Revision Rhinoplasty
Rhinoplasty is considered one of the most complex plastic surgery procedures. This is due to the intricate anatomy of the nose, involving delicate interconnections of bone, cartilage and soft tissue. In addition, being one of the most visible features of a person’s face, attention to detail is very important. Finally, not only are aesthetics important, but an understanding of the functional aspects are critical to a successful outcome.
Even with highly skilled surgeons, post-operative issues such as external deformities or breathing difficulties can arise due unpredictable nature of the healing process.
In instances where a secondary surgical intervention is required, the expertise of the surgeon becomes paramount. Dr. Thomassen possesses extensive experience in performing secondary and tertiary rhinoplasty to rectify unsatisfactory outcomes.
For individuals who have undergone rhinoplasty and are experiencing issues with breathing or dissatisfaction with the external appearance of their nose, a consultation with Dr. Thomassen can help assess eligibility for corrective procedures.
Why undergo a revision rhinoplasty?
As mentioned earier, the main reasons for seeking a revision are dissatisfaction with the appearance or function of the nose. Below are some of the most common reasons people seek a revision.
Inadequate Treatment of a Problem
Appearance issues are mostly due to inadequate treatment of issues that prompted the original rhinoplasty in the first place. It is common to meet patients that sought a rhinoplasty for a dorsal hump, still complain of a residual bump that was not adequately treated. Also, an excessively wide bridge that was not narrowed sufficiently in the first surgery is a common complaint.
Dissatisfaction with tip aesthetics is also common due to inadequate tip projection and lack of a pleasing supratip break after the primary rhinoplasty.
Changes of the nose seen months after the primary rhinoplasty
In some cases, patients are originally satisfied with the primary procedure. However, over time, changes can occur that distort the nasal appearance and result in an objectionable deformity. This can be due to deposition of scar tissue in areas, mostly the supratip area that distorts a pleasing tip. It can also occur when cartilage grafts are placed superficially and distort over time, leading to contour irregularities.
Another common concern that occurs months after a primary rhinoplasty is asymmetry of the bridge and tip that was not visible immediately after surgery. This occurs if careful attention is not placed to ensuring symmetric placement of bone osteotomies and suturing of bridge and tip cartilages to ensure a cartilage construct that is stable and will not warp with time.
Breathing difficulties
In some instances, the reduction in cartilage and soft tissue done to shape a small and delicate nose, can result in loss of structural support. This can lead to breathing obstruction in one or both airways. It is important for surgeons to recognize the key anatomic features that give the nose support and maintain these features to avoid breathing difficulties after surgery.
In some cases, surgeons do not recognize that adding a procedure like a septoplasty to a rhinoplasty can help avoid obstruction issues and these are not added during the primary procedure. Having a thorough evaluation of the external and internal anatomy of a nose prior to surgery can avoid these situations.
Common Revision Rhinoplasty Procedures
Spreader Grafts
Injury to the upper lateral cartilages (cartilaginous bridge) can lead to narrowing of the opening in the midvault of the nose. These are cartilage grafts placed along the bridge of the nose on each side of the septum in order to widen the internal nasal aperture and allow increased airflow through the nasal cavities.
Lateral crural strut grafts
Excessive narrowing of the lower lateral cartilages can lead to collapse of the nasal opening at the tip called the external nasal valve. This results in obstruction, specially with deep or fast inspiration as when exercising or in exertion. These grafts help splint the external valve open.
Septal extension grafts and Columellar Strut Grafts
Lack of tip support after a primary rhinoplasty is a common problem leading to an unaesthetic tip without the classic supratip break. Adding additional tip support with cartilage grafts is a common procedure in revision rhinoplasty. These include columellar strut grafts and septal extension grafts. They may have been used initially but were not large enough or supported enough to give the tip the support needed for a pleasing result.
Osteotomies
Nasal bone infracturing in the upper bridge of the nose is done to improve the appearance of an excessively wide nose. Frequently this step in the primary procedure is not done adequately.
Challenges with Revision Rhinoplasty
Lack of Cartilage
Septal cartilage is often deficient in revision rhinoplasty procedures since they were already used in the first procedures. Surgeons often must choose cartilage from elsewhere in the body, particularly the ear and occasionally the rib. There is an option for fresh frozen cadaveric cartilage and this can be discussed in the preoperative visit.
Need for soft tissue lost in prior surgery
Soft tissue irregularities on the nose may need a permanent “natural filler.” Temporalis fascia, taken from within the hairline, is ideal and leaves no visible scar or deficit. Sometimes, skin grafts are needed to correct scarring inside the nasal airway.
Patient Imposed Restrictions
Frequently patients desire an improvement in just one part of the nose like the tip or the bridge. It is important to understand that a beautiful nose requires harmony of the tip and bridge aesthetics. Many times, only addressing one part will not lead to a successful outcome since the other part is not in harmony with the changes made. In revision procedures, it is important to not hamstring your surgeon by only allowing changes to one part of the nose. During surgery, changes to the tip, bridge, and alar base may become necessary for an excellent outcome.
What about Computer Imaging?
Computer-assisted imaging is used to help visualize what changes you can expect after your revision rhinoplasty. This can help determine if the vision you have matches with Dr. Thomassen’s recommended procedure.
I am interested! What is the next step?
If you are interested in this procedure, we would first schedule a consultation with Dr. Thomassen. This can be done via telemedicine for convenience if you are traveling from afar.
The timing for a revision procedure can vary. Generally, it is not intended to be done before the 6 month mark, when all swelling from the prior procedure is complete. In rare instances, the concern is so apparent and distressing that surgery is done in a quicker timeframe to relieve a particularly distressing result.
It is not necessary to wait a full year before undergoing a revision. If the nasal tissues are soft and pliable then swelling has resolved enough to allow for a successful revision.
The Procedure
The procedure is typically conducted under general anesthesia. Incisions are predominantly internal, with a minor external incision also being utilized. The bone and cartilage of the nose are reshaped, ensuring the preservation of its breathing function. As mentioned, the harvesting of cartilage from the ear or rib is performed if there is deficient septal cartilage. Septoplasty, spreader grafts or lateral crural strut grafts are used to improve breathing. Cases typically take between 2-3 hours; four hours for a rib graft procedure.
Recovery
The recovery is like that of a primary rhinoplasty. You need a week to relax and recover without any external distractions. You should be comfortable at home with the medications prescribed. At one week, internal and external splints are removed, and you should see a nice result immediately. Most patients feel comfortable resuming many of their regular activities at this time.
Results will improve over the next 2-3 weeks as swelling dissipates. Dr. Thomassen will follow you throughout this process to ensure an excellent result.
How much does a revision nose job cost?
Revision rhinoplasty typically costs more than standard rhinoplasty because it involves advanced techniques, harvesting of cartilage grafts and other soft tissue grafts, and longer surgical and anesthesia times. It is difficult to give an estimate without a consultation to determine the extent of the revision. You can find a current estimate of the cost in the RealSelf website.
References
Michael J. Brenner MD, Peter A. Hilger MD, FACS. Grafting in Rhinoplasty. Facial Plastic Surgery Clinics of North America, Volume 17, Issue 1, February 2009, Pages 91-113.
Ali Seyed Resuli, Fatih Oktem. A New Graft Technique For Rhinoplasty: Modified One-Piece Nasal Cap With Alar Strut Graft. November 2020The Journal of craniofacial surgery Publish Ahead of Print.
Rod J. Rohrich and Jon Kurkjian. Plastic Surgery Key. Fastest Plastic Surgery & Dermatology.