Reconstructive surgery of the nose
What is Revision Rhinoplasty?
Revision rhinoplasty involves re-operating a nose to improve a previous poor result and can be one of the most difficult surgeries to perform in plastic surgery. Revision rhinoplasty can take two forms. The first is the small “touch up” revision of an acceptable previous result. The patient may be happy with the overall appearance of the nose, but may wish a small and slight improvement. For example, a small tiny bump was left on the bridge or a small visible edge on the tip. Revision rhinoplasty in this case is usually a less involved operation. The patient is typically content with having the surgery performed by the original surgeon since trust was not lost. Patients are typically not emotionally upset.
The second form is when the revision rhinoplasty is performed to reconstruct a previous poor result. A failed rhinoplasty can be one of the most devastating experiences a patient undergoing plastic surgery can have. Patients that undergo rhinoplasty have usually thought about the surgery for several years. When the result is a nose that is worse in appearance than the original nose, the patient can become extremely disappointed. Self esteem and confidence may decrease and affect the person’s social activities. I have a deep and personal understanding of the emotional distress that patients undergoing through this feel and I am committed to helping them.
There are several reasons why rhinoplasty can fail. However, the most common reason is technical error during the surgery. Surgical experience, pre-operative planning, and meticulous surgical technique are essential to a good rhinoplasty outcome. Improperly placed incisions, aggressive removal of cartilage and bone of the nasal bridge, and aggressive removal of nasal tip cartilages leading to poor structural support can all lead to an unnatural and awkward appearance. This in turn will draw unpleasant attention to the nose.
With the increasing numbers of cosmetic procedures being performed, there has been an increase in the demand for rhinoplasty surgery. While many surgeons perform plastic surgery throughout the body, few are specialists in the nose and face. A plastic surgeon that performs only 5 to 10 rhinoplasties a year may not be the best surgeon to perform a rhinoplasty. He may not have sufficient experience or the proper training to perform the rhinoplasty procedure. At the same time the rhinoplasty consumer has developed a sophisticated sense of nasal aesthetics. The delivery of poor surgical results and elevated expectations has resulted in an increase the number of revision rhinoplasty procedures being performed today.
Revision rhinoplasty can be one of the most difficult plastic surgery procedures to perform. The restoration of the damaged nose can be technically and artistically challenging. Often, the nasal cartilages have been removed and scar tissue has replaced much of the structural framework. The remaining nasal cartilages are often warped or misshaped. The nasal structure must be recreated using cartilage grafts to mimic the framework of a virgin, or non-operated, nose.
This reconstruction must be exact and flow together in a 3-dimensional fashion to give the appearance of a beautiful nose that will balance the patient’s facial features. Scarred and altered tissues must be placed back in the proper place by re-arranging the nasal framework. All this must be done while combating the distorting effects of a skin and soft tissues that have been scarred by the previous poor surgical result.
The structure must be strong enough to withstand the tremendous scar formation forces that are sometimes present during the healing period of previously operated noses. The function of the nose, that is breathing, must be maintained or, in many times, repaired. This is done by strengthening those elements of the nose that are responsible for maintaining the air passages open.
Return to normalcy
My philosophy when confronting severely distorted noses is the following: to return the nose to normalcy, so that the nose appears normal and is no longer the center of attention. Often, the noses have an operated or surgical appearance that attracts attention. My goal is to give the nose a natural and non-operated look, so that it is no longer the center of attention.
In other words, to remove the surgical appearance and make the nose normal. There are noses that because of the damage they suffered, may never achieve perfection. However, I strongly believe that if they are brought back to normalcy, they well blend with the facial features and will not attract undue attention.
Am I a Candidate for Revision Rhinoplasty?
The ideal candidate for revision rhinoplasty is a healthy person who is not content with their previous rhinoplasty result. The timing of revision surgery should be approximately a year after the previous surgery. Although patients may feel compelled to undergo the surgery at an earlier time, patience is a real virtue here. Allowing adequate time for the post-operative swelling to completely subside will help to avoid a surgical error.
