What is a revision rhinoplasty?

Revision rhinoplasty addresses an instance when a nose has not healed properly from the original surgery or maintains residual deformities.  Typically revision rhinoplasty requires cartilage to be harvested from the nasal septum and ear.  These grafts are then utilized to reconstruct the defect that could be causing breathing difficulty and/or a visual cosmetic problem. 

Due to the unpredictability of secondary contraction of scar tissue and healing, the complexity of revision rhinoplasty is greater than the initial rhinoplasty and is still considered cosmetic by nature.

A revision rhinoplasty refers to a procedure done to correct a deformity or breathing problem resulting from a previous rhinoplasty surgery. In general, revision rhinoplasty is reported to occur at a rate of about 5%-18%. It is important to remember that problems leading to revision surgery can result in any patient and any surgeon - regardless of experience or training.

Although the deformities for which patients seek revision may occur in any patient and with any surgeon, the risk or rate of needing revision rhinoplasty is certainly noted to be higher in the hands of inexperienced surgeons.

In medical literature, the reasons for a patient seeking revision rhinoplasty are given as the following:

1. Poor surgical technique - clear inexperience resulting in improperly done surgery. In my practice, many of these types of revisions come from outside of the country, with the majority being done in Mexico or South America (a warning against medical tourism). Although, I have treated several patients who have had surgery in Beverly Hills and surrounding areas. Generally, a major revision needs to be done in this setting involving grafting (movement of cartilage from other areas to strangthen or replace tissues weakened by the first surgery). Many of these changes are covered up by swelling during the initial months, but eventually as the healing process continues, and swelling reduces - deformities that may have gone unnoticed initially begin to appear.

2. Poor surgical planning or judgment - This can result from inexperience, being rushed, surgical complications or variations such as bleeding, or excessive swelling during the surgery, and may not always be as dramatic as those above. In general, a little too much bone, or cartilage left in the bridge, or under-narrowing of the tip.

3. Airway problems - these may be problems that result from the structural changes in the nose as a result of cosmetic surgery, or airway problems that were left untreated during the first operation. The classic airway problem resulting from rhinoplasty is collapse or narrowing of the lower third of the bridge. This results in a narrowing of the area called the "nasal valve". Generally, this complication can be avoided by steps taken to maintain an appropriate amount of width and strength in the cartilages responsible for holding the nose open during inspiration.

4. Pursuit of perfection - these are the cases to which some of the surgeons on this site have alluded that we all see for consultation, but cannot find anything worth undergoing surgery to correct. There are a subset of people who, after a rhinoplasty with "acceptable" results, or in some people's eyes good results, will look for perfection. In my practice, we urge patients to seek my care for improvements such as these, and consequently we have come up with many less invasive and less expensive ways to improve upon good results that the patient perceives as imperfect. The truth is that it is hard to find a perfect result anywhere, and what we consider perfect may not necessarily be the right nose on a given patient's face. Although consultations held with patients unhappy with a seemingly good result are difficult, I would urge you to avoid a revision operation in which a surgeon is too eager to jump into surgery - especially if other experienced revision rhinoplasty specialists have advised against it. The push for better results may lead you down the road to worse.

Athough detailed classification of postoperative deformities have been published in the past, the truth is that all patients are different, all previously operated noses are different, and all will need a combination of different reconstructive techniques to improve upon their results.

When choosing a surgeon for a revision rhinoplasty, the important topics are your trust for the surgeon, the surgeon's experience with revision surgery and, most importantly, the setting of realistic goals for both the patient and the surgeon.

A revision rhinoplasty is when a surgeon performs a rhinoplasty (nose job) on a patient who has already had one or more rhinoplasty procedures performed on him/her in the past.

Often times, a revision rhinoplasty is performed to improve the external shape of the nose and/or to improve the inside of the nose to allow the patient to breathe better.

Revision rhinoplasty is the term that usually covers any kind of secondary correction procedure on a patient who had a rhinoplasty before. The patient might have had a procedure a year ago or twenty years ago.

Revision rhinoplasty is usually more complex that primary rhinoplasty, sometimes significantly more complex, and should only be performed by the surgeons with adequate experience and credentials. Many times we have to deal with severe scarring from previous surgery, collapse of the tissues inside and outside, missing cartilage pieces. We have to restore the functional airway for the patient as well as achieve the perfect cosmetic result. It is one of the most challenging and rewarding procedures in facial plastic surgery.

Revision Rhinoplasty refers to any Rhinoplasty that is done in order to revise or improve upon a previous Rhinoplasty surgery. It is also sometimes called Secondary Rhinoplasty. These revision procedures are done to correct cosmetic deficiencies and/or breathing concerns that arose from (or at least weren't addressed by) the previous surgery.

People undergoing a Revision Rhinoplasty may have had one previous nasal procedure or five! Now, you're probably asking yourself, why in the world would someone need to have 3 or 4 or 5 surgeries on his or her nose? Well, the answer is that Rhinoplasty is arguably the most difficult and most unforgiving procedure of any elective surgery. Rhinoplasty novices and experts alike share this view. This has to do with the technical challenges of the procedure and sometimes the vagaries of healing. After all, we are trying to make very specific alterations to a very complex anatomical structure that has a very distinctive surface appearance, all while enhancing its breathing function. Whereas surgery in other areas is a game of inches, Rhinoplasty is a game of millimeters. And, it's no game. Every step in Rhinoplasty depends on and affects the step before and after, and influences the final outcome.

The reported revision rate for Rhinoplasty is about 8 to 15%. You might think that seems rather high. The truth is, it is probably even higher than that. Why is that the case? Because you can do most anything to a nose and it may look good for a while after surgery. Rhinoplasty problems begin to crop up after many months or even years after surgery. This is because the nasal skin 'shrink wraps' down onto the new structure underneath over many long months to reveal the final result. This constant contraction of the skin will expose irregularities in the anatomy and will eventually cause collapse of the nose if it is not well supported. So, we have to plan alterations during surgery not based on how your nose looks at the moment in the operating room, but on how we think it will heal down the road. And that's no easy task.

So, why do some surgeons seem to continue to do 'bad noses'? Well, they probably think that they are doing good work. They simply may not be seeing their patients for long enough to see some of the problems. And patients 'vote with their feet'. If we save up to go to a great restaurant and encounter a lousy meal, most of us probably wouldn't give the chef another chance. Our trust is eroded. The same is true of Rhinoplasty, though it's not like getting over a bad meal. The sour taste stays with you forever. So, rather than confront their surgeons, many patients move on to someone they hope will fix the problem. And the original surgeon never gets better.

The result is that a select few surgeons in every region of the country become the Rhinoplasty Revision experts... which brings me to my last point. If you are facing a Rhinoplasty Revision, you should make every effort to see one of these experts. If you're going skydiving, it would be nice to know that the person who packed your parachute wasn't doing it for the first time. Rhinoplasty is hard enough to begin with, but revisions are even more so. They may require complex grafting and other procedures that are a topic for another article. The emotional and financial toll of a revision is high enough. Don't take more chances with your most prominent facial feature.