Key points
- Revision rhinoplasty is considered one of the most difficult operations because of the nose's complex three-dimensional anatomy and the psychological impact on the patient [1].
- The causes of revision surgery can be grouped into cases where too little or too much tissue was removed, problems related to sutures or grafts, and functional problems [3].
- The open approach is recommended for many revision surgeries, and the wide view it gives is described as helpful, especially when many grafts are needed or when the first surgery was done by another surgeon [3].
- Even with good planning and technique, further revision may become necessary, so patient and surgeon need to understand together the limits of surgical technique and of each person's anatomy [2].
Why is revision surgery difficult?
In the nose, cartilage, bone, and soft tissue fit together intricately to create its shape and function, and because the nose sits in the center of the face, it greatly affects facial harmony and the impression a face gives [1]. One review considered revision rhinoplasty one of the most difficult operations because of this complex three-dimensional anatomy and its psychological impact on patients [1].
It has also been pointed out that revision surgery can be an emotionally difficult process for both surgeon and patient [2]. Adding to the difficulty, the structure often has to be rebuilt after the first surgery has reduced the cartilage or left scar tissue.
Why people seek revision surgery
One review explained revision surgery by grouping it according to the problems that arose from the first surgery. The main topics were cases where too little tissue was removed and cases where too much was removed, problems that arose from handling tissue with sutures or grafts, and functional problems in secondary surgery [3].
Another review, based on the author's 30 years of rhinoplasty experience and the published literature, summarized the common motivations and anatomical findings of patients seeking revision surgery [1]. Not only dissatisfaction with appearance but also function, such as breathing, needs to be addressed in planning revision surgery [3].
Cases with abnormalities in structure and growth from the start, such as secondary rhinoplasty for the nasal deformity that accompanies a cleft lip, are considered especially challenging both cosmetically and functionally [6]. One review approached these cases by dividing them into seven areas: underdevelopment of the bone around the nasal opening, reconstruction of the septum, the shape of the bridge, the shape of the tip, tip projection, the shape of the nostril wings, and the position of the nostril wings [6].
Surgical planning and approach
The starting point of revision surgery is an accurate diagnosis. Because there are many pitfalls to avoid, the literature stresses that careful diagnosis and surgical planning are always advisable [2].
One review recommended the open approach for most revision rhinoplasties. The explanation is that it offers better visibility and access, so treatment goals can be achieved more predictably, especially when many grafts are needed or when the first surgery was done by another surgeon [3].
A review of the shape of the bridge summarized its key concepts as adequate exposure of the key areas, separating the components and reducing them in steps, straightening the septum and centering it, and moving and refining the nasal bones with osteotomies and bone reshaping [4]. It also stressed the importance of powered and piezoelectric instruments, simulation, and computed tomography (CT) in work on the bones and septum, and it covered the principles of rebuilding the bridge in revision surgery [4].
Rebuilding the bridge and graft materials
In revision surgery, a bridge that has become deficient sometimes needs to be built up again. Indications for bridge augmentation can arise in both first and revision surgeries, and facial analysis that considers the overall balance of the nose and face is described as essential to the surgical plan [5].
Both the patient's own tissue (autologous tissue) and other materials (donor tissue and synthetic materials) are used around the world, and each has pros and cons [5]. The authors of that review stated that they regard autologous grafts as the most suitable material because of their biocompatibility and natural, long-lasting results, but this is the authors' opinion [5].
Which material is right depends on how much cartilage remains, the condition of the skin, and any implants used before, so it is decided through an examination.
What to expect, and the limits
In revision surgery, it is important to set realistic expectations. The literature notes that even with the best planning and surgical technique, further revision may become necessary, and that patient and surgeon need to understand the limits of surgical technique and of each person's anatomy [2].
Scar tissue, skin thickness and elasticity, and the condition of the remaining cartilage differ from person to person, so even with the same goal, how close you can get differs. There are also risks such as bleeding, infection, problems related to graft materials, and asymmetry, and recovery time varies from person to person.
What to check during your consultation
For a revision consultation, it helps to come with a clear, specific list of what bothers you now and the changes you want. After examining the remaining structures and the condition of your skin, the specialist can explain the possible methods and their limits.
- Records of the first surgery: the implants and graft materials used, and how much tissue was removed
- Whether what bothers you is the appearance, your breathing, or both
- Where the cartilage for grafting will come from
- Whether imaging such as CT is needed
- Your goals and what is realistically possible
Frequently asked questions
- Why is revision surgery harder than a first surgery?
- The nose is a three-dimensional structure in which cartilage, bone, and soft tissue fit together in complex ways, and revision surgery also places a heavy psychological burden on the patient [1]. It often involves dealing with problems such as too much or too little tissue removed in the first surgery, or issues related to grafts [3]. That is why an accurate diagnosis and plan are especially important.
- What materials are used in revision surgery?
- For building up the bridge, the patient's own tissue, donor tissue, and synthetic materials are used, and each has pros and cons [5]. The authors of one review stated that they prefer autologous grafts because of their biocompatibility [5]. The right material depends on the remaining cartilage and the condition of your skin.
- If I have revision surgery, will I get the result I want this time?
- The literature notes that even with good planning and technique, another revision may become necessary [2]. Surgical technique and individual anatomy both have limits, so it is important for patient and surgeon to understand them together [2]. It is a good idea to confirm specifically during your consultation what is possible.
References
- Loyo M, Wang TD. Revision Rhinoplasty. Clin Plast Surg. 2016.PubMed 26616705DOI
- Waite PD. Avoiding revision rhinoplasty. Oral Maxillofac Surg Clin North Am. 2011.PubMed 21126884DOI
- Cuzalina A, Qaqish C. Revision rhinoplasty. Oral Maxillofac Surg Clin North Am. 2012.PubMed 22284401DOI
- Robotti E. Shaping the nasal dorsum. HNO. 2018.PubMed 29085975DOI
- Graw GJ, Calvert JW. Dorsal Augmentation. Clin Plast Surg. 2022.PubMed 34782132DOI
- Rohrich RJ, Benkler M, Avashia YJ, et al. Secondary Rhinoplasty for Unilateral Cleft Nasal Deformity. Plast Reconstr Surg. 2021.PubMed 34076624DOI
This article is an English translation of general health information that DOY JUN Plastic Surgery compiled in Korean from the summaries (abstracts) of papers in international academic journals. Treatment methods and results vary depending on each person's condition, so please consult a specialist for an accurate diagnosis and treatment plan.
