Rhinoplasty surgery is technically challenging, and should only be performed by skilled, experienced plastic surgeons. It is often said that rhinoplasty surgery is the most technically challenging procedure and the reason for this is that the anatomy of the nose is variable, the analysis of facial proportions requires years of experience, and the surgery itself requires extreme precision. Even then, what is achieved at the time of Rhinoplasty surgery can change during the healing process resulting in unpredictable changes that sometimes require an adjustment or ‘revision’ known as ‘Revision rhinoplasty’ surgery.
Revision rhinoplasty procedure is usually required in between 5 to 10% of cases depending on the complexity of the original procedure. This itself does not mean that the initial rhinoplasty procedure was carried out inappropriately, but that some unpredictable changes have occurred during the healing period which has changed the appearance which was achieved at the time of surgery. Any skilled rhinoplasty surgeon will have patients on whom a revision rhinoplasty procedure will need to be carried out. In these situations, any respectable rhinoplasty surgeon will perform this procedure himself. However, occasionally ones see situations where the rhinoplasty surgeon is unable to carry out the adjustment himself since it is deemed too difficult, this may require referral to another more experienced revision rhinoplasty surgeon.
Sometimes there has been a breakdown in communication between the patient and surgeon resulting in the patient requiring a revision to be carried out by another surgeon. Another situation which occurs is that patients can present several years after the original rhinoplasty unhappy with the original result and request a further modification by a revision rhinoplasty surgeon.
In choosing a revision rhinoplasty surgeon it is important to consider the level of experience of the surgeon and to consider the number of rhinoplasty procedures the surgeon carries out. It is important to establish whether the surgeon is confident to carry out the revision and usually you can get a sense of this level of confidence at the consultation. At the consultation, it is important to understand that the complexity of the procedure is realised and if the procedure is dumbed down to be simple by the surgeon then this also is inappropriate, since there is no such thing as a ‘straightforward’ revision procedure.
As a starting point, it is best to choose a specialist plastic surgeon who has an interest in rhinoplasty and is a member of the British Association of Aesthetic Plastic Surgeons (BAAPS). Next, it is important to ensure that you have a consultation during which all your concerns have been fully addressed, and the exact operative plan, the likely result you can expect to achieve and all the risks have been discussed.
Choosing a revision rhinoplasty surgeon who also carries out nasal reconstruction for cancer cases and trauma is an important factor since this indicates wide background experience in plastic surgery and is useful when various types of grafts need to be acquired for the revision surgery. Many Plastic Surgeons who specialise in facial surgery will have this extra experience.
What is different about revision rhinoplasty surgery?
The essential difference is that there is more scarring within the nose and that the anatomical structures which include the skin, cartilage, bone and the lining of the nose have already been adjusted. In order to re-adjust these structures, an open rhinoplasty is usually required. Sometimes grafts may be required to add tissue for structural support and to correct any previous breathing issues. The usual place to obtain these grafts is the nasal septum but usually, this has been used in previous surgery. The surgeon has to use grafts from elsewhere and the common sources of these grafts is the cartilage from the ear or in severe cases a cartilage graft from one of the rib cartilages.
When should a revision rhinoplasty be carried out?
As a minimum, a revision should not be carried until approximately 9 months after the initial surgery. This allows the tissues to settle and enables the surgeon to establish the true result from the surgery. It is known that it takes 9 months to one year for the tissues to settle after any rhinoplasty and for all the swelling to subside.
What happens during the surgery?
The procedure will be performed under general anaesthetic, and will usually be performed as an open procedure.The reason revision rhinoplasty requires an open approach is to allow improved access to tissue, bone and cartilage. This is required to accurately establish any alteration in anatomy and to position any grafts which may be required with precision. An open rhinoplasty requires the creation of a small incision made on the columella which is the narrow skin bridge that divides the two nostrils. Postoperatively, this incision usually leaves a scar which is a hardly visible scar after a period of a few months.
If grafts are needed this may involve a small incision behind the ear to take a small piece of cartilage graft. Alternatively, in more complex cases, an incision is needed on the chest to take a small piece of rib graft cartilage. In cases where the dorsum of the mose has been over-resected and the bridge line needs to be built up or augmented then pieces of cartilage are diced up and wrapped in a piece of fascia graft. This is called a diced fascial graft (DCF). The cartilage may come from the septum, ear or from the rib cartilage. The fascia, which is a deeper sheet of soft connective tissue, is usually taken from a small opening made in the hairline of the temple. No hair needs to be shaved and this heals hidden within the hair.
If you would like a consultation to discuss a revision rhinoplasty please contact Mr Chana at his clinic. He will give you a realistic idea of what is involved and what can be achieved. Mr Chana has a huge experience in rhinoplasty surgery and carries out both cosmetic rhinoplasty surgery and complex nasal reconstruction surgery for trauma and cancer cases. This gives him a breadth of experience in all types of rhinoplasty cases both primary and revision cases. Mr Jag Chana was chosen to feature in the Sunday Times as one of UK’s best rhinoplasty surgeons and you can read about this here.