Key points

Introduction

Revision rhinoplasty is one of the most challenging operations the facial plastic surgeon performs given the complex 3-dimensional anatomy of the nose and the psychological impact it has on patients. The intricate interplay of cartilages, bone, and soft tissue in the nose gives it its aesthetic and function. Facial harmony and attractiveness depends greatly on the nose given its central position in the face. In the following article, the authors review common motivations and anatomic findings for patients seeking revision rhinoplasty based on the senior author’s 30-year experience with rhinoplasty and a review of the literature.

Introduction

Revision rhinoplasty is one of the most challenging operations the facial plastic surgeon performs given the complex 3-dimensional anatomy of the nose and the psychological impact it has on patients. The intricate interplay of cartilages, bone, and soft tissue in the nose gives it its aesthetic and function. Facial harmony and attractiveness depends greatly on the nose given its central position in the face. In the following article, the authors review common motivations and anatomic findings for patients seeking revision rhinoplasty based on the senior author’s 30-year experience with rhinoplasty and a review of the literature.

Assessment of patients with revision rhinoplasty

Every rhinoplasty surgery is performed with the intent of improving appearance and nasal breathing and achieving a satisfactory outcome. Despite our best efforts, rhinoplasty revision ranges in the literature from 5.0% to 15.5%. At a certain level, all patients who are seeking revision surgery experience disappointment with their original surgery. The possibility of a dissatisfied patient is very real. Being prepared to treat patients seeking revision rhinoplasty is part of the facial plastic surgeon’s practice. Additionally, as a surgeon becomes more experienced and established in the community, more patients seeking revision rhinoplasty will come to his or her practice. A facial plastic surgeon should prepare thoughtfully for these challenging cases.

Analyzing a nose preoperatively to prevent the need for revision requires careful assessment of the anatomy. Surgical maneuvers should be planned to produce the desired effects in a durable fashion that will remain satisfactory through the long process of healing and many years after the initial surgery. Surgeons should take into account that subcutaneous fat of the nose thins with aging and grafts placed in the nose of a teenager may show in later adult years. Modern rhinoplasty has shifted away from reduction rhinoplasty to techniques that reshape and support the nose. In reduction rhinoplasty, weakened cartilages collapse and twist under the strong forces of scar contraction that over time, sometimes decades later, gives an unappealing external appearance to the nose and cripple breathing. Support is particularly important in revision rhinoplasty where strong scar contractions are present. Experience will help the rhinoplasty surgeon with these intraoperative decisions to establish the size and shape of cartilages and grafts that will provide the desired outcome.

In a recent retrospective review of an established rhinoplasty practice, Dr VanderWoude and colleagues identified risk factors for postoperative dissatisfaction and need for revision rhinoplasty. Postoperative complications, a history of nasal fracture, and lack of anatomic correlation were risk factors for dissatisfaction. Postoperative infections, displaced nasal stents or casts, and scarring led to poor healing and negatively impacted the patients’ outcomes. Traumatic crooked noses are well recognized as a technically challenging rhinoplasty group. In a prospective study by Cingi and Eskiizmir in Turkey, patients with deviated noses undergoing rhinoplasty experienced decreased satisfaction and worse postoperative quality of life as compared with patients with straight noses. Technical and, perhaps more importantly, psychological aspects impact these differences. In the study, the outcomes of patients with deviated noses were judged equally successful to the nondeviated noses by peers and surgeons. The patients did not agree with other examiners.

Psychological aspects are often quoted as the most difficult aspect of revision rhinoplasty by experienced surgeons. In order to have a successful surgery, the surgeon must understand what motivates patients to seek revision. Specific alterations to the nose or concerns with nasal obstruction and nasal breathing should be discussed. Accurate and open communication will help define the operative goal. Communication is crucial for the doctor and patients to have a satisfactory outcome. It is important to note that often the patients and the surgeon differ in their evaluation of the nose. Studies have shown rhinoplasty surgeons will identify many more abnormalities than what the patients themselves point out. Rhinoplasty surgeons are trained to look at noses critically. In a recent study, the surgeon identified approximately 40% more nasal deformities than the patients. The surgeon must recognize the patients’ concerns and make it a priority to address them. Gaining the patients’ trust depends on the physician being able to understand the patients’ concerns and expectations and project realistic outcomes. Evaluating the nose together, with the use of a mirror or photography, facilitates communication. Consider using computer simulations, either 2-dimensional or 3-dimensioal, if it will improve communication.

