surgical technique must be meticulous and compulsive to the most minute detail. His or her sense of beauty and understanding of three dimensional spatial relationships must be finely developed. Finally, he or she must have the communication skills to understand the patients aesthetic goals precisely, even if the patient is unable to articulate them.
Fulfillment of these criteria notwithstanding, complications are frequent and revision surgery common. According to an often cited text, “…in the best of surgical hands, secondary surgery of the nose will be necessary in approximately 5 to 10% of patients1” (1. T.D. Rees, Secondary rhinoplasty, basic considerations, T.D. Rees, Editor, Rhinoplasty, problems and controversies, CV Mosby, St.Louis (1988)). Unfortunately, not all hands are the best. Over 100,000 rhinoplasty procedures are performed yearly in the US alone. The number of patients who are left unsatisfied numbers well over 10,000 each year. Not all of these patients have bad results right away. Some are pleased with their outcome for several years, only to see their nose twist or indent as scar tissue accumulates.
Revision surgery of any kind is always technically more difficult than the primary operation because the surgeon is operating through scar tissue. Revision rhinoplasty procedures especially are more prone to complications and are less likely to achieve the desired aesthetic result. My advice to patients considering revision is to do it only if it is absolutely necessary and if there is no other way. If their rhinoplasty resulted in difficulty breathing through their nose, surgery is the only way to correct that. If the graft that was placed is too big and needs to be reduced, that is a surgical problem. If the scar tissue has caused the nose to twist significantly, surgical correction is probably the only option.
In the majority of cases, however, non surgical correction is an excellent option. Non surgical rhinoplasty for a previously operated nose can be a tricky procedure. The skin is thinner with a less robust blood supply, so there is a real danger of necrosis (dead skin) if the injector uses too much filler in certain areas. Scar tissue tethers the skin down and makes it difficult to lift with fillers. This is a procedure that should only be performed by physicians who have years of experience injecting the nose.
The following are some examples of the more common complications that I see in my office:
-
Saddle nose deformity – collapse of the cartilage around the midpoint of the bridge due to over-resection and scarring.
-
Pinched tip – due to scarring
-
Deepened supra-alar crease – due to scarring
-
Polly beak deformity – scar tissue formation on the bridge of the nose, just before the tip resulting in excessive curvature of the lower third of the nose.
Open roof deformity – failure of the bones of the nose to re-approximate in a pyramid shape after hump removal, leaving a gap at the top. This is usually due to incomplete or omitted osteotomy (controlled fracture of the bones) – a part of the rhinoplasty procedure specifically designed to avoid this complication.
