Revision Rhinoplasty

Overview

What is revision rhinoplasty?

Rhinoplasty, also known as nose job or nasal reconstruction, is a plastic surgical operation used to reshape and reconstruct the nose.

For a variety of reasons, most plastic surgeons think that rhinoplasty is one of the most complex cosmetic (aesthetic) plastic surgery operations.

The nose is a complicated structure that sits prominently in the center of one's face.
Expert rhinoplasty necessitates treating nasal abnormalities while maintaining maximum nasal function. It is impossible to make a nose seem beautiful without addressing nasal airway function.

Revision rhinoplasty is a surgery performed on a nose that has already undergone surgical alterations. It is a procedure that entails surgically reshaping the nose as well as adjustments to the interior and exterior components in order to enhance the look and function of the nose.

Despite the best efforts of doctors, revision rhinoplasty has a greater revision rate than original rhinoplasty (no prior nasal surgery). Statistics vary, but it is estimated that around 15% of original rhinoplasty procedures require revisions for one cause or another.

Patients should be aware of this since no ethical plastic surgeon can guarantee the success of revision rhinoplasty or any other cosmetic plastic surgery operation.

Patients who want to get a revision rhinoplasty should wait until they have totally healed from their previous rhinoplasty. It is suggested that a patient wait at least a year after their prior operation. Returning for surgery too soon may result in further, more significant nose damage that is difficult to repair.

Why people seek Revision Rhinoplasty?

Revision Rhinoplasty Operation

Patients who have undergone previous procedures with poor results may need revision surgery.
You may dislike the appearance of your nose and believe that more should have been done. This may occur frequently as a result of a breakdown in communication with your original surgeon.
Some patients may experience nasal drooping, hooded nasal tip, nasal bone abnormalities, nasal asymmetry, infections, and excessive scar tissue formation as a result of their initial operation.
Patients who have had implants inserted may get draining infections that are resistant to medications.
At times, patients may have difficulties breathing. This might be due to internal nose weakness, asymmetrical nose settling, or excessive scar development from the initial operation. In such circumstances, the interior anatomy of the nose must be restructured and restored.
Finally, people who have had nasal surgery more than ten years ago may experience subsequent weakening and abnormalities in nasal architecture that worsen as they age.

A retrospective study of primary (308 surgeries) versus revision (92 operations) rhinoplasty procedures revealed that the most prevalent problems for patients undergoing primary rhinoplasty were a dorsal hump (50 percent), a big nose (44 percent), a bulbous tip (44 percent), and nasal blockage (33 percent).

On the other hand, patients undergoing revision rhinoplasty, complain of persisting deviation (38%), nasal blockage (36%), bulbous tip (33%), and big nose (25 percent).

Tip asymmetry (22%) increased dramatically in revision procedures compared to first surgery, as did dorsal sloop (11%), large nostrils (19%), columellar show (11%), and alar retraction (4%). Prior rhinoplasty stigmata leading to unnatural outcomes, such as those stated previously, were frequently identified as causes for revision surgery.

Why Revision Rhinoplasty is difficult?

Rhinoplasties

Rhinoplasties are among the most challenging cases that aesthetic plastic surgeons encounter for a variety of reasons, including:

Patients are frequently dissatisfied with their previous surgery and may be unaware that further rhinoplasty may not be helpful in totally repairing cosmetic defects that were not repaired in the previous surgery or developed as a result of the operation.
Scar tissue from previous rhinoplasty is frequently a concern in revision patients and can affect the ultimate result since it can return even after successful revision rhinoplasty.
In revision rhinoplasty, cartilage is frequently used to repair damaged and/or inadequate cartilage removed during the previous procedure.

Because the nose has been affected by previous operations, the inside and exterior structures of the nose are frequently different. Parts of the nose may be absent or distorted in size or form.

Because of this disparity in anatomy, the surgeon must be able to replace, reshape, and reconstruct the nose in order to restore healthy anatomy, function, and cosmetics. Surgeons must often have the necessary experience and skill sets to reconstruct a nose. Such abilities include the utilization of rib and ear grafting, as well as free grafting, to integrate into the new nose. Surgeons must also be experienced in the art of local and regional reconstruction, depending on patient’s major complaint.

Preoperative assessment of patients for revision rhinoplasty

rhinoplasty surgery assessment

Every rhinoplasty surgery is conducted with the goal of enhancing the look and nose breathing and obtaining a desirable result.

