Revision rhinoplasty

It is performed to correct the unsuccessful results of a previous rhinoplasty. Unfortunately, rhinoplasty may not be successful in every patient. The nasal tip may appear pinched, narrowed, wide, asymmetric, drooping or over-rotated (a “pig nose”). The nostrils may be asymmetric or wide. There may be collapse of the lateral walls of the nose and difficulty breathing. On the nasal dorsum there may be a pollybeak appearance caused by insufficient removal of the cartilaginous part, or a saddle-nose depression caused by removing too much. In the middle third of the nose there may be an inverted-V deformity, a twisted nose, persisting deviation, irregularity of the dorsum, scar-tissue formation inside or outside the nose, and skin and soft-tissue problems.

Firstly, a revision operation may be needed in 5–8% of cases after rhinoplasty. Some of these require a minor intervention, others a major one. In a minor revision the result of the first operation can be accepted as close to normal, and only a small intervention is made. The patient may be satisfied with their current nose and overall appearance but may want small corrections. If there are serious deformities after the previous operation, a major revision operation is performed.

Why does rhinoplasty fail?

• Insufficient experience of the surgeon
• Unrealistic expectations of the patient
• Problems caused by poor healing and scar tissue
• Nasal trauma after the operation.

To prevent or reduce failure:

1. A detailed examination before surgery, a good plan, and careful and patient work during the operation are essential. It is not the duration of the operation but always its result that matters.

2. The nose must be corrected as a whole — that is, both externally and internally, in functional terms.

Although revision rhinoplasty can be performed as early as 6 months after the first operation, it is worth waiting 9–12 months. In some noses with thick skin it is necessary to wait 2–3 years for the nose to form completely.

Anterior rhinoscopy reveals abnormalities such as septal deviation, enlargement of the inferior turbinate (“nasal flesh”), synechiae, scarring, septal perforation, etc. Other findings (concha bullosa, adenoids, polyps, chronic sinusitis, choanal stenosis) may not be seen with this examination. Therefore an endoscopic examination must be carried out and, if necessary, a sinus CT scan performed.

Course of the operation:

Open or closed rhinoplasty can be performed. Open or closed is not a surgical technique but the route used to reach the bones and cartilage of the nose. In the open approach, the skin is lifted with an inverted-V incision on the columella (the part that separates the nostrils from each other) to reach the bony and cartilaginous parts. At the end of the operation the incision is closed with sutures. During recovery the scar is almost imperceptible; it can be noticed only on careful, very close inspection. In the closed technique the incision is inside the nose. There is no rule as to whether the open or the closed technique is better for the nose. The main point here is what intervention the nose needs and by which method it will be solved. In cleft lip, nasal-tip asymmetry, a twisted nose and noses requiring major revision, the open approach is used. The advantage of the open approach is that it allows full control of the nose and the use of various graft and suturing techniques.