Revision cosmetic rhinoplasty is one of the most difficult challenges that face every cosmetic rhinoplasty surgeon. It is much easier to work with a structure before it has been altered, broken, made smaller, had cartilage and bone removed. Typically the patients who had cosmetic rhinoplasty surgery 10-20 years ago had a reduction rhinoplasty where the nose was just made smaller by removing cartilage and bone.
The most common problem we find in patients who are unhappy with their previous rhinoplasty is that their shape has changed over time.
- The nose continued to scar.
- The tip began to elevate.
- The nostrils began to pull.
- The breathing became worse.
Most patients have a relatively good experience with their original cosmetic nasal surgery (except they hated the "20 feet of packing" and just assume that having it done again or perhaps a third time is "no big deal". This isn't true. Revision nasal surgery leaves cosmetic rhinoplasty surgeons with less material and structure to work with and forces us to work in a field that already has scar tissue and therefore is less resilient to the changes we wish to make.
Can we help you if your nose has been operated on by another surgeon at some point in the past? Sometimes. We will need to sit down with you and discuss what changes you would like to make and look over your nasal structure that remains and the reports of what was done in the past. Using all this information we can then decide if it is worth it for us to try to fix the problems that concern you the most. For those of us who truly love the art of cosmetic rhinoplasty surgery, a revision rhinoplasty can be not only challenging but also very rewarding. Therefore, after our consultation, if we truly believe that we can help you with what you are interested in, then we will do the best we can to work with you as long as we feel you are well prepared.
How is revision cosmetic rhinoplasty different during surgery? Since you have probably already had a septoplasty done in the past you have less cartilage and bone available to us to use for grafting. Most likely the structure needs support from the previous removal and weakening. We will of course look for cartilage and bone inside your nose and in the septum that we can use to support your nose; however, frequently at least part of this has been removed by a surgeon in the past. In this case we will need cartilage and/or bone and/or grafts from other parts of the body to replace the structure of your nose. Our most common grafts are taken from the bowl of the ear. We like this cartilage particularly to reconstruct the nostril cartilage since the curve can be used to recreate the shape of a nostril that has collapsed or pinched. Occasionally there is no ear cartilage or we need even more or straighter cartilage, in which case we are required to harvest some cartilage from the ribs of the chest. Typically we take the outer portion of the cartilage from the lowest ribs on the rib cage on the front of the chest. We of course prefer to use ear cartilage but sometimes there is just not enough structural support. Occasionally in patients who have severe nasal defects they will require bone as well. Typically we harvest bone from somewhere under the hair of the scalp, taking only 1/2 thickness of bone such that we leave an intact layer of bone under the scalp. Clearly if we need other sources of bone or cartilage the surgery becomes more complicated in that the recovery time will be longer and other incisions will be required.
The more times a nose has been operated on, the longer the swelling will last following surgery. This doesn't mean that the swelling won't eventually decrease but surgical swelling, which normally might come down in 6-8 weeks, might take 3-6 months. Some swelling may even last as long as a year to a year and a half following revision surgery. This doesn't necessarily mean that the nose will be obviously swollen to everyone who sees them; however, some swelling will still remain for quite some time. Other than an increased amount of swelling and potentially other surgical sites, for example in the ear or ribs, our surgical postop course is very similar to the course following cosmetic rhinoplasty. If we use an ear cartilage graft we keep a cotton ball in the bowl of the ear for 5 days and stitches in for the same period of time. Five days following surgery the cotton ball is removed and the stitches are removed. If we need cartilage for the nose from the ear we use cartilage from the bowl of the ear since this doesn't usually make a large impact in the shape of the ear and is almost always minimally noticeable to our patients or the people in their lives.
Dr. Neal Goldman is a skilled, experienced, facial plastic surgeon who is specialized in cosmetic and reconstructive surgery of the face and neck. He is board certified by the American Academy of Facial Plastic and Reconstructive Surgery and the American Board of Otolarnygology-Head and Neck Surgery.
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