Preoperatively analyzing a nose to avoid the need for revision necessitates a thorough study of the anatomy.

Surgical techniques should be designed to accomplish the intended benefits in a long-lasting manner that will be satisfying during the long healing phase and for many years after the first operation.

Surgeons should keep in mind that the subcutaneous fat of the nose thins with age, and grafts implanted in a teenager's nose may show up in later adulthood.

Modern rhinoplasty procedures have turned away from reduction rhinoplasty and toward reshaping and supporting the nose. In reduction rhinoplasty, compromised cartilages collapse and twist under the powerful forces of scar contraction, possibly decades later; giving the nose an unpleasant external look and limiting respiration over time.

Support is especially crucial in revision rhinoplasty because of the presence of significant scar contractions. Experience will aid the rhinoplasty surgeon in making intraoperative judgments about the size and form of cartilages and grafts that will offer the desired result.

A recent retrospective study of an established rhinoplasty practice listed the risk factors for postoperative dissatisfaction and the need for revision rhinoplasty. Dissatisfaction was increased by:

Postoperative complications.
A history of nasal fracture.
Lack of anatomic association.

Postoperative infections, dislodged nasal stents or casts, and scarring hampered recovery and worsened patients' prognosis. Traumatic crooked noses are well known as a technically difficult rhinoplasty group.

To perform a successful surgery, the surgeon must first understand why patients desire revision. Specific nose changes, as well as issues with nasal blockage and nasal breathing, should be highlighted. Accurate and transparent communication will aid in the definition of the operational aim. Communication is essential for both the doctor and the patient to have a positive outcome. It is crucial to remember that patients and surgeons frequently differ in their assessment of the nose.

Studies have demonstrated that rhinoplasty surgeons will notice many more defects than people do; rhinoplasty specialists are trained to examine noses closely. In recent research, the surgeon discovered almost 40% more nasal abnormalities than the patients.

The surgeon must recognize the patients' concerns and prioritize addressing them. Gaining the patients' confidence requires the physician to understand their worries and expectations and to present realistic outcomes.

The use of a mirror or photography to evaluate the nose jointly enhances communication. your doctor may consider employing 2-dimensional or 3-dimensional computer simulations to better communication.

The anatomy of the individual nose and face may have restrictions that exclude a certain result. Each patient has a distinct face structure and nose, as well as characteristics such as cartilage contour, strength, and skin thickness and quality. Each feature has advantages and disadvantages that will necessitate distinct surgical approaches.

Patients with thick skin, for example, who require more grafting and more projection to enhance the shape, are generally hesitant to select this option for fear of having a large nose.

Preparing for revision rhinoplasty

Preparing for revision rhinoplasty

Preparing for revision surgery necessitates a thorough assessment and the creation of a conceptual surgical plan. Surgeons should take the time to evaluate the images and design a strategy after discussing them with patients and examining historical photographs and surgical records.

In revision surgery, the options vary from less invasive filler augmentation for modest contour depressions to more substantial repair including rib cartilage transplantation.

When scheduling a revision surgery, keep in mind that a revision case will take longer than a primary case. Revision operations are sometimes more complicated because of the scar tissue and alterations to the anatomic components of the nose.

Nasal bones and cartilages are frequently folded, weak, deformed, or missing. The doctor must be prepared to spend the time necessary in surgery to repair and improve the nose's complicated architecture. Commonly, septal cartilage and even auricular cartilage may be depleted. Autologous costal cartilage can be considered.

Common surgical deformities and corrective procedures

Common surgical deformities

The surgical procedures utilized to fix the nose during revision surgery are similar to those employed in original rhinoplasty.

It is not uncommon to need more extensive repair of previously removed or altered cartilages. Difficult dissection through the scar and previous grafts may be required. However, the procedures and concepts of initial and revision rhinoplasty remain consistent.

The first and probably most critical step is accurately identifying the abnormality to be corrected.

This section provides a brief overview of typical abnormalities and the methods used to repair them during revision rhinoplasty.

Upper Third of the Nose

Upper Third of the Nose

The most prevalent nasal dorsum abnormalities are under-resection, over-resection, and persistent deviations.

Under-resection: Repeat hump removal with osteotomes or raspatories (a surgical instrument for abrading) can correct the under-resection of the bony nasal dorsum.
Over-resection: Dorsal grafting can be used to repair an over-resected or scooped dorsum.

