Revision Rhino Advise - How to select the right surgeon when their opinions contradict each other? (photos)

Question

In need of revision rhinoplasty after a 2016 surgery gone wrong, I'm deciding between 2 skilled surgeons. The first, with 25+ years of experience, proposes an open approach, emphasizing 95% success chance, the need for spreader grafts, and also claims closed is a bad approach. The second, with 35+ years of experience, suggests that the closed approach will work fine, assuring improvement w/o grafts. Both received many positive patient reviews that I personally contacted too. Who to pick?

Eric M. Joseph, MD · Answer

We would only offer an open approach to perform your surgery. Revision rhinoplasty is exponentially more difficult than primary rhinoplasty surgery so in our opinion, having a wide exposure of your underlying nasal skeleton is important for achieving a desired result. I hope this helps! And I wish you good luck. Sincerely, Dr Joseph

Gianfranco Frojo, MD · Answer

Regardless of the approach utilized, your surgeon needs to be very comfortable with using either one. That is far more important than the type of approach utilized...a surgeon skilled utilizing the selected approach for your nose is the key!

Stephen Prendiville, MD · Answer

It sounds as if you have two very qualified and experienced Surgeons.  So, which approach is the best?  The one that works best for that particular Surgeon.  Personally, I prefer an open approach for a revision Rhinoplasty and many primary rhinoplasties.  However, many well trained experienced Surgeons like the closed approach.  
However, analyzing your photos, you have a significant dorsal hump and a ptotic tip that will require extensive work.  Spreader grafts are certainly not out of the question, as would be a caudal septal extension graft (CSEG) to assist in tip elevation.

William Portuese, MD · Answer

Open versus Closed Rhinoplasty is only about the approach on how you get into the nose, not the maneuvers that are performed inside of the nose itself. You have a residual dorsal hump, which needs to be shaved down, a droopy and wide nasal tip and an inverted upper lateral cartilage on your left side, which will definitely require a spreader graft. It's important to know if there's any cartilage left over on the inside of your nose for grafting purposes. If not, a Cartilage graft, may be needed to be harvested from your ear. Osteotomies also be required to close the open roof, which occurs when the hump removal takes place. For over 30 years, we have only performed closed rhinoplasty.

Mats Hagstrom, MD (license on probation) · Answer

Selecting the right plastic surgeon is not easy. I always recommend patients have multiple in person consultations before choosing a surgeon. Sometimes people need to have more than two consultations to find the ideal provider. The general idea is to schedule as many consultations as possible because you’re never know who is going to have, the greatest insight, skill and experience, which is difficult to tell without meeting people in person.
Using the Internet is inherently limited. Some extremely talented providers have minimal Internet presence, and this can cause people to overlook some superstar providers who don’t focus on self promotion. 
For complex procedures, I generally encourage people to start the process by having at least five in person consultations. Sometimes people are lucky and find the right provider quickly. You know firsthand the cost of not putting enough effort in vetting providers.
During each consultation asked each provider to open up their entire portfolio of previous patients who had similar nasal characteristics to your own. I highly experienced plastic surgeon should have no difficulty showing you the before and after pictures of at least 50 previous patients. They may not have that many pictures of patients having revision surgery that have the same problems that you do. You want to see evidence that the surgeon has done the same procedure, or some version of it many times previously. 25 years doesn’t mean much if the provider doesn’t specialize in rhinoplasty surgery. Try to find providers who focus exclusively on rhinoplasty surgery, or have a very strong emphasis on nasal surgery in their practice.
Look at the percentage of before, and after pictures on their website that represent rhinoplasty surgery versus other procedures.
Haily Experian surgeon should in fact have hundreds or preferably thousands of before and after pictures to choose from. In the hands of the ideal provider, the collection of before, and after pictures should seem like a telephone book.
Quality plastic surgeons should be detailed oriented and spend a sufficient amount of time during the consultation. Ask each provider what the revision rate is, but the most common revision operation is and what the revision policy is.Open versus closed. Rhinoplasty is a personal decision, and often is based on what plastic surgeons were taught during their residency, and how they evolved their practice. Generally, speaking, and open rhinoplasty has slightly higher success rates, but has potential drawbacks regarding scarring and numbness of the nasal tip.
Older plastic surgeon may favor, close rhinoplasty, while younger plastic surgeons may favor open rhinoplasty. In the end, it’s not that important in comparison to the ability to do the procedure well. Having direct direct visual access is always desirable, so I am slight favor of open, rhinoplasty surgery for complex procedures, such as yours.
When in doubt, slow down and schedule more consultations. It’s also not wrong to follow up and have a follow up consultation with somebody you’ve previously consulted with.
We all understand there is significant anxiety with revision surgery. You probably already have this information but it’s very important when you have consultations to come prepared bringing with you a complete set of proper before and after pictures from the first operation and a copy of your operative report. If you don’t have those, then contact your original surgeon and have them forward the entire medical records.
In the end, you’re the one who has to make the decision.
May be having a few more consultations first will help you hone in on the right provider.
Generally speaking, I always recommend in person, consultations and recommend people avoid virtual consultations whenever possible. I generally do not recommend traveling long distances for elective surgical procedures unless you’re willing to travel for the consultation and stay for appropriate postoperative care.
Sometimes traveling for specialty procedures is indicated, but generally speaking, it’s always better to be close to home.
Best,
Mats Hagstrom, MD

Revision Rhino Advise - How to select the right surgeon when their opinions contradict each other? (photos)

Answers (5)

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