Establishing realistic goals for surgery is key in achieving satisfaction. It is necessary to differentiate and recognize patients’ perceived and truly inadequate results. A quest for a perfect nose can have high risks with minimal benefits and should be addressed before moving forward with surgery. The anatomy of the particular nose and face might have limitations that preclude a specific outcome. Every patient has a unique facial structure and nose with certain traits, such as cartilage shape, strength, and skin thickness and quality. With each trait come certain advantages and disadvantages that will require different handling in surgery. Patients with thick skin that requires more grafting and increased projection to enhance definition are often hesitant to choose this option for fear of a big nose. Successful surgeons are able to discuss these issues with their patients and manage expectation. Finally, identifying patients with depression and body dysmorphic disorder (BDD) can help prevent unhappy patients. The incidence of BDD can be as high as 13% of the patients seeking cosmetic surgery. Do not be afraid to turn patients down or refer them to another surgeon.

Common motivation for patients seeking revision rhinoplasty

Rhinoplasty surgeons continue to try to understand the type of defect that leads to revision rhinoplasty. In the following section, the authors review studies that have looked at common complaints and findings in patients with revision rhinoplasty. Patients seeking revision rhinoplasty often have different concerns than those of patients seeking primary rhinoplasty. Adamson and colleagues performed a retrospective review of primary (308 surgeries) versus revision (92 patients) rhinoplasty during 9 years of their practice. The most common concerns for patients with primary rhinoplasty were a dorsal hump (50%), large nose (44%), bulbous tip (44%), and nasal obstruction (33%). In contrast, patients with revision rhinoplasty complain of persistent deviation (38%), nasal obstruction (36%), bulbous tip (33%), and large nose (25%). Complaints that had a dramatic increase in revision surgeries compared with primary surgery were tip asymmetry (22%), dorsal sloop (11%), wide nostrils (19%), columellar show (11%), and alar retraction (4%). Stigmata of prior rhinoplasty leading to unnatural results, such as those discussed earlier, were often mentioned as causes for revision surgery. In a different study, Guyron and colleagues analyzed 100 consecutive revision rhinoplasties to identify the most common causes of revision. The most common causes for revision were nasal obstruction (65%), dorsum asymmetry (33%), nostril asymmetry (18%), and tip asymmetry (14%). In the study, septoplasty was performed in 71% of patients. Other maneuvers commonly performed were alar rim graft (67%), dorsal graft (63%), osteotomies (60%), and dorsal hump removal (46%). The final study in the literature assessing the motivations for patients to undergo revision rhinoplasty is by Constantian, who interviewed 150 patients in his practice. Commonly, patient motivation was a new deformity after rhinoplasty (40%). Other common motivations were failure to correct the original deformity (33%) and loss of a familial or ethnic trait (15%). The importance of understanding different ethnic and cultural backgrounds will continue to grow as the population in the United States and the world continues to diversify. Interestingly, 10% of patients found their initial results to be good but were seeking rhinoplasty for further improvement.

The relatively high degree of nasal obstruction in patients seeking revision rhinoplasty in these studies is striking. These findings highlight function is as important as appearance in rhinoplasty. Surgeons must address the septum and internal nasal valve to prevent nasal obstruction in patients with rhinoplasty. A recent study of patients with primary and revision rhinoplasty using rhinomanometry found that nasal valve obstruction and lateral wall collapse were equal or surpassed the degree of obstruction caused by a septal deviation. Additionally, patients who have procedures to address their nasal valve have the same degree of improvement as patients who had procedures to address the nasal valve and the septum. The importance of the internal nasal valve should not be underestimated.

An encouraging finding for both patients and surgeon embarking on revision rhinoplasty is the high success rate of this surgery in adequately selected patients. In the study by Constantian, self-reported patient satisfaction was 97%. A study from Netherlands reported 88% of patients had significant improvement 2 years after revision rhinoplasty using a validated questionnaire and 79% of patients would undergo surgery again.

Preoperative and 1-year postoperative pictures of a case of revision septorhinoplasty are shown in Fig. 1 .