To strengthen the dorsum, diced cartilage grafts or carved “onlay” dorsal struts may be applied.
As a dorsal onlay, a long piece of cartilage from the septum or rib is preferable.
The disadvantages of employing a single piece of cartilage as a dorsal onlay include the requirement for a relatively long straight piece of cartilage as well as the potential of warping.

The septum is the nose's backbone, and any remaining septal deviation should be treated during the correction.

Failure to straighten the nose is associated with increased incidence for persistent crookedness. Straightening rhinoplasty is one of the most difficult technical procedures in rhinoplasty, requiring the surgeon to overcome not only bony and cartilaginous abnormalities, but also tissue memory and soft tissue.
Extracorporeal septoplasty can be used to replace the whole septum. When doing full septal replacements, surgeons prefer to leave a dorsal strut in situ to prevent dorsal asymmetries, improve reconstruction, and provide dorsal support.
To straighten the nose, bilateral lateral osteotomies (cutting the bone) with either an intermediate osteotomy on the longer side or bilateral medial osteotomies.
The doctors prefer the intermediate osteotomy because it retains dorsal support at the rhinion (the lower end of the median suture joining the nasal bones) and prevents asymmetries in the nose's weakest skin region.
In extreme cases, a transverse osteotomy to remove the ethmoid's perpendicular plate from the base of the skull may be required.
Both intermediate and bilateral medial osteotomies can be performed effectively. Camouflage grafts are useful in correcting residual dorsal asymmetries or deviations.

Middle Third of the Nose

A typical finding in revision surgery is nasal blockage caused by persisting asymmetries in the middle portion of the nose. High septal deviations that were not previously corrected are frequently addressed during revision septoplasty. Internal nasal valve stenosis and/or inverted V deformities can be treated using spreader grafts.

Pollybeak deformity (extra tissue over the supratip area) with supratip prominence (region over the bridge of the nose directly before the nasal tip) can be caused by insufficient cartilage lowering and/or soft tissue scarring. The combination of a relatively high anterior septal angle and poor tip support is a cause for postoperative pollybeak as scarring causes nasal tip contraction and deprojection.

The cartilaginous pollybeak can be corrected by reducing the anterior septal angles and projecting and supporting the nasal tip.
Soft tissue pollybeak is frequently the consequence of scarring caused by an extensive supratip break. Patients may be predisposed to this consequence if the subdermal plexus is disrupted. In the early postoperative phase, steroid injections in the supratip region can be beneficial in correcting soft tissue pollybeak deformity.

Lower Third of the Nose

The most difficult aspect of revision rhinoplasty is frequently nasal tip revision. Surgeons’ approach to the nasal tip begins with a columellar strut, tongue-in-groove, or caudal septal extension graft to provide support and a stable foundation for the nasal tip's core complex.

Many of the tip support mechanisms are damaged during primary rhinoplasty, and regaining the support is required to get outcomes that will withstand the stress of healing and time.

Crura: The segment of alar cartilage found above the nostril and below the nasal dome.

The medial crura are commonly secured to the central stabilizing graft and to each other. Following that, the direction and symmetry of the lower lateral crura is addressed. Lateral crural struts, and, if necessary, lateral crura relocation are technical measures to strengthen the lower lateral crura.

The final stage is to determine whether or not the tip and dome projection is adequate. A dome division might be considered if the nasal tip is over-projected. At this time, lateral crura overlaps can also be applied.

Alar retraction, whether hereditary or as a result of rhinoplasty, is quite obvious and disturbing.

When evaluating patients with alar retraction, determine whether the nose is over-rotated and shortened, and distinguish between excessive columellar show and real alar retraction are important aspects.
Alar rim graft, lateral crura repositioning, and composite auricular grafts to the vestibule are all techniques used to repair and prevent alar retraction.

After deprojection on a reduction rhinoplasty, alar base widening might occur. Following considerable deprojection, the alar base should be examined for excess alar flare, enlarged nostril size, or a combination of these conditions. Local anesthesia is used to accomplish an alar base reduction in the office.

Soft tissue of the Nose

Soft tissue of the Nose

The most difficult abnormality to correct in rhinoplasty is soft tissue scarring and contracture. Infection or vascular damage can both damage the skin.

Severe alar notching caused by a soft tissue injury is sometimes treated solely by enlarging the soft tissue envelope, and composite grafts are useful in these cases.

Incisions that are improperly placed are difficult to repair.

