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.

 

- The surgeon may have inadequate experience.

 

- The patient may have unrealistic expectations.

 

- The surgeon’s goals may be excessive.

 

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

 

- 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.

 

 

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.