Preoperative and 1-year postoperative photographs of a patient with revision rhinoplasty.

Preparing for revision rhinoplasty

Preparing for the revision surgery requires performing a detailed examination and constructing a mental plan for surgery. After discussing with patients and reviewing old photographs and operative notes, surgeons should take time to analyze the photographs and construct a plan. Although flexibility is still required during surgery, anticipating challenges will minimize improvisation. Tailor your treatment to your goal minimizing any majorly disruptive maneuvers. The authors recommend following a reconstructive ladder. The spectrum in revision surgery ranges from minimally invasive filler augmentation for small contour depressions to more extensive reconstruction with rib cartilage grafting. Complete deconstruction of the nose is not necessary in all cases. A word of caution is warranted for the use of filler for augmentation rhinoplasty. The risk of vascular occlusion leading to skin necrosis is real, and the correct plane of injection should be within deep to the superficial musculoaponeurotic system (SMAS). Infection is another known complication of filler injection. Different surgeons can be very opinionated as to advocate for or against the use of nasal filler. Current available evidence shows that complications do occur with nasal fillers, but the incidence is rare. Webster and colleagues published their results with 347 patients who had silicone injected in the nose, establishing a safety profile for this material. More modern fillers have the advantage of being temporary. The largest series of temporary filler augmentation of the nose comes from Dr Rivkin. In the calcium hydroxyapatite (Radiesse, Merz Aesthetic, Frankfurt, Germany) study, 385 patients underwent injections with satisfactory outcomes. There were 2 cases of partial skin necrosis that required wound care. Of note, 46% of patients required reinjection.

When planning for a revision surgery, expect a revision case to take longer than a primary case. Revision surgeries are often more complex because of the scar tissue and the changes to the anatomic components of the nose. Revision might seem deceptively simple but often take longer as tedious and delicate dissection is necessary. Be prepared to take the time needed in surgery to restore and refine the intricate anatomy of the nose. Nasal bones and cartilages are often collapsed, weak, twisted, or nearly absent. Restoring all of the components while maintaining a natural external appearance requires precision and surgical proficiency. Waiting 1 year for optimal healing before attempting revision has long been customary. The authors adhere to this rule, with some exceptions. When there is an abnormality that will not improve with time and decreased swelling, the authors will proceed with revision earlier. In a recent survey of the Rhinoplasty Society members, most surgeons reported using open rhinoplasty in most of their revision cases instead of an endonasal approach and at increased frequency when compared with primary rhinoplasty.

Planning for revision rhinoplasty also requires the surgeon to discuss with patients the materials that will be used. Commonly, septal cartilage and even auricular cartilage may be depleted. Autologous costal cartilage can be considered.

A recent meta-analysis reports the rate of warping at 3.0%, reabsorption at 0.2%, infection at 0.5%, migration at 0.3%, unfavorable chest scar at 3.0%, and pneumothorax at 0% (range 0%–0.32%). Irradiated rib is also a convenient option given the lack of donor-site morbidity. This option has long been criticized for its risk of reabsorption; however, in the authors’ experience, reabsorption has been rare. The largest available case series to date in irradiated rib graft for rhinoplasty is by Kridel and colleagues, which evaluated 1025 grafts and describes a rate of warping at 3.25%, infection at 0.9%, and reabsorption at 1.2%. Some of the patients in the study had follow-up of longer than 10 years. Alloplast is also an option for rhinoplasty. The most commonly used alloplastic materials for rhinoplasty are silicone, expanded polytetrafluoroethylene (e-PTFE, Gore-Tex WL Gore and Associates, Flagstaff, AZ) and porous polyethylene (Medpor, Porex Surgical, Newnan, GA). Historically, alloplastic grafting materials have been considered less desirable than autologous materials because of reports of infection, migration, and extrusion. However, the unlimited supply, along with no donor-site morbidity, has always made alloplastic material an attractive option. Recent case series and meta-analysis place the risk of infection as high as 12.6% and extrusion at 16.0%. Extrusion can occur many years after implantation, and cases of extrusion decades after implantation are not uncommon in the literature. The available studies on alloplasts have the limitations of being retrospective and subject to recall bias likely underestimating the rates of complications. Additionally, different locations might exhibit different rates of complications. The nasal dorsum might have a lower risk of complications and the nasal tip an increased risk.