Will Getting Rhinoplasty for the Third Time Be Possible?

Question

I had Rhinoplasty done twice by the same doctor back to back and it's been 2-3 years. Both times, during the healing process, my nose started to come out crooked and uneven. All I want is for my nose to be straight and look even from both sides.

	I'm worried that if I get it done the third time it will look over done or that my nose will fall off. What procedure will the doctor perform to make it straight? Is this procedure difficult? Can you recommend a good surgeon in NYC and FL?

Oakley Smith, MD, FRCSC · Answer

Each time a nose is operated on, it becomes more difficult. And therefore the success decreases and the goals of surgery are lowered. The first time is the best time. That isn't to say revision surgery can't be successful. Its just more difficult and takes longer. This is reflected in the cost. A primary nose job usually takes between 1 to 2 hours, while a revision takes between 2 and 5 hours. There are outliers, minor 'touch ups' or complete complex nasal reconstructions using multiple ear, rib or skull grafts.

	I have recently set a new personal record of sorts. I operated on a young lady for the eighth time! She had, over the years, had 7 surgeries of one description or another by the same surgeon. I wouldn't recommend this. If a surgeon can't achieve mutually agreed upon goals after 2 surgeries, it time to move on or up. Will your nose fall off? No. Will your nose be straight? Maybe. And you increase your chances by taking the time to find the best, most experienced rhinoplasty surgeon you can find.

Jacob Sedgh, MD · Answer

Getting a crooked nose totally straight is considered one of the more challenging tasks of a rhinoplasty. However if the deviation is significant it is not unreasonable to consider a third time revision with an experienced revision rhinoplasty surgeon. In such cases, usually application of rib cartilage graft is favored due to it’s stiffness to counteract the previously stubborn and unfavorable deviations. Obviously, this can only be evaluated with a thorough internal and external examination of the nose and on a case-by-case basis.

Sam Rizk, MD · Answer

Yes, it is possible for a patient to seek a second revision rhinoplasty should the first two nose jobs not be up to par with his or her expectations. I highly recommend that you wait at least one year after your original revision rhinoplasty to consider this third surgery. If you are still unhappy with the results of your previous nose jobs, you may want to re-visit the same surgeon who performed your initial revision rhinoplasty, or you may want to find a new surgeon altogether. At this point, however, it is important to understand that with each additional surgery comes the possibility of increased complications and unnatural results.

Rod J. Rohrich, MD · Answer

Having a rhinoplasty the second or third time is very complicated and one has to look seriously at this because one can only have so many rhinoplasties before needing significant nasal reconstruction. I would definitely seek a Board Certified Plastic Surgeon that has significant expertise and experience in secondary and tertiary rhinoplasty procedures because these are completely different operative procedures that require additional experience and judgment.

Raffy Karamanoukian, MD, FACS · Answer

You may need revision rhinoplasty that addresses the bony and cartilaginous septum of the nose.  Simple cartilaginous tip work will not correct the problem.

Sam Naficy, MD, FACS · Answer

Your nose could be asymmetric for a number of reasons:

Your septum is deviated 
Your nasal bones are deviated
Your nasal cartilages have inherent asymmetry
You have facial asymmetry

Stephen Prendiville, MD · Answer

Generally speaking, a tertiary revision is possible but more information is needed to determine this. The specifics of what needs to be done depends partially on what was done on the first and second attempt, presence or absence of a septal perforation, and history of nasal substance use.  I agree with previous posts which state that your nose can be made more straight, but may not be perfect. More than likely, an open rhinoplasty approach will be required, the nasal bones will need to b broken (osteotomies), and spreader grafts will be necessary to help make your nose more straight.  In addition, some elements of the left to right direction of your nose may be related to asymmetry of your facial bones (maxilla).
Choose an experienced, well qualified Facial Plastic Surgeon with a good local reputation for this pocedure.

David C. Pearson, MD · Answer

Revision rhinoplasty is always complex. Straightening a crooked nose is also difficult. There are, however, techniques for improving the appearance of a crooked or twisted nose: spreaders, clocking sutures, osteotomies, and camouflage grafts are just a few of the options I'll bring to bear on the twisted nose. I prefer an open approach for these case, as would most of my colleagues, in all likelihood.
 
Keep in mind that a perfectly straight nose is unrealistic. As a colleague of mine likes to say, these are "-ER" cases...better (not best), straighter (not straight).
 
And while it's true that risk increases with each revision, a third operation is often possible if a patient is otherwise healthy and has appropriate expectations and motivations. If you go to a consultation for a revision, be sure to bring the operative notes from the previous surgeries and even a copy of the pre-op photos, too. Every bit of information about the prior state of the nose and what's been done can be helpful.
 
--DCP

Barry M. Weintraub, MD, FACS · Answer

Revision rhinoplasty requires a significant level of precision and skill, as well as decades of experience in the hands of a specialized board certified plastic surgeon who regularly performs revision rhinoplasty.  In my practice, I often have patients who visit me in my NYC office displeased with their results from other offices.  Some are excellent candidates, requiring secondary, tertiary and even quaternary revision. For other patients, the risk/reward ratio is not worth it.  It is extremely important to recognize when a further surgery might do more damage than good, and I do not hesitate to inform patients of this, since it is in their best interests.  In summary, whether a revision rhinoplasty is possible is determined on a case-by-case basis.

Julian De Silva, MD · Answer

A third rhinoplasty can be done. However,
multiple rhinoplasties increase the complexity of the surgery. The risk of scar
tissue, the possibility of excessive removal cartilage and bone tissue, the
chance of improper healing–all these increase with each subsequent surgery. It
is best consult with a surgeon who is specializes in rhinoplasty and has a
great deal of experience with revision procedures. Before you decide on another
surgery, you should speak realistically about your expectations.