The Second Time Around

Revision rhinoplasty is considered one of the most complicated of all facial plastic surgery procedures because the nasal structure may have lost some of its original anatomical characteristics and their tends to be an accumulation of scar tissue. It has also become increasingly common. A recent study by the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS) reported that secondary surgery including revision rhinoplasty accounts for approximately one fourth or up to 27 percent of all surgical procedures performed. In my practice, that percentage is considerably higher.

The reasons for dissatisfaction with rhinoplasty procedures vary, and may include cosmetic and functional issues. For some, it is either a new or an under-or over-corrected cosmetic issue. The nose may look unnatural or ‘done’, too small, or the nasal tip may have taken on a pointy, over resected or twisted appearance. For others, there is a new, remaining or worsening functional concern that affects nasal breathing.  In other cases, the nose may be picture perfect and technically well corrected, but is not in balance with other facial features.

The extent of the revision rhinoplasty performed is based upon the individual patient’s aesthetic or functional concerns. Some revisions are simple fixes that can be done fairly soon after the initial surgery, and often by the same surgeon. In general, however, it is advisable to wait at least one year before undergoing revision rhinoplasty as it can take this long for all of the swelling to fully abate and the nasal shape to settle down.

It is important to choose a surgeon who has a high level of experience in secondary rhinoplasty. Revision rhinoplasty is a small specialty within a specialty. To do it well requires extensive expertise and indepth knowledge of nasal anatomy. It also is attached to a lofty set of goals, including improving upon the results of previous surgery, preventing additional complications from arising, and/or restoring the functional airways.

Every revision rhinoplasty operation is unique. I never do the same exact procedure twice to any nose I operate on. There are two main approaches to revision rhinoplasty—endonasal (closed) or open rhinoplasty (external). The first step is a thorough examination and a frank discussion about aesthetic and the patient’s functional goals and expectations. Considerations also include thickness of the skin, nasal bones, previous incisions, and internal structures.  Based on these findings, it may be necessary to rebuild collapsed areas with grafting techniques.  Cartilage sources may include septum, ear, or banked rib cartilage. In some cases, nasal implants are needed. Other procedures may involve smoothing out sharp edges of cartilage grafts. There is no one-sized fist all revision rhinoplasty surgical plan.

Revision rhinoplasty can take longer and cost more than primary surgery. I use a 3D High Definition technology and powered micro-instruments in all of my revision rhinoplasty procedures to achieve precise, natural-looking nose. This method also reduces bruising and shortens recovery time. It iscrucial to work under the muscles because preserving the soft tissue envelope of the nose helps avoid irregularities, asymmetries, and helps to maintain the soft and natural appearance of the nose. With these techniques and tools, revision surgery can be extremely successful and restore balance to the face.

About The Author

Sam Rizk, M.D., FACS is double board-certified in facial plastic surgery and otolaryngology in New York City.