There is no other procedure in aesthetic plastic surgery that requires patients to trust the aesthetic judgment of their surgeon more than a revision, or “secondary,” rhinoplasty. Much has been said and written about the goals of secondary rhinoplasty, the various techniques employed, the use of a variety of “visible” and “invisible” grafts and the need for a detailed anatomical plan.
It strikes me that as carefully as some plastic surgeons plan and execute, too many rhinoplasties appear to have been carried out in a “destructive” rather than a “constructive” manner.
Revision Rhinoplasty: Achieving the Best Results
There is no operation more satisfying to me than a properly planned and precisely performed secondary rhinoplasty. Above any other aesthetic procedure, this operation should not be predicated on sensational marketing or computer constructs designed to allay fears and “sell” the surgery. All noses and faces are different, but the common denominator of a “bad” nose is that it is distracting to the observer.
There can be no harmony of facial features when a distracting nose is the focus of the face. Hence, I love a beautiful nose but beauty need not be defined by it. The observer needs to see beyond or even through the nose to notice those features that should characterize appearance. In my view, the ultimate in a lovely secondary rhinoplasty lies in its subtlety and lack of attention.
Common Reasons for Revision Rhinoplasty
As different as all noses can be, I see a consistent set of secondary rhinoplasty deformities. Most commonly, I see patients with an over resected dorsum often paired with a tip that has had little or nothing done to address its projection, rotation or shape. Occasionally, the structure of the nose has been stripped down to the point where the tip is pinched, rotated up and the nostrils may show offensively. In extreme cases, previous destructive surgery can cause collapse of supportive structures and contracture or scarring of overlying soft tissues.
Open Rhinoplasty vs. Closed Rhinoplasty
In the revision rhinoplasty cases that I perform (and most primary rhinoplasties in my practice), I prefer an “open” approach. The difference between this “open” technique and the more commonly performed “closed” or “endonasal” approach is that the open approach requires a small inconspicuous incision on the bottom of the nose. This permits me direct visualization of all nasal structures and allows me to execute corrective maneuvers with unparalleled technical control and accuracy.
Proponents of the closed approach argue that there is adequate surgical exposure with only internal incisions and claim that the open approach results in more scar formation and prolonged healing. My personal experience is that the superior control and unencumbered access to all of the nasal structures permits me to precisely control my outcomes in the most reproducible manner. Furthermore, meticulous dissection and gentle handling of nasal tissues gives me comparable levels of swelling.
My patients are almost always pleased at the first week post-op when I remove their nasal splints. Although they predictably look even better at 6-12 weeks and best at 6-12 months, there is rarely a need for me to encourage them to “just wait” before they can appreciate their results.
In the more complex revision rhinoplasties I do, particularly if it requires corrective structural grafting, the swelling may be a bit more significant and lasting than that of the primary rhinoplasties I perform. When done properly, your nose should look nice right at the time of surgery and then on through the recovery beginning in the immediate post-op period.
Final Thoughts
In my experience, the relation amongst revision rhinoplasty patients is their strong dissatisfaction with their nose’s appearance matched only by their fear of undergoing another disappointing operation. The prevalence of this mindset discourages most plastic surgeons from doing many secondary rhinoplasties.
Conversely, a significant number of rhinoplasties in my practice are secondary and tertiary. I believe that my success in this practice results from my strong interest in rhinoplasty, my aesthetic judgment and my motivation to be the expert in this difficult niche of aesthetic plastic surgery. At the very least, I believe that secondary rhinoplasty is always worth an evaluation, a conversation and careful consideration.
