Revisions After Rhinoplasty
26 November 2019 onur
Anyone who is considering a rhinoplasty must have knowledge of “revisions”.
Revisions are not something that you can see briefly on the consent form the day before the surgery and thus completely learn about.
Considering the plastic surgery literature, the rate of revisions after rhinoplasty varies between 5-15% while post-surgical dissatisfaction rates vary between 15-30%.
Plastic surgeons and training clinics that present this data to the plastic surgery literature are perhaps the most respected members of the scientific community and are not “knowledgeable novices”.
Unfortunately, I come across some expressions such as “guaranteed” rhinoplasty on the Internet and social media.
If a surgeon doesn’t tell you about the possibility and strategies for revision during the initial examination, run away.
Everything in life that seems too good to be true is often not true.
Today, social media has come to a very decisive position in the surgical preferences of rhinoplasty candidates. In all these media, what we call “selection bias” in the scientific community can be observed. Everyone puts their best results on Instagram, and you don’t see the bad ones. When you look at them, there are 500 patient photographs, each of which is more beautiful than the other, but 50 revision photos are not there.
There are various factors that affect the revision rate of surgeons.
The first of these is the quality standards you set in surgery. If it is a sufficient result for a surgeon to give a nose that is “better” than the baseline, that surgeon’s revision rates will be low. If you set your standard as “the best possible for a patient”, your revision rates will rise in an instant.
Another factor that determines the revision rate is the time allocated to preoperative planning and the habit of performing surgery in accordance with the plan. A pre-rhinoplasty interview cannot take only 10 minutes. In my practice, I allocate 30 minutes to the first patient interview for rhinoplasty. In addition, there is a second 30-minute examination devoted to preoperative planning. During this second examination, the nose is photographed and measured, and a digital plan is made. Although we cannot apply the preoperative plan exactly in every patient, preoperative digital planning virtually eliminates the possibility of significant deviations from the plan.
The main factor determining the revision rate is the experience of the surgeon. The first 100 cases of any surgeon are a minefield. As a plastic surgery proverb says, “If a surgeon is not piling up money in an operation, he is piling up experience.” If you choose to be operated by a research assistant in their 3rd year of medical specialty education on plastic surgery, you automatically accept a more average result and a higher probability of revision.
Experience alone is not enough to save the day. Imagine a surgeon who performed 2,000 rhinoplasties using the same technique. An experienced surgeon can really master their own technique, and they can be one of the best practitioners of that technique in the world. However, even if they do 10,000 cases, they are still doomed to be stuck within the limits of that technique. Two heads are better than one. You must follow the literature and the relevant developments in your field. The most recent example in this field has been the tremendous change in the techniques and technology we use in shaping the nasal bones in the last 5 years. In the conventional technique, we break the nasal bones by hitting a metal chisel with a hammer, but no matter how good your hand skills are and how much experience you have, in some cases, the bone is broken where it is weakest, not where you want it to break. This is a technical limitation independent of the surgeon’s experience. Thanks to the ultrasonic bone cutting (piezo) technology, which has been used in this field in the last 5 years, we can now see the bone with bare eyes and cut it like we are drawing with a pencil. Ultrasonic bone cutting technology has virtually eliminated irregularities and stairstep deformities on bone fracture lines. We have now become able to perform many different surgical maneuvers that cannot be done with a hammer and chisel.
Another factor that determines the revision rate is the factor of chance. A group of unfortunate patients encounter very rare conditions such as infection, early trauma, and postoperative bleeding, and these can spoil even a beautifully-made nose. Sometimes the surgeon-related factors have implications on the patient. Being the fourth case on a given surgery day and being the only patient on a given surgery day are two very different situations in terms of the surgeon’s concentration and “aesthetic appetite”. No work of art or craftsmanship ever comes out of mass production.
Now, let’s get to the subject of revisions:
Revisions after rhinoplasty can be classified into two main groups.
