Is risk of necrosis too high with the scar tissue in my nose tip? (photo)

Question

I recently had my consultation and was told rhinoplasty was too risky due to the scar tissue in the tip of my nose causing not enough bloodflow post op and leading to necrosis. Will all surgeons feel this way? It was very disappointing news considering I have a large dorsal hump and a crooked nose, all of which I'd like fixed.

Steven M. Denenberg, MD · Answer

Usually, if there's scar tissue in the tip, that means there's been previous surgery. Did you already have a rhinoplasty?Carving excess scar tissue out of the tip isn't something that should cause necrosis, unless it's done too aggressively. How good of a candidate you are for revision (or a primary) depends so much on what your nose looks like now. Photos would sure help. Photos would allow for morphs.
In fact, I'd love for you to see some excellent professionally-designed morphs of what could possibly be done with your nose. Morphs could also help you identify what's bothering you, and help you set a goal for the rhinoplasty that's accurate for your tastes.  (Side note: in my opinion, morphs should always be done by the surgeon, or he should direct an assistant as she makes the morphs. Morphs should be made with a constant eye to what actually *can* be done in surgery, for that particular nose, and only the surgeon has that information and judgment. Another aside: I also recommend that you not show morphs made by one surgeon to a different surgeon. If a surgeon makes his *own* morphs, you get to see whether he understands the important issues of your nose, and how your nose should be changed. But if you show the surgeon someone else's morphs, and he says "Of course I can make your nose look like that," then you don't really know if he fully understands, or even recognizes, the important changes shown in those morphs. And you don't know if he can make those changes during surgery.)
Remember also that rhinoplasty is an exquisitely difficult operation to get right, and you should only have surgery if you are able to make yourself very confident in your surgeon's skills. The changes that a revision nose needs require advanced techniques, and skill that most plastic surgeons don't possess with expertise. For most noses, it's much better to not have surgery than to have inexpertly-performed surgery. Read my essay on how to stay out of trouble while selecting a rhinoplasty surgeon. And for those who have had previous surgery, it also discusses how to tell whether your first surgeon should be performing your revision. And it also discusses how to take photos that are best for online evaluations.
Your nose is also a perfect example of why computer imaging is mandatory in rhinoplasty. You need to know exactly what the surgeon is planning to accomplish -- what features he thinks he can change, and by how much he thinks he can change them. I always email morphs to my online rhinoplasty consultations. When you see the surgeon's goals in the morphs, you'll know whether he has an eye for an attractive nose, and whether he shares your opinion of what constitutes an attractive nose. You'll also know whether the changes he proposes are large enough to be meaningful to you, and whether he understands your wishes enough to address all of your priorities. How would you ever get that figured out without the morphs?

Andrew Miller, MD · Answer

In the hands of a rhinoplasty specialist, skin necrosis is extremely rare. We have performed revision rhinoplasty on many patients who had multiple rhinoplasty surgeries previously with no issues like that. While an exam is necessary to know for sure, you should be able to have your bump taken down and your nose made straighter.

Ronald J. Edelson, MD · Answer

Unless you had multiple previous rhinoplasty I don’t see the risk of skin necrosis being an issue. Perhaps the surgeon you sent to doesn’t do many noses. Get a few other opinions.

Eric M. Joseph, MD · Answer

I don't think scar tissue in the nose is a risk factor for necrosis, or dead skin after revision rhinoplasty. We have offered tertiary revision rhinoplasty surgery many times, and necrosis has not been a problem. After four surgeries, blood flow may be compromised, but the nose is a most vascular organ. Consider getting another opinion from another rhinoplasty specialist. Hope this helps! Dr Joseph

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. I am not sure why you were told this. When good technique is used, the risk of necrosis is truly minimal. Based on your photograph, you may benefit from a tip refining rhinoplasty which can be performed by trimming, suturing, and reshaping the cartilage in your lower nose. You may also benefit from a spreader grafts to help straighten your nose and a dorsal hump reduction. Make sure you specifically look at before and after pictures of real patients who have had this surgery performed by your surgeon and not just a computer animation system. You should be able to view numerous pictures of actual patients with noses similar to yours performed by your surgeon. If you cannot find enough real before and after pictures, then consider continuing your search for a surgeon.Best wishes and good luck.

Richard G. Reish, M.D. FACS

Harvard-trained plastic surgeon

Richard G. Reish, M.D. FACS

Harvard-trained plastic surgeon

Daniel Zeichner, MD · Answer

From your limited photograph, the previous scar appears limited to the nasal tip. The longer the period of time between your previous injury and your anticipated surgery, the better. Complete revascularization of the area may take a year or more. If the blood supply is marginal, it should be clinically apparent. The correction of a crooked nose and / or dorsal hump does not involve dissection of the tip and should not be at increased risk. The risk of tip plasty will be slightly higher but not prohibitive if performed conservatively. 
Seek a second opinion from a board certified plastic surgeon.

Jay Calvert, MD, FACS · Answer

The skin in rhinoplasty is always a major consideration because it is what shows the result of the operation.  The photo you have presented doesn't show any hints of impending problems, but that doesn't mean you cannot have any.  A good discussion with your surgeon is definitely in order!

William Portuese, MD · Answer

Much more information is needed, such as whether or not you've had any previous rhinoplasty surgery, and how many. If you have, it's best to get copies of the operative reports to show your next surgeon. A closed rhinoplasty approach is less invasive and would be extremely rare to have any necrosis of the nasal tip

Alexander Ovchinsky, MD · Answer

The risk of skin necrosis in well performed rhinoplasty is very low, even in revision surgeries.   Unless there is something we are not aware of in your past medical or surgical history, I am not sure why you were advised to avoid the surgery. Maybe you should consider a second opinion to put your mind at ease.

Michael Elam, MD (retired) · Answer

Dear Polite2646, An in office evaluation would be needed to determine your candidacy for rhinoplasty. Unsure what the scar tissue is from however many patients undergo revision rhinoplasty and have scar tissue and these procedures are performed quite often with no complications. It sounds like if you have a dorsal hump and crooked nose you should be a candidate for surgery. I would suggest seeking some secondary opinions. Best regards, Michael V. Elam, M.D.

Is risk of necrosis too high with the scar tissue in my nose tip? (photo)

Answers (11)

More Rhinoplasty Questions

WE SEND PRETTY
EMAILS

Answers (11)

More Rhinoplasty Questions

If a doctor writes on their website that they've never lost a patient or had an anesthesia complication can I trust them?

Can you make the nose more defined and chiseled by adding to the existing structure?

Morphs versus reality, how close is a doctor able to get to the morphs?

Is it possible to give more character to a nose by adding a small bump, for example? photo)

Is a micro-rhinoplasty right for me?

Is there a way to create a "chiseled" nasal tip with rhinoplasty? (Photo)

WE SEND PRETTY EMAILS

WE SEND PRETTY
EMAILS