Revision rhinoplasty refers to performing a rhinoplasty on a nose that has been previously operated on one or more times. It is usually carried out as a result of complications or suboptimal results from the previous surgery. Complications that can lead to the need for a revision rhinoplasty include infection or extrusion of a nasal implant. Extrusion refers to exposure of the implant to the external environment due to breakdown of the integrity of the skin or inner lining of the nose. Suboptimal results that can lead the patient to seek a revision rhinoplasty include a nasal implant that is tilted, curved, displaced from the midline, or sitting too high up on the nasal bridge causing the radix (the junction of the forehead and nose) to look unnaturally high. Other causes of suboptimal results include a nasal tip that is too short, too bulky or both. This is sometimes associated with excessive exposure of the nostrils.
A significant proportion of Dr Huang’s rhinoplasty cases are revision rhinoplasties to address the issues described above.
Revision rhinoplasty always requires an open rhinoplasty approach, as it is usually a complicated, lengthy and technically challenging procedure. The open approach allows the surgeon to obtain complete access to the internal structures of the nose so that the procedure can be carried out and as efficiently as possible.
The native cartilage parts of the nose and any cartilage grafts that may have been previously placed are identified, dissected and exposed. Old cartilage grafts are then removed and saved for possible reuse later in the operation. The implant, if present, is removed, together with part of the capsule of scar tissue surrounding the implant (partial capsulectomy). All other scar tissue is carefully removed or cut loose, so that the nasal cartilages, internal lining and external skin and soft tissue envelope can be freely mobilized.
Cartilage grafts are then harvested from available donor sites as needed: the nasal septum, one or both ears, or a rib. The cartilage grafts are designed and cut to the appropriate shape and size. They are then used, together with any usable previous cartilage grafts to create a new nasal tip which is usually longer and has increased definition. In addition, if the previous nasal tip was overly rotated upwards, this is corrected as well.
Next, a new nasal implant of suitable material and dimensions is placed directly on the bone of the patient’s own nasal bridge extending from the radix to the supratip (the area just short of the tip). The new nose is thus made up of multiple cartilage grafts (for the tip) and a new implant (for the bridge). The inner lining and skin, having been previously mobilized, are now stretched and draped over the new nasal infrastructure and the incisions are closed with fine sutures.
Surgical tape is then applied over the nose to stabilize the implant and reduce swelling.
Postoperative pain following a revision rhinoplasty is minimal and well controlled with oral pain medications. Swelling is usually moderate, and may be more than after a primary rhinoplasty. There may be mild bruising. The nose will feel blocked for the first few days due to internal swelling. The tapes and stitches are removed after one week. Downtime is usually about two weeks. By then, about half of the swelling will have subsided and the nose looks fairly presentable. Exercise can be resumed after one month. The swelling from a revision rhinoplasty may ultimately take longer to completely subside compared to a primary rhinoplasty, although by one month postoperatively the majority of the swelling is likely to have subsided.
Revision rhinoplasty does not necessarily carry increased risks than primary rhinoplasty as long as the principle of not using an implant to create the new tip is adhered to. Having only the patient’s own cartilage in the nasal tip greatly enhances safety and protects the tip from infections and extrusions. Blood loss may be slightly increased in a revision but is usually still not significant. As with a primary rhinoplasty, the risk of the implant tilting or going out of position is minimized by judicious selection of implant size and shape, good surgical technique, and careful and close monitoring and adjustment (where necessary) of the implant position during the recovery period.
A revision rhinoplasty will usually be more costly than a primary rhinoplasty because it is more difficult, complicated and time consuming. This is unfortunately unavoidable and applies to virtually all types of revisionary surgery. However, it is usually possible to successfully correct most types of suboptimal results from primary rhinoplasties by using the techniques described above, and patient satisfaction levels therefore tend to be high. This makes the higher cost worthwhile in terms of the benefits obtained.