Minor revisions are performed to fix minor issues. Minor problems are millimetric minor defects that occur after surgery. It is possible to see similar defects in most non-operated normal noses. Small pits or bumps on the nasal dorsum, millimetric differences between the nasal wings, deviation of the nasal tip from the midline by 1-2 degrees, the nasal wings being slightly wider than the nasal tip, the nasal tip being lifted or lowered 1-2 degrees more than desired are common minor defects. These problems can be solved in clinical conditions, under local anesthesia, through complementary procedures taking 15-20 minutes with materials the size of a dental filling. Adding adipose tissue and cartilage to the nose, supportive suture techniques, nasal wing narrowing, minor rasping, and cartilage weakening are the most common forms of minor revisions. Minor revisions are elective, so you either take it or leave it, but it will kind of be better if you take it. They are not major procedures allowing space for making a drama out of it, asking “Will I have a second surgery?” but rather small touches or “touch-ups”. I see my patients in the 3rd, 6th and 12th months after surgery, and if we detect anything during these controls that requires a revision, we make these revisions at the clinic right there and then. It may be necessary to perform some minor revisions under anesthesia in the operating room, considering the comfort of the patient.
Major revisions are performed to address “major”, that is, more obvious structural problems. These are the difficult operations you should be concerned about. In major revisions, it is necessary to reopen the nose and separate the cartilage/skin/bone/mucous layers that make up the nose from each other. While this isolation process requires an effort of 15-20 minutes in a nose that has not been operated before, it may take 1-2 hours in operated noses. As the number of previous surgeries increases, the tissues become more adhesive and thus more difficult to separate. Some surgeons may prefer to make revisions with a closed approach based on the camouflage principle because they are afraid of this separation stage. Major revisions are almost always caused by structural problems in the nose, and it is almost impossible to reconstruct a defective nasal structure with the closed technique in accordance with the original anatomy. Therefore, I always employ the open technique for major revisions.
In cases requiring major revision, tissue deficiencies are often observed after the tissues are isolated. The skin may have hardened and lost its flexibility, the cartilages may have been reduced or deformed by excessive removal, and the fracture lines in the bones may have set incorrectly. If there is tissue deficiency, it may be necessary to transplant external cartilage. We can harvest these cartilages from the ribs, ear or inside the nose. Major revisions are usually caused by mistakes in planning and execution, and less commonly by factors beyond the surgeon’s control, such as infection. Reinforcing the nasal structure as much as possible in the first surgery also simplifies the revisions that may be needed later. I recommend you take a look at my blog post on the “structural rhinoplasty” technique, which strengthens the nasal structure. If there is sufficient cartilage in the nose and the tissue volume is preserved in the first surgery, it is possible to go back and reshape the nose using the tissues available.
The most common reason for major revisions is that the nasal tip is not in the desired position after the surgery or that it cannot stay in the position secured during surgery. The second most common reason is the problems related to the nasal bones and nasal dorsum. Major revisions require more experience, take longer and are more expensive than primary surgery. Difficulty/time/price can be maximal, particularly if we use a rib graft. I recommend you take a look at my blog post on rib grafting.
Another point to consider about revisions is the unrealistic patient expectations.
For instance, the patient’s nose looks beautiful, but it does not fit with the ‘model’ the patient initially wanted. Rhinoplasty is not influenced by neither fashion nor popular trends. One cannot speak of popular techniques and popular surgeons when rhinoplasty is concerned. Those who want to change this model today will want to switch to another model tomorrow. As a matter of principle, I do not operate on patients who have been operated by another colleague and have a beautiful nose but still want to change the ‘model’. Indeed, I do not refuse the revision requests from the patients I operated if we have achieved a significantly different postoperative result than what was planned preoperatively (which is extremely rare).
During rhinoplasty, we always prioritize expanding the airway as a principle. This surgical approach is called volumetric (volume-focused) rhinoplasty. Although we optimize your intranasal volume during surgery, allergic/reactive enlargement of the nasal concha may be observed in the future, and these might make breathing difficult. In this case called turbinate hypertrophy, we initially start a drug treatment. If we do not get a response, surgical reduction of the nasal concha may be required. Such secondary procedures should not be considered as revision of rhinoplasty.
Please feel free to contact us for detailed information on revisions after rhinoplasty.
Take good care…
… of yourself and your beauty.