Whether a rite of passage among teens, an antidote to aging, or something in between, when it comes to facial aesthetic surgery, rhinoplasties—which can improve the nose aesthetically and functionally so a person can breathe more easily—are very popular, reliably landing among the most-requested procedures. Last year, for instance, nose jobs were the third most common cosmetic procedure, with more than 44,000 performed, according to the American Society of Plastic Surgeons.
Unfortunately, when it comes to revision surgery, rhinoplasty is also very common, with studies showing that up to 15% of rhinoplasty patients seek a second surgery due to breathing difficulties or cosmetic issues.
Such a high revision rate isn’t surprising, when you consider that rhinoplasty is widely regarded as the most challenging of all plastic surgery procedures. Even in the best of hands and using precise surgical technique, problems can occur. Chalk it up, at least in part, to the complicated anatomy of the nose (it’s the only part of the body that has three tissue structures—skin, cartilage, and bone—encompassed in one) and the vagaries of healing.
“Noses are incredibly difficult, mainly because they’re very unforgiving of minor irregularities,” explains Dr. Dara Liotta, a double board-certified facial plastic surgeon in New York City. “Millimeters matter in a way that they may not in other parts of the body.” Add to this the fact that the nose is not just for decoration. “At the end of surgery, noses need to breathe and be structurally sound, not just look pretty,” says Dr. Liotta, who performs up to 15 rhinoplasties a week, half of which are revisions of someone else’s work.
Revision rhinoplasty: a second chance to get it right
If primary (or first-time) rhinoplasty is a hard surgery to get right, revision rhinoplasty is even more difficult—it has a higher revision rate than primary rhinoplasty. “A revision rhinoplasty is always going to be considered more challenging, even if it may seem like a ‘small refinement’ to a patient,” says Dr. Sarmela Sunder, a board-certified facial plastic surgeon and rhinoplasty specialist in Beverly Hills, California. “There is extensive scar tissue after the first rhinoplasty, and the skin of the nose doesn’t have the same robust blood supply after a previous rhinoplasty.” Weakened internal structures can also make working inside the nose more complicated. The upshot: “There are no guarantees with revision rhinoplasty,” says Dr. Liotta. “The ultimate potential for improvement depends on what we’ve been left with after the first surgery.”
Despite the risk of further dissatisfaction, rhinoplasty patients with imperfect surgical outcomes are often motivated to seek a revision to fix a range of issues, from minor irregularities to obvious deformities that are telltale signs of a “done” nose. Be aware, however, that not all imperfections after primary rhinoplasty are improvable with more surgery. “Some issues can get worse,” warns Dr. Liotta, and consulting a board-certified surgeon who’s experienced in secondary surgery is key to knowing what’s fixable and what’s not and getting it done right—”because each time you do a revision, it becomes more and more challenging,” says Dr. Sunder.
Luckily, these six common concerns are correctable with revision surgery. Bear in mind that every nose is unique and there are many reasons various issues occur. As a result, “there’s no cookie-cutter answer,” says Dr. Sunder. “You have to address it to the situation.”
6 most common issues in revision rhinoplasty cases
1. What’s wrong: Breathing difficulties, which can develop after a rhinoplasty, whether or not someone had breathing problems to begin with.
What caused it: If someone had breathing problems prior to surgery, it could have been multifactorial—for instance, deviation of the septum, the thin wall of cartilage and bone that separates the inside of your nose into right and left halves, or collapse of an external and/or internal airway valve—and only one of the causes was addressed during surgery, explains Dr. Sunder. Another possibility is that in trying to achieve optimum aesthetic results, function was compromised—for example, because too much cartilage was removed to narrow a nose, the lack of nasal support makes it difficult for air to flow through your nostrils. “The nose is such an intricate structure, where one millimeter [mm] can make a massive difference in terms of functionality and breathing,” says Dr. Sunder. “All it requires is a tiny shift.”
Solution: In the best-case scenario, patience is a great healer. “A little swelling on the inside of the nose can create significant congestion,” says Dr. Sunder. “So for a lot of people who have difficulty breathing after surgery, it can improve over time.”
This is why surgeons advise waiting at least a year before undergoing revision surgery, to give the soft-tissue structures of the nose time to heal and settle. “Improvements in nose contour occur gradually because the soft tissues remain swollen longer than soft tissue in other parts of your body,” says Dr. Sunder.
If problems persist, then surgical interventions can be explored. For instance, to correct an overoperated area of the nose, a surgeon can regraft cartilage, often taken from another part of your body, like your ear or rib, as reinforcement to keep the nostrils from collapsing. Similarly, grafts can be used to widen your nasal valves to ease breathing.