Patients that suffer from a poor previous rhinoplasty result often feel uncomfortable with the appearance of their nose. They may feel embarrassed or insecure with themselves. In addition, they may have difficulty breathing. It is for these two reasons, aesthetics and breathing, that the decision of having a revision rhinoplasty procedure is an extremely important one. This is because every time that the nose is operated, the probability of having a satisfactory result decreases
What is the Importance of Skin in a Revision Rhinoplasty?
The skin and soft tissue envelope is an important anatomical component of the nose. Understanding its importance in revision rhinoplasty is paramount. As a result of previous surgery, the skin and the soft tissues are often scarred to the remaining nasal framework. This scar tissue can replace the cartilage that was removed during the original surgery.
The dissection must be meticulous to avoid damage to the skin, which is often thin. In addition, one of the main differences between primary and revision rhinoplasty is the intense inflammatory response seen in the nasal soft tissue that occurs after the revision surgery. While the normal inflammatory reaction seen after a primary rhinoplasty is mild, the nasal soft tissues may react very differently after a revision rhinoplasty.
This reaction is more intense with an increasing number of surgeries. This can damage an otherwise good cosmetic result. It is imperative that the surgery be performed in an atraumatic and meticulous fashion to prevent inflammation and scar tissue formation.
Patients with thick skin must be dealt with in a very different way than those with thin skin. There are several issues that must be considered. First, patients with thick skin need very strong nasal tip support to help keep the tip in the ideal position. Because thick skin is heavy, the tendency is for the weight of the skin to pull the nasal tip down.
What are the Risks of Revision Rhinoplasty?
Every surgical procedure has certain risks. As far as a revision rhinoplasty is concerned, there are some possible complications. Bleeding after surgery occurs less than 1% and is rare. Most of the time it can be controlled with cauterization or light packing. Infection is rare and also occurs less than 1% of the time. If it does occur, it can usually be treated with oral antibiotics.
The risks of revision rhinoplasty are almost always higher than those associated with primary rhinoplasty. The surgeon must recreate the structural framework of the nose that was removed during the original rhinoplasty. In addition, your doctor must deal with the consequences of soft tissue scar formation and airway compromise. Even when the surgical operation is properly executed, there are factors that can affect the final result. Scar tissue formation, graft failure, graft shifting, or warping, and prolonged swelling can turn a otherwise successful result into a les than perfect outcome. That being said, most patients that have realistic expectations are happy with an improved nasal appearance.
How is the Recovery for Revision Rhinoplasty?
Your doctor would like for his patients to spend the night of the revision rhinoplasty in a relaxed atmosphere. Patients should rest and relax. The patient should maintain a liquid diet for the first twelve hours after anesthesia. Two pillows should be used to keep the head elevated. This helps to reduce swelling. Small zip-lock bags filled with frozen peas should be kept on the eyes every ten minutes an hour for the first forty-eight hours. This will help to reduce the eye and nasal swelling.
Most patients that undergo revision rhinoplasty do not experience any pain. In fact, most patients do not take the pain medication that is given to them. Occasionally, your doctor may place a small cotton ball in the nostrils. If this is done, they are removed the next day in the office. A small cast is always placed on the bridge of the nose. This is removed on the fifth or sixth day after surgery. Most patients can return to work on the sixth day after surgery. Patients may fly home on the sixth day after their revision rhinoplasty if they wish. Exercise is allowed three weeks after surgery.
The nasal swelling after a revision rhinoplasty varies. About seventy percent of the swelling resolves after the first month. The last thirty percent may take up to a year or more, depending on the thickness of the skin. In individuals with thick skin, the swelling may take a year and a half to fully disappear. Even though the swelling after a revision rhinoplasty takes some time to resolve, most patients look much better than before surgery right when the cast is removed on the fifth or sixth post-operative day.
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