Incisions made in the alar rim and soft tissue triangle rather than the margins frequently result in noticeable scars that change the contour of the nostril. Composite grafts can be used to improve a scarred soft tissue triangle.
Lowering the lar base Incisions that destroy the alar-facial sulcus will give the patient a strange look. V-to-Y advances can be used to correct alar base reduction and assist restore the previously effaced alar-facial sulcus.
Finally, laser or skin resurfacing with Dermabrasion can help heal external scars. This abrasive action improves skin contour as it scrapes away top layers of skin to unveil smooth new skin.

What are the Complications of Revision Rhinoplasty?

complications of revision rhinoplasty

Some revision rhinoplasty dangers and risks may emerge from your previous surgery, including internal scarring, impaired blood flow, decreased skin elasticity, and damaged or missing cartilage and bone. In rare circumstances, the abnormalities caused by an unskilled original rhinoplasty are so severe that total repair and normalization of the nose cannot be accomplished in a single revision operation.

According to statistics, the vast majority of cosmetic rhinoplasty patients do not encounter significant consequences. Some patients have worse outcomes as a result of the surgeon's poor technical execution.

Complications and hazards associated with revision rhinoplasty may be classified into four broad groups according on when they occur:

Intra-operative – Occurring during the surgery.
Immediate postoperative – Occurring within the recovery suite.
Short-term postoperative – Occurring within the days or weeks following surgery.
Long-term postoperative – Occurring within the months or years following surgery.

Every procedure has some risk. Bleeding, bruising, swelling, infection, and scarring are all hazards that may be reduced with skilled medical care and a competent surgeon. Reactions to general and local anesthetics are also typical concerns, which can be reduced with the knowledge and competence of an anesthesiologist, surgeon, and attending personnel.

Intra-operative Complications of Revision Rhinoplasty:

Loss of dorsal support.
Unstable nasal bones.
Perforation of the Septum.

Immediate Complications of Revision Rhinoplasty:

Airway obstruction.
Bleeding.
Visual impairment: Temporary deterioration or impairment of a patient’s vision may occur after a local anesthetic and/or vasoconstrictor injection.

Short-term Complications of Revision Rhinoplasty:

Asymmetry.
Bleeding from the nose: Also known as epistaxis.
Infection.

Long-term complications of Revision Rhinoplasty:

Airway Reduction.
Excessive Tearing.
Nasal Drip.

Conclusion

Revision Rhinoplasty

Rhinoplasty, also known as nose job or nasal reconstruction, is a plastic surgical operation used to reshape and reconstruct the nose.

Rhinoplasty is considered one of the most complex plastic surgery operations.

Revision rhinoplasty is a surgery performed on a nose that has already undergone surgical alterations. It is a procedure that entails surgically reshaping the nose as well as adjustments to the interior and exterior components in order to enhance the look and function of the nose.

Patients who want to get a revision rhinoplasty should wait until they have totally healed from their previous rhinoplasty. It is suggested that a patient wait at least a year after their prior operation. Returning for surgery too soon may result in further, more significant nose damage that is difficult to repair.

To repair the outcomes of a previous nose operation, patients seek revision rhinoplasty. The patient may be dissatisfied with the outcome because they believe their nose is still too large, that it has thrown their face out of symmetry, or that they are experiencing breathing issues as a result of previous rhinoplasty.

Revision rhinoplasty surgeries are more difficult than primary rhinoplasty because the nose has been affected by previous operations, and the inside and exterior structures of the nose are frequently different. Parts of the nose may be absent or distorted in size or form.

Preoperatively analyzing a nose to avoid the need for revision necessitates a thorough study of the anatomy.

Surgical techniques should be designed to accomplish the intended benefits in a long-lasting manner that will be satisfying during the long healing phase and for many years after the first operation.

The surgeon must recognize the patients' concerns and prioritize addressing them. Gaining the patients' confidence requires the physician to understand their worries and expectations and to present realistic outcomes.

Preparing for revision surgery necessitates a thorough assessment and the creation of a conceptual surgical plan. Surgeons should take the time to evaluate the images and design a strategy after discussing them with patients and examining historical photographs and surgical records.

The surgical procedures utilized to fix the nose during revision surgery are similar to those employed in original rhinoplasty.

In addition to general surgical and aesthetical complications, some revision rhinoplasty dangers and risks may emerge from your previous surgery, including internal scarring, impaired blood flow, decreased skin elasticity, and damaged or missing cartilage and bone.