Where does the problem usually go wrong in the first surgery? With computer imaging, I'd assume the doctor would be able to match the end result with the preoperative expectation before closing the patient up. Is it during the healing process where the aesthetic irregularities occur, or is it because the doctor made a mistake and decided to finish up before fixing it? Or do they not realize their mistake until after the surgery? Are the results difficult to predict for an alar wedge excision?
Reason for High Demand for Revision Rhinoplasty?
Doctor Answers 15
Computer Imaging is not perfect
Reason for rhinoplasty revision
The reason is combination of the technical challenges mentioned by others as well the prominent and central location of the nose in the middle of the face where even slight asymmetries and imperfections are noticed.
Reasons for Revision Rhinoplasty
There is probably no more challenging plastic surgery procedure than rhinoplasty. Even top surgeons will have some cases they do revisions on, especially if the surgeon is a perfectionist. This is mainly because of the difficulty in controlling how the skin heals over the underlying cartilages and bone that have been sculpted. It is so important to choose a surgeon who “gets” what you are seeking, as well as one who has extensive experience.
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High Demand for Revision Rhinoplasty
Rhinoplasty is the most common and most challenging cosmetic operation that is done. Some patients have undesirable results when they have their surgery done by inexperienced surgeons. However, revisions may be necessary because of the complex anatomy and unexpected scarring even when the opertion is done by the best. If you need a revision select a surgeon who specializes in this work. Unfortunately, revisions are common - over 2/3rds of the noses we do are revisions of rhinoplasties done by other surgeons before we see them.
Rhinoplasty, nasal surgery
Facial imaging for nose surgery especially cannot predict the results that a plastic surgeon can achieve. I can show incredible results with a computer which would never translate into what I could accomplish at surgery for it depends on the thickness of the skin covering the underlying structures-cartilage, bone as well as the structures themselves.
Predicting the results from alar wedge excision though is much easier and realistic. Watch my videos.
Reasons for high demand for revision rhinoplasty.
Although there always can be errors of commission (too much removed, not enough removed, malposition of structural parts, etc.) these actually are usually relatively uncommon. Careful pre-operative planning (with or without computer video imaging, which is a "tool," not a guarantee of a specific post-operative result) in conjunction with back-and-forth discussion with the prospective patient allows the surgeon to have a detailed plan as to "what and how much" in each of the individual steps in a rhinoplasty procedure will be carried out. An experienced rhinoplasty surgeon knows the procedural steps and the surgical manipulations possible in any nose surgery--how and to what extent each of these detailed intricate surgical maneuvers is carried out is the art and science of the procedure. It does take at least 100-200 noses and a decade or more experience to really become facile at this operation, IMHO.
And then there's the part that each surgeon cannot control--patient genetics, scar formation (amount, location, and degree of contraction and/or potential distortion), swelling, bruising, healing, nerve regeneration, nausea and vomiting after anesthesia (causing more bleeding, bruising, swelling, and scar tissue), and all of the unique patient variables that neither the doctor nor the patient have any control over.
The last, but not least important, variable is patient compliance. You might not believe that a patient would spend thousands of dollars, undergo an anesthetic and operation, wear a splint, etc., miss work and social activities, and CHOOSE to violate their doctor's recommendations, but it happens much more than you think. Patients second-guess their surgeon's advice (this happens all the time; see the questions on this site!), decide they can disregard precautions, remove their splint prematurely, etc., etc. Truly, it's amazing and disheartening after the detail and precision we invest in our most complex cosmetic procedure and our cherished patients. But it DOES occur. Bad outcomes result, and patients are quick to "blame" their doctor!
Alar excision should be reserved for the extremely wide or asymmetric nostril; this can be done under local anesthesia, and need not be part of an initial rhinoplasty if there is any question about its being necessary. This is best discussed with your surgeon!
There should not be a high demand for revision rhinoplasty
Rhinoplasties are each unique. Each nose has different characteristics such as skin quality, cartilage quality and septal support. These can be manipulated in the operating room to give the desired result. Computer imaging is only a representation and should be used conservatively to help demonstrate the desired outcome. Each person will heal their wounds according to their own behavior and ability to heal.
Why is revision needed so often after rhinoplasty?
There is a great deal of anatomy and interaction between structural elements and soft tissue, all in a very small area. No surgeon would finish a procedure without thinking that there would be a good result, but sometimes trying to get a great result can lead to problems. Sometimes a nose can look perfect on the table and then there can be problems with healing.
The good news is that alar wedge resection can be done quite acurately.
Rhinoplasty is by far the most difficult cosmetic surgical procedure. Assuming that there are no miscommunications between patient and surgeon there are still numerous possible missteps in a pricedure that takes over 100 steps to do plus the factor of healing that is sometimes unpredictable. A famous rhinoplasty surgeon in New York City once said in jest, after having done over 12,000 (!) rhinoplasties that he would like to redo all !!! Of course, this is just to exemplify how intircate the procedure is. But having said all this a 5% revision rate is probably a reasonale one in any experienced hand.
Why is there high demand for revision rhinoplasty?
There are a few reasons that patient end up pursuing revision rhinoplasty:
- Lack of communication between the surgeon and patient. This relates to the use of computer imaging. I always tell patients that the morphed images are not like an architectural blueprint where I can guarantee the end result will be identical. It does form a great baseline from which the surgeon and patient can formulate what areas they want to change and by roughly how much. It's important to make sure that the patient's expectations are realistic.
- Uncontrollable healing variances. The forces of scar contracture on the nose can create unwanted asymmetries, cartilage buckling, etc. One approach to rhinoplasty (which I follow) involves focusing on making sure the structural support of the nose is able to withstand these forces. Otherwise, one will often find that years down the road unwanted pinching, collapse, or functional problems may ensue. Even in the best of hands, variability will occur. No surgeon has a 0% revision rate.
- Lack of rhinoplasty experience/misjudgment. Having extensive experience in performing rhinoplasty allows a surgeon to better guage how a particular nose will heal and how the changes made to the nasal structure will translate to the final result. I also feel that many less than desireable rhinoplasty outcomes are due to a incomplete treatment of the patient's nasal problems. I most commonly see this regarding the nasal tip - which is much more complex than the bridge to treat well.