Revision rhinoplasty is a highly complex and specialized “surgery of a lifelong disappointment.” This text is dedicated to sharing experiences with revision surgery and the strategies adopted to yield the best results for the patient.
Revision rhinoplasty has become a part of everyday rhinoplasty surgeries these days. Rhinoplasty is the fourth most common procedure, with consecutive revisions accounting for 10 to 15 percent of the procedures. Apart from the technicalities mentioned, what also requires far more attention in these cases is the emotional aspect of the patients. Revision rhinoplasty has been shown to be more devastating for the patients, not just psychosocially but also economically. Labor time, material cost, and skills required are threefold or more than the virgin rhinoplasty surgery. In most cases, they are emotionally broken and are suffering from issues affecting their mental well-being.
The complexity of a revision rhinoplasty surgery starts with the preoperative assessment, and as a surgeon, incorporating the patient’s concerns is the most important part of the treatment. There are a multitude of circumstances and variants with rhinoplasty outcomes and patient concerns. In the preoperative assessment, apart from the routine evaluation, once the changes in the operated area are evaluated, the primary step and the most important aspect is independent documentation of the photographs and an analysis of the superimposition of the preoperative scans with the operative scans, which gives the surgeon detailed insight into the discordance and the exact areas that are manipulated and over-operated. This, if possible, increases surgical precision and fosters trust and information exchange with the patient.
Many primary rhinoplasty operations must and will require revised surgery. After primary surgery, aesthetic concerns include asymmetries secondary nose surgery to over-resected cartilages, dorsal irregularities from re-notched or fractured nasal bones, retraction of the alar rim and/or alar-columellar discrepancy. Histories of poor healing require careful pre-revision evaluation. Almost all experts and their patients can add more sequelae that can and often do occur with their revision candidates. Thus, the panel uses surgical mishaps as subsections focusing on aesthetic, functional, and soft-tissue problems.
Patients undergoing a primary procedure can present with several, often concurrent, complaints. Although a surgical candidate can self-perceive a range of problems going into a tertiary operation, the goal would be to divide the revision complexities into aesthetic, functional, and surgical complications. Those problems viewed from a patient perspective most notably include complications with contour, profile, tip, dorsum, and patient desire. Breathing complaints bother many who have had an initial operation. A less inflammatory anesthesia copes with aesthetics, psychology, surgical risks, and the logical details after the listing of systemic illnesses. Each of the foregoing comments on functional history and lower numbers decreased after the completion of primary, secondary nose surgery, or failed tertiary surgery must be specifically identified during patient interviews, on physical examination, photography, and personal reflection. Complications of a higher elevation and other familial or social postoperative stigma disruptions must be sought by observation.
In revision rhinoplasty, as in every operation, the assessment and planning stages make up the most important period of the surgery. To ensure a good result and eliminate complications, a comprehensive examination that includes all possible deformities, expectations of the patient, her wishes to be carried out, and a good operation plan are required. In this way, in the planned and structured assessment and in the elimination of the complications, the relation with the patient that will progress within a respectful frame is the primary issue. In the first evaluation of patients, a comprehensive interview is performed to obtain the patient’s general health information, current and previous specific diseases, and information on drug use, smoking, and alcohol consumption.
A specific subsection of the existing item form covering the history of previous surgeries and possible complications is created, and questions are asked within this framework, and a video imaging that fits the patient’s 3D surgical results is taken. According to the patient’s deformities, possible preferences and expectations will be planned by considering the desired end stage. The head and neck zone and the shape of the face are evaluated in harmony with the nose. A comprehensive physical examination is performed, and all anatomic changes and complications are documented via photo and video. Prior to this, dysmorphology syndromes and diseases should be deposited in memory and ruled out as a result of this syndrome.
To nose correction a deeply failing rhinoplasty, a whole armamentarium of surgical techniques is tailored to the needs of each case. The first task is to restore the structural integrity of the nose. In a successful primary rhinoplasty, reconstructive rhinoplasty techniques strive to conserve, rather than disrupt nasal cartilaginous form, and judiciously employ cartilage to this end. Fixing a bad nose job, however, one must judge whether to remove deformed and nonfunctional cartilage and insert “new” cartilage for support and contour. Aesthetic tips can also be sculpted to refine their round or boxy shapes via fibrous scar resection, without cartilage grafts. Instead of sculpting the cartilage, it can also be repositioned or reshaped by suture-shaping techniques to improve tip support or symmetry.
Graft materials can be further divided according to their source into autografts, allografts, and synthetic implants. Autologous graft harvesting often requires the removal of septal cartilage, followed by ear cartilage, rib cartilage, or cranial bone. The combined use of these materials is common in large rhinoplasty cases. When materials must be sourced from multiple sites, caution must be shown in order not to overly traumatize a patient with multiple incisions. Synthetic implants are non-bioreactor; that is, they do not undergo resorption or migration. Each of these materials has a theoretical ideal anatomical site to insert them for fixation. At the same time, all grafts must be well-recessed underneath the skin-soft tissue layer in order to prevent visibility or extrusion. The reconstructive facial plastic surgeon must be resourceful in using these surgical techniques, sometimes in tandem, in the order of fixing a bad nose job. Anatomy evolves as surgical experience and research evolve.
After the surgery, the patient will have external nasal splints with dressings inside the nose. The splints and dressings will be removed in the doctor’s office 5 to 7 days after surgery, as well as the non-resorbable sutures on the nasal skin and the absorbable sutures inside the nose. The external splints are to be left alone and fall off by themselves in a period of around 10 days after surgery. If you have any concerns about detergents or adhesives you would like to use on your skin, you can discuss this with your doctor. You can expect your doctor to show you how to care for your incisions and how to change your nasal dressings, so that you know how to do it at home. The usual postoperative antisecretory treatment will be prescribed: inhalations, glycosides, and antihistamines are recommended in case you have to have a primary connection with a person infected with the flu, etc.
If the adjustment involves positioning or reshaping the septal cartilage inside your nose, small plastic splints will be inserted and they are to be removed about 7 to 10 days after surgery. In case the procedure involved repositioning the septum, you can expect a slight splinting of the nose to be left that will prevent and maintain a nose correction (revision rhinoplasty) septal set, and to allow the reestablishment of the functions of the nose. The nose should also be packed after surgery depending on the intervention procedures, but removal is generally 24 to 72 hours after surgery, so breathing can improve and the packs and bandages are not very unpleasant. The patient should pay special attention to nasal hygiene in the first 1 to 2 months following surgery, as well as lung function, to prevent early postoperative infections and potentially severe complications, and they are to be very careful with their new nose for 1 to 2 months ahead.