2. What’s wrong: A hanging columella, the bridge of tissue that separates the nostrils at the bottom of your nose. Ideally, the columella is positioned so that at most 4 mm of nostril is seen on profile view. A nose is said to have increased “columella show” when more than 4 mm of the nostril is visible.
What caused it: This rounding-down of the columella is most commonly caused by not properly supporting the nasal tip cartilage during surgery. Columellar struts, which are implanted during surgery to support the nose tip, can also be too long, causing a disproportionate protruding of the new nasal tip that affects the look of the columella. Another possibility: if someone naturally has a disproportionately long septum, the cartilage underneath the columella may not have been shortened (or sufficiently shortened) during surgery.
Solution: “This is something I see in virtually every revision rhinoplasty, and it can often be fixed quite easily by simply cutting back that cartilage a few millimeters,” says Dr. Ronald Edelson, a board-certified plastic surgeon in San Diego. Other fixes include trimming the end of an overly long nasal septum or moving the two nasal tip cartilages that sit within the columella upward and stitch to the septum.
3. What’s wrong: An inverted V deformity, a shadow across the bridge of the nose that’s shaped like an upside-down V.
What caused it: A classic post-rhinoplasty cosmetic complication, it results from primary surgery where a dorsal hump (a bump on the bridge of the nose) is removed and the nasal bones are broken to narrow the nose, but the cartilage structures of the nose aren’t properly supported—so the middle portion of the bridge becomes pinched. “Visually, it creates an unflattering shadow,” says Dr. Liotta. “Functionally, it can also cause breathing problems.”
Solution: The way to fix this is to reconstruct the area from the inside using cartilage grafts (aka spreader grafts), which are matchstick-shaped pieces of cartilage that push the nasal cartilage outward, to smooth the surface transition between the bone and the cartilage so that the shadow disappears.
4. What’s wrong: A pollybeak deformity is excessive fullness in the area above the nasal tip (the supratip, in medical speak) on profile view. This causes the nose to be beak-shaped in appearance (like that of a parrot), hence the name.
What caused it: The pollybeak can come from not taking off enough cartilage above the nasal tip, taking too much bone from the top of the bridge of the nose (where the nose starts), or not properly supporting the tip of the nose so that it drops relative to the bridge, Dr. Liotta explains. Solution: “The fix depends upon the cause, the condition of the cartilage in the area, the surgical maneuvers that were previously performed, what material is left to work with, skin thickness, and the amount and tension ofq scar tissue that’s formed after the primary rhinoplasty,” says Dr. Liotta. An exam is important in determining the cause and key to developing a good treatment plan.
5. What’s wrong: An over-rotated nasal tip is a tip that’s turned too far upward, making the nose appear short and allowing you to see too far up the nostrils.
What caused it: The over-rotated nose (aka the “piggy nose”) can be caused intentionally by a misguided aesthetic choice or by removing too much structure inside the nose, says Dr. Liotta.
Solution: In a nose that looks slightly turned up, dermal filler injections into the bridge (known as a nonsurgical rhinoplasty) can soften the appearance and create the illusion of a more proportionate nose. More severe cases will generally require a surgical correction, including cartilage grafts to lengthen the nose and restore the position and rotation of the nasal tip.
6. What’s wrong: Asymmetry of the nose
What caused it: There’s a host of reasons a nose can appear crooked after surgery, from too much cartilage being resected on one side to issues with healing and scar contracture. “As the tissue contracts over time, if it pulls in one direction more than the other, that could cause asymmetry,” says Dr. Sunder. Sometimes solving one problem (removing a bump) creates another problem (exposing the underlying crookedness of a nose).
Solution: In the right candidate, a liquid rhinoplasty can make the nose appear straighter. If need be, it can also even out irregularities along the bridge of the nose, raise the nasal bridge, or camouflage a dorsal hump on the profile view. Just be sure to seek out a board-certified injector with experience, advises Dr. Liotta, because there is a learning curve.
Likewise, if you go the surgical route to revise a crooked nose, be aware that it often involves advanced techniques—including osteotomies, or surgical cutting of the nasal bones, to straighten them and spreader grafts, to create cosmetic balance. So be sure to choose your surgeon very wisely based on extensive experience, says Dr. William Portuese, a double board-certified facial plastic surgeon and rhinoplasty specialist in Seattle. He notes that “revision rhinoplasty for a crooked nose can be one of the most difficult procedures to perform correctly in the entire field of cosmetic surgery.”
