Why is Revision Rhinoplasty Tougher?

Revision rhinoplasty, also commonly referred to as secondary rhinoplasty, is any time the nose has surgery performed on it after the first surgery. Revision rhinoplasty is more often than not more difficult to perform than a primary (first time) procedure. It takes more time to complete, will often require materials gained from other parts of the body, and requires more knowledge, experience, and technical skills on the surgeon’s side. 

So why is secondary rhinoplasty much tougher to perform? Well, to begin with, the anatomy is no longer pristine, but rather, there will often be an abundance of thick, hard scar tissue from the previous operation. Scar tissue obscures the natural tissue planes that separate the various cartilages, bone, and soft tissue within the nose. Precise and careful dissection is often painstakingly necessary to separate the scar tissue from normal structures of the nose.

Defining the normal existing anatomy of the nose is only the beginning and this alone can take hours. Once the existing anatomy of the nose has been clearly defined, the surgeon then has to assess what’s present, what’s absent, what’s normal, and what’s abnormal. This assessment is followed by correlation with the current clinical picture and what is the desired final outcome. To achieve this desired result, the surgeon then has to begin formulating a plan to “re-build” the nose. 

The nose is like a tent, supported by its poles. Underneath the skin of the nose, there are inter-related cartilage structures that give shape to the nose. More importantly, these cartilages also keep the nostrils open and allows a patent airway to breathe through. Not uncommonly, a revision rhinoplasty case will present a nose that lacks structural support. Imagine a tent which has weak tent poles. A nose like this will lack strength and is at risk of collapse. One of the reasons why this type of nose may lack support may be due to over-removal of tissue from the previous operation.

To restore structural support to the nose, one has to find material (usually cartilage) to build and also support the construct of the nose. The cartilage that is used is often taken from the septum (the structure that runs down the middle of the nose), the ear, or the rib. “Harvesting” this cartilage material is another factor which adds to the complexity and time required for a revision rhinoplasty. It also adds to another scar on the patient. 

At the outset at any rhinoplasty, one has to devise a plan together with the patient that aims to achieve the ideal outcome through one, first, and final, procedure. That been said, as with any other surgery, there is always the chance that the outcome achieved may not be 100% in line with what the patient expects. Complications can occur, and revision surgery is always a possibility. With nose surgery, both surgeon and patient need to be extra patient before they evaluate the final result. Swelling in the nose can persist for many months after surgery, especially in men and in thick skinned people.

One must be careful not to rush into performing a revision before the final shape of the nose is realised. The shape and function of the nose will continue to change and often improve as swelling subsides and the scar mature. Regular follow up between the patient and surgeon is therefore crucial to ensure that the patient is progressing in the right direction.