REVISION RHINOPLASTY

Revision Rhinoplasty

Revision Rhinoplasty (Corrective Nasal Aesthetics Surgery)

Revision rhinoplasty or corrective nasal surgery is performed to remedy the undesired results of a previous rhinoplasty operation. Some disputes regarding the terminology exist. According to some, the subsequent operation(s) performed by the same surgeon to correct the unfavorable results arising from the first operation is called revision rhinoplasty while secondary rhinoplasty is the name given to corrective operation(s) performed by other surgeons. However, Secondary Rhinoplasty is widely referred to as the corrective nasal aesthetics surgery performed for the second or more times regardless of the performing surgeon in the first operation. 

Unfortunately not every rhinoplasty operation can produce desirable results. A broad, bulbous or pinched tip, asymmetry, droopiness, and extremely short or raised (pig nose) nose may be the case. Nostrils may be asymmetric or wide. There may be a collapse of the nasal sidewalls (alar collapse) and difficulty breathing. There may still be a hump or collapse of the nasal bridge. The nose may resemble a parrot’s beak (Polly-beak) due to insufficient removal of cartilage or there may be a collapse in the nasal bridge (saddle nose) due to excessive removal of cartilage. An inverted V look in the middle of the nose, twisted nose, continued deviation, irregularities on the nasal bridge, excessive scar tissue development inside and outside the nose, skin and soft tissue problems may exist.

Actually, the aesthetic and functional complications in the primary rhinoplasty account for the possible indications that may arise in the revision rhinoplasty.

Unfortunately, 7-15% of primary rhinoplasty operations require secondary (revision) rhinoplasty. Some of these operations call for minor revisions while some involve major corrections. In a minor revision surgery, the results of the first operation are acceptable and only small touchups are necessary. The patient may be happy with the look and feel of the current nose in general, but ask for small revisions. However, if the previous rhinoplasty surgery has caused obvious shape deformities, a major corrective revision surgery is required. An unsuccessful rhinoplasty surgery may lower a patient’s self-confidence and cause the patient to shy away from social activities. Generally, such patients are both unhappy with their noses and scared of a revision surgery. (What if it fails again? Could it get worse? Could I trust my doctor? etc.)

Common Reasons why a Rhinoplasty (nasal aesthetic surgery) may fail. 

1. The surgeon may have inadequate experience.

2. The patient may have unrealistic expectations.

3. The surgeon’s goals may be excessive.

4. Functional problems may occur due to poor healing and tissue scarring.

5. A postoperative nasal trauma may have occurred.

 

How can Failure be Avoided or Minimized?

 

1. Examination

The surgeon must do a full preoperative examination of the patient, plan a good course of action, and perform patiently and meticulously during the operation. Incorrect incisions, the excessive or inadequate removal of cartilage or bones, the inability to repair nasal support mechanisms are the most commonly observed reasons for undesirable consequences. The surgeon mustn’t rush through the operation. In cases where the surgeon isn’t fully satisfied with the results, it is critical to start over and make the necessary revisions. The result of the operation is of the essence, not the duration.

 

2. Experience

Rhinoplasty requires an experience of at least 5-7 years. It is often mentioned both by ear, nose and throat specialists and plastic surgeons that Rhinoplasty is one of the most challenging and demanding surgeries among aesthetic operations. Being a good surgeon alone doesn’t cut it. It also demands a surgeon with a strong artistic eye who works with patience and rigor and treats tissue with sensitivity and respect. It is vital to consider the many structures that make up the nose and their three dimensional relation to each other to operate and fix for desired results. In addition, it is necessary to anticipate what forces, and at what capacity, will have an impact on the nose postoperative and how to stabilize the nose in the long run. All of this demands experience. Revision rhinoplasty requires extra experience compared with regular rhinoplasty.

 

3. Focus

It should be kept in mind that the main function of a nose is to breathe healthily and visual appearance should not be the sole area of focus. The emphasis should be on fixing the nose without neither sacrificing the appearance nor healthy breathing. It is advised to wait for at least a year after the first operation to undergo revision rhinoplasty. 

 

Preoperative Evaluation

Although the preoperative evaluation is the same as of the primary rhinoplasty, it requires a more in-depth look and care. Moreover, the surgeon should determine any need for grafts and their possible resources, and secure patient approval.

 

Aesthetic Evaluation

A detailed analysis of the nose is a must for a successful surgery. First, the skin is examined.

The thickness, quality, fullness, and integrity of the skin and subcutaneous tissue and its relation with the nasal structures underneath are assessed. In the meantime, resections of any kind, insufficient, excessive, or asymmetrical are established. The surgeon tries to identify the untouched areas in the nose in the previous operation. Next, the surgeon looks into the possible graft areas.

