Your question: What is Wrong? What Should I Do Next? Revision Rhinoplasty 21 Months Ago?

My initial operation left me being unable to breathe through my left nostril. My nose looks ok from profile but facing on, very wide and a small piece of cartilage??is poking out mid bridge on the right side Should my nose be this wide after grafts? Initially my nose was slim with a bump. I would be grateful for some advice. Thankyou

Dr. Denenberg's answer: That bump can be removed, and your nose might benefit from a profile adjustment, too

I see the areas that you complain of. If you have grafts in the nose, and it is hard cartilage that is causing the bump on the right side and the excess width, it can be predictable to narrow the nose by removing or adjusting the offending graft. You probably also have some scar tissue under the skin that could be trimmed. See the Web reference link for a digital modification of your photo showing the improvements.
I personally think your profile could be made more natural as well. The tip of your nose is projecting forward, beyond the line described by the bridge of your nose. I'd like to see the tip of your nose closer to your face, and the very bottom of the nose tucked up a small amount to decrease the amount of the inside of your nose that is visible from the side view. I made a modification of that view as well. Bringing the tip of the nose back closer to the face is one of the most predictable changes in revision rhinoplasty, in competent hands.< p>

From Steven M. Denenberg, M.D.:

Here is the before and after I made of your nose. I brought the tip of your nose back closer to your face, "deprojecting" it, and decreased the amount of the septum, the inside of your nose, that is visible from this side view.

Note that I did not build up the bridge at all. I think that's a more risky procedure, and it opens up the possibility of more complications:

Click the image above if you wish see more before and after photos of revision rhinoplasty patients.

Here is an animation of that change:

 

And here is an animation of making the frontal view more narrow. You'll see that I only narrowed it a small amount; narrowing the frontal view of the nose is difficult, and I don't like to show too much narrowing on an animation:

 

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Plain talk about picking a plastic surgeon for your first-time or revision rhinoplasty.

I do lots and lots of revision rhinoplasties, and I'll try to give you some advice here, to maximize the chances that you'll be happy after surgery, and to minimize the chances you'll need a revision.

Important!!  How to tell whether your consultation was acceptable:

Photos.  If a surgeon doesn't show you before and after photographs, scratch him off of your list. Period. No exceptions. Deal-breaker.

You pick a surgeon primarily from his before and after photos. Diplomas, board certifications, hospital affiliations, academic appointment, and even reputation tell you nothing: a surgeon is never tested for his skill, his artistic eye, the quality of his outcomes, or even whether he cares that his patients are happy.

You must see photos of other patients who had some features similar to your nose. For example, if your nose has a wide and drooping tip, don't accept profile-only photos of patients who had a hump carved down. You can't see the width of the tip on a profile photo.

Revision nose operations are much more difficult than first-time operations, so if you are consulting a surgeon about a revision operation, you must see photos of his revision patients.

If you see the surgeon's photos, but you don't love them, scratch him off your list. You want to use a surgeon whose work you like. Don't assume that he'll do great on you when he didn't do great on the other people.

Communication. If the doctor treats you disrespectfully, scratch him off your list. If he won't patiently listen to what you want for your nose, same thing. How will he know how to make you happy if he won't hear what you want for your nose?

If he conducts the consultation from behind his desk and doesn't examine your nose, deal-breaker. If it's the nurse and not the surgeon who conducts the consultation, run away fastest. All due respect to the nurse, she doesn't know what's possible and what isn't. If the plan is to see the surgeon for the first time on the morning of surgery, deal-breaker. For sure.

Computer morphing. If the surgeon doesn't do computer morphing of your nose, scratch him off your list. The morphing is crucial, so the surgeon can prove to you that he understands exactly what your goals are. Also, if the surgeon recommends some changes that you hadn't thought of, you need to see the morphs, so you can see whether you like those changes.

Your intuition. If your gut tells you "no," don't use the surgeon. Don't ever use a surgeon only because you know him, or your kids know him, or he lives on your street, or your primary care doctor referred you to him, or he did your breasts, or your tonsils, or your wisdom teeth, or you saw his advertisement, or his awards.

I hear these stories all the time from my revision rhinoplasty patients. You must do your own evaluation of any surgeon you visit. And by "evaluation," again, we're talking mostly about seeing his photos and seeing how well he communicates with you. Don't bother checking the surgeon's licensure and board certification and hospital affiliations and all that; it'll just distract you from what's important.

Conclusion. The fact is, the great majority of plastic surgeons who perform rhinoplasty shouldn't be doing the operation. It's an incredibly difficult procedure, technically demanding, requiring experience, skill, judgment, an artistic eye, an exceptional level of communication and thoughtfulness, and a rare level of empathy and caring for the patient. No hospital board protects you by judging the quality of a surgeon's rhinoplasties and prohibiting him from operating if he's terrible. It's the wild, wild west out there, folks.

 

More plain talk: should you let your primary surgeon perform your revision?

Rhinoplasty is by far the most difficult of the facial plastic surgery operations. And revision rhinoplasty is ten times more difficult than a first-time operation.

First, you need to consider whether things didn't turn out great on your first operation because of some unusual circumstance with the surgery or the healing, or whether things went wrong because your doctor was not expert in rhinoplasty in the first place.

Evaluate your surgeon again. Read the section above, on how to evaluate a surgeon for a rhinoplasty. If you saw lots of before and after photos of your surgeon's other patients who got excellent results, in noses at least somewhat similar to yours, then your surgeon probably knows what he is doing, and you can consider letting him perform your revision. Even the very best surgeon has the occasional disappointing result.

However, if, on looking back, you decide that you did not do excellent research on your original surgeon -- perhaps you relied on a referral, or on his board certification, without being able to see his photos -- then you probably should not have him perform the revision. If he couldn't get you close to your goal the first time because of a lack of skill, he will have no chance at all on the second try, and then you'll be in the tough position of looking for a third operation.

 

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