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wasperformed FacialSurgery.com
Steven M. Denenberg, M.D.
Dr. Denenberg's articles on Medium.com.


What can be improved during a revision rhinoplasty?

Sometimes great improvements can be made, and sometimes very few.  Let's divide this discussion into two categories: A) where the primary surgeon did not have a good grasp of how to perform a rhinoplasty, and B) where the primary rhinoplasty was competently performed, but after surgery the nose still has features that the patient and her surgeon would like to improve.

A) The primary rhinoplasty was not excellent

In this category, a common complaint is that the nose is still too projecting (sticks out forward too far from the face) or too long.  I'll define those measurements for you.  The nose below left is projecting: it sticks out forward, away from the person's face.  The nose below right is long, where we measure length along the bridge of the nose down to the tip.

Correction of projecting and long noses requires detailed work on the nose's tip cartilages, something most plastic surgeons don't know how to handle.  If those tip cartilages were not severely altered during the first operation, we can often shorten and deproject the nose a great deal during a revision.

If a hump is still present, the hump can usually be taken down more.  Also, if a hump was over-resected, leaving the patient with a "scooped-out" appearance, the height of the nasal bridge can be built up again.

If the upper half of the nose is still too wide, perhaps the nasal bones weren't narrowed during the first operation, and that can be accomplished.  If the lower half of the nose is too wide, work on the tip cartilages can narrow the tip, or perhaps the nose is wide because there is a large amount of scar tissue under the skin, scar tissue that could be removed during the revision operation.

Most complaints that people have after an unsatisfactory primary operation can at least be addressed, and it's up to the revision surgeon to communicate to the patient how much improvement he feels he can achieve in each area of the patient's dissatisfaction.

B) The primary rhinoplasty was competently performed

If the primary rhinoplasty was competently performed, then the patient/surgeon discussion about whether to perform a revision rhinoplasty is usually related an isolated, well-defined feature, such as a small remaining hump, an asymmetry, or the nose not having moved enough in some direction: it's still a little too long, or a little too wide, etc.

A decision on whether to proceed with a revision requires that we evaluate a few factors:

Is it worth it to the patient?  A rhinoplasty patient will always notice imperfections in her nose after surgery, because no nose is perfect after a rhinoplasty.  But if the patient was well-counseled before surgery, she knew and understood and accepted that limitation, and perhaps the imperfections that she sees don't bother her enough to give them a second thought, much less to request a revision.

Is it possible to correct the area of concern?  Sometimes it's not.  For example, if the nose looks great, but it's just a little off center from the frontal view, that problem can be so difficult to predictably correct that it might not be advisable to try.  On the other end of the difficulty spectrum, a small hump remaining on the bridge of the nose can usually be corrected with safety.

Here's another example: let's say that the patient and surgeon think that the tip of the nose is still a bit too wide.  The surgeon checks his operative report and sees that the technique he used to narrow the tip of the nose was the strongest, most effective technique available.  The skin on the tip of the patient's nose is a little thicker than average, too.  The surgeon may advise against a revision, because he wouldn't be able to narrow the tip any more; the cartilages have been narrowed as much as possible already.

Finally, what are the risks of the revision?  Any nasal operation comes with risks.  If the feature that the patient notices is improvable, but attempting to correct it would put some other nice features of the nose at great risk, and the feature to correct isn't all that bad, the patient and surgeon might decide to forego an attempt at revision after carefully weighing all of these considerations.


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