The osteotomies and their positions on the nasal dorsum are evaluated. They may be very high, normal or very low. Are they straight, crooked, wide or narrow? Will there be a need for revision osteotomies? Is there an Open Roof Deformity or Rocker Deformity in hand? In addition, the surgeon should evaluate whether an excessive or inadequate removal of the nasal hump or the nasal bone is in question. Also, the nasal dorsum should be examined in terms of irregularity.

In the evaluation of the middle vault, the surgeon should look for any inverse V deformities and narrowness. It should be assessed whether grafts are needed or not. The cartilage is examined to figure out if there are any insufficient or excessive resections, irregularities, or crookedness. Anterior septal angle is studied to assess its role in the Polly-beak deformity.

In the evaluation of the nasal tip, symmetry, projection, rotation, alar-columella relationship, and the state of the lower lateral cartilage are assessed. Tip support and the tip of the septum cartilage are examined. All the incisions inside and outside the nose are checked out. Any possible presence of grafts is analyzed.

 

Functional Evaluation

Static or dynamic valve collapse (shrinkage or collapse in the nasal valve) is widely observed among revision rhinoplasty patients. Narrowness in the nasal lateral wall and collapse in the nasal ala when breathing are significant signs of valve narrowing. An immediate diagnosis is possible through the observation of the patient during regular and deep breathing.

The modified Cottler’s maneuver (the visible improvement in the patient’s breathing when the nasal lateral wall is supported by a plug curette) supports the diagnosis.

Anterior rhinoscopy can help determine septum deviation, inferior turbinate hypertrophy (enlargement of the inferior turbinates), synechia (adhesion), scar, septum perforation, and other anomalies. However, in 40% of patients, some anomalies (such as adenoid hypertrophy, middle turbinate hypertrophy, concha bullosa, choanal stenoz, nasal polyposis, chronic sinusitis…) may not be detected in this type of examination . Therefore, an endoscopic examination is required and a sinus tomography must be taken if necessary.

 

Photo Shoot and Computer Analysis

Photo shoot for a revision rhinoplasty is the same as for a rhinoplasty. In a standard photo shoot, the nose is shot from six different angles including the front, the bottom, the right side (profile) the right oblique (45°), the left side (profile), and the left oblique (45°). I take photos of the patient smiling and from the top in addition to these standard shots. While pictures of smiles show lip to nose correlation, deviations from the center are best seen in pictures taken from atop. Next, the pictures are transferred to the computer and the most suitable nose shape for the face is designed with the help of proprietary software. The target nose design has to be realistic and achievable. Otherwise, it may lead to disappointment. The computer-assisted design imaging process is instrumental in planning the operation. However, it should be kept in mind that a significantly close visual appearance is to be achieved rather than a one-to-one, identical appearance to the computer simulation.

It is essential to be in honest and open communication with the patient and inform them of any possible favorable and adverse outcomes. It goes without saying that it is every revision surgeon’s goal to achieve successful and pleasing results. However, if there are serious reservations surrounding any restrictions to achieve better results, surgical boundaries are better kept unchallenged, and this case should be shared with the patient. “Primum Nihil Nocere” (first, do no harm!) is the founding principle of medicine.

Patients must inform their surgeon of any regularly taken medication, chronic diseases (hypertension, diabetes, etc.) any previous operations, allergies, and bleeding related issues. It is advised that patients stop taking aspirin and similar blood thinner painkillers (naprosyn®, ibuprofen), vitamin A, Ginkgo Biloba (they may cause increased bruises and swelling) 10 days, and cut out alcohol consumption (it may cause increased edema) 5 days before the operation as well as giving up smoking (delays healing of wounds, increases lung problems and risk of infection post anesthesia).

 

Revision Rhinoplasty Procedure

Revisions rhinoplasty can be performed both open and closed as in primary rhinoplasty. It should be known here that open or closed approaches are not surgery techniques but rather methods applied to reach the cartilage and bone structures of the nose.

In the open, also known as, the External approach, the skin is lifted to reach the cartilage and bone structures via a small inverted V or W shaped incision applied to the columella (the structure separating the nostrils). The incision is sewn closed in the last stage of the operation. This incision is usually unobservable postoperative unless looked at closely and carefully. In the closed approach, all the incisions are made inside the nose. There is no clearly stated rule here that one of the approaches, open or closed, is better than the other. The determining factors here are the required interventions on the nose and which approach can manage their complete delivery. No interference with the nose tip support mechanisms, decreased trauma, faster healing and disappearance of postoperative edema, and no postoperative numbness on the nasal tip can be counted as some of the advantages of the closed approach. I prefer the open approach on noses that are crooked, require major revisions, and with distinct asymmetry on the tip as well as in half lip rhinoplasty. The advantage of open rhinoplasty is the ability to be in command of the whole nose cartilage and the bone structures and its allowance for the application of any kind of graft and suture techniques.  

Revision surgery involves differences from primary surgery. Some tissues have often narrowed, valuable cartilage and bone tissues have been excessively or asymmetrically removed and the weak or weakened cartilages have been twisted. This situation requires more delicate and meticulous work during the operation. Skin and soft tissues are essential in a revision rhinoplasty. Most of the time, skin has scarred tissue. There is more intensive tissue inflammation in revision rhinoplasty compared with primary rhinoplasty. All the protruding structures in patients with thin skin must be filed, the grafts must be thinned correctly, and if necessary, must be wrapped in fascia and used.  In patients with thick skin, strong cartilage is needed to stabilize the nasal tip and to bear the weight of the nose skin. It takes longer for the swelling to go down in patients with thick skin. It may take up to two years. The duration of the operation varies between 30 minutes to 4 hours depending on the shape of the nose and the approach applied.  While minor touches can be carried out in 30 minutes, major revisions may require 3-4 hours. Most of the time, revision rhinoplasty demands the use of grafts. Nasal septum cartilage is frequently overused or insufficient due to the previous operation. In such cases, cartilage from the ears or the rib (costal) cartilage may be used depending on the need, and the operation takes longer. However, it should be kept in mind that the priority is the result of the operation and not the duration.

The success of the revision rhinoplasty depends on a well-developed judgment, competence, knowledge, and above all, experience. It is vital that the surgeon has significant knowledge of anatomy and is on top of surgical approaches in this process. In addition, the surgeon must be equipped to handle undesired results and challenges. Postoperative patient follow up should be in place for a long time.

My philosophy in rhinoplasty is to be the first and the last surgeon performing the operation. And, my philosophy in revision rhinoplasty is to make the patient happy and be the last surgeon performing the operation. The postoperative process is the same as in primary rhinoplasty.

 

Frequently Asked Questions

When can Revision Rhinoplasty be done at the Earliest?

There is a waiting period of at least one year for the primary rhinoplasty results to settle and for the surgeon to correctly determine the required interventions in the revision rhinoplasty.

Where do you procure the Cartilage from when needed in a Revision Rhinoplasty?

Grafts are the structural components we use in shaping the nose from time to time. If need be, I primarily use cartilage from the septum provided that it doesn’t disturb nose support. If not, from the ear, and if that’s not sufficient either or if there are major revisions requiring structural support, I use the rib cartilage I obtain from the patient. While we can almost always fulfill the entire need for graft with cartilage from the septum in primary rhinoplasty, ear or rib cartilage are needed most of the time in a revision rhinoplasty depending on the scope of the deformities.

Cartilage can be removed from the nose septum provided that a 1,5cm L shaped support is left behind in place. Cartilage from the septum is my first preference both because it exists in the operative field, and therefore, doesn’t require extra incisions and also because it is easily shaped, can create structural support, and maintain its shape. However, the remaining cartilage is often inadequate for revision rhinoplasty due to the frequent use of cartilage from the septum in the previous surgeries.

There may be incisions to the front or back of the ear when taking cartilage from the ear. The incisions are unobservable after healing since the incisions are made to correspond to the ear folds. No changes occur in the shape of the ear since cartilage from only the pit is removed. There is no interference with hearing. Grafts may be obtained from both ears depending on need. Ribcage cartilage is removed from the cartilage where the 7th rib unites with the chest bone. The rib cartilage is accessed via a 2-3cm incision and the required size of cartilage is removed.

Choice of Anesthesia

General or local anesthesia or intravenous sedation (no loss of consciousness) is applied in a revision rhinoplasty. Surgeries performed under 1-1.5 hrs. utilize local anesthesia or intravenous sedation. My preference is general anesthesia both in terms of the patient’s comfort and my ease of work.  Plus, general anesthesia has become much safer with the increase of experienced anesthesia specialists and the advancements in anesthesia equipment.

Is it a painful process?

There may be mild to moderate pain postoperative revision rhinoplasty. These pains can easily go away with painkillers.

How long does a revision rhinoplasty operation take?

The operation takes between 1-4 hrs. depending on the shape of the nose, the actions required, and the approach utilized. This period may be delayed if grafts are to be obtained from the ear or the rib. Minor revisions usually take 30-60 minutes.

What are the risks in a revision rhinoplasty?

Revision rhinoplasty is riskier than a primary rhinoplasty. Occurrence of scar tissue, dislocation of grafts, insufficiency, delayed swelling are more frequent.

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