The 10 Questions Everyone Asks About Revision Rhinoplasty

Dr. DeBusk (00:11):
Today we're doing the top 10 questions people ask about revision rhinoplasty. So how is revision rhinoplasty different from a primary rhinoplasty? So there's a lot of different things when we look at revision rhinoplasty. One, rhinoplasty is already a technically difficult surgery to perform. It's my favorite surgery to do, but when we look at a nose, there are so many components to the nose and it's very intimate relationships with each component of the nose that you have to take into account. Now, revision rhinoplasty makes it even more challenging because one, we're dealing with scar. Two, the tissue planes have been completely disrupted, so that can make surgery a little bit more bloody. Or again, you're dealing with scar that makes the tissue a little bit less reliable or more difficult to control. Another reason that revision rhinoplasty is different is because oftentimes cartilage has been removed during the primary rhinoplasty, whether it's just the septal cartilage, whether it's the cartilage from the upper lateral cartilages of the nose or cartilage from the tip of the nose, and you never really know the quality of the cartilage until you get into a rhinoplasty.

(01:20):
Because of that, you always have to have a plan with your revision rhinoplasty, and part of that plan is having grafting material. Every time I do a revision rhinoplasty, I always have access to extra cartilage, which is typically rib cartilage as well as fascia. Also with revision rhinoplasty, the revision rates after that can be a little bit higher. Sometimes we quote 15 to 20% of patients who undergo a revision may end up wanting some sort of procedure even after the revision rhinoplasty, whether that's small amount of filler to improve contour irregularities or even the need for a third rhinoplasty. That's why it's very important for patients who want to have a revision to seek out a surgeon that is very comfortable with revision rhinoplasty and that has a high volume practice of rhinoplasty surgeries. Now, how is the cost difficulty technique and recovery different from a primary versus a revision?

(02:14):
Now, revisions are going to be more costly for many reasons. One, because we have to utilize rib cartilage, we have to utilize fascia from above the ear. Also, the surgeries typically take longer again, because we have to take into account the amount of scar that has developed as well as the quality of the cartilage, which has been significantly augmented because of the primary surgery. Revision rhinoplasty surgery is technically more difficult. Again because the quality of the tissue is unknown to the surgeon until you get into the nose and you're really able to explore and investigate how much cartilage is left, what type of techniques or maneuvers you have to do or utilize in order to obtain the patient's ultimate aesthetic and functional goals. Recovery after revision rhinoplasty is typically a little bit longer than patients undergoing a primary. The reason being is because again, there's a lot of scar tissue under the soft tissue envelope of the nose.

(03:11):
So because we are surgically manipulating a scar plane, it just takes a little bit longer for patients to heal. So instead of having the typical swelling for one to four weeks after surgery, sometimes it can take several months before we really start to see the overall shape of the nose. Also, depending on the amount of scar or the tissue quality, we may have to utilize different techniques or different adjuvant treatments such as hyperbaric oxygen therapy or nano fat injections to maximize the patient's oxygenation of the tissues, as well as really introducing growth factors and things like that that you get with nano fat. Again, to optimize the healing of the skin after the rhinoplasty surgery. What are the reasons someone would need a revision rhinoplasty? So a lot of times patients want a revision surgery because they're not happy with the overall shape of the nose.

(04:06):
Oftentimes we see patients initially want the hump or the bridge reduced or straightened, and they may have a residual or persistent hump. Again, when taking down a hump during the primary rhinoplasty, what can happen is you can get sharp edges of the bone or the bone may not heal together completely leaving what we call an open roof deformity. Or again, you can have just irregularities of the bone under the skin of the nose, which are visible after your initial rhinoplasty. And this can be managed with softening or smoothing down the bone or utilizing that fascia that we talk about as a graft that basically cushions the bone between the skin and can help to hide any of those irregularities. Other reasons people want revision rhinoplasty, I would say probably is the most common, is the tip shape or the shape of the nasal tip. So oftentimes people undergo their original rhinoplasty and the tip contour is not necessarily what they anticipated or what they wanted.

(05:06):
That can either be due to the thickness of their skin or surgical techniques, not necessarily giving as refined or as contoured of a nasal tip as they wanted during their first surgery. So these are things that we can address and change and improve during a revision, but again, we'd have to utilize rib cartilage as well as fascia grafting in order to really maximize the healing and then maximize the ability to get the patient that contour that they're looking for. Another reason patients may want a revision rhinoplasty is they may have persistent nasal breathing issues or they may have developed nasal breathing issues after surgery. These are things that we can fix from a functional standpoint in order to improve the patient's ability to breathe after surgery. Another reason somebody may want a revision rhinoplasty is if they over resection of the bridge of the nose.

(05:59):
And we see this often when a hump is taken down that too much bone or too much cartilage may have been removed and people may have developed what we call saddle nose deformity. And if that happens, then we have to rebuild the bridge, improve the contours of the nasal dorsum in order to give them a more normal shape. So how common is revision rhinoplasty? So revision rhinoplasty, when I talk to my patients, we quote about 10% of patients undergoing a primary rhinoplasty may need or want a revision. It really depends on the surgeon and who's doing the original rhinoplasty surgery. If you go to a surgeon who is well versed in rhinoplasty, has a high volume rhinoplasty practice, those patients tend to require revision rhinoplasties less, as opposed to somebody that doesn't do many rhinoplasties. I would say that those patients may experience a higher revision rate.

(06:54):
That being said, rhinoplasty is one of the most technically challenging surgeries that we do in plastic surgery. There's many factors that surgeons can't control for, one, mainly is patient's ability to heal and sometimes as patients heal, unfortunately, it may get cartilage grafts may shift or resorb, which can result in undesired cosmetic outcomes. And if this is the case, then you may need a revision rhinoplasty to address those issues to achieve your aesthetic goals. What are the risks of revision rhinoplasty? So the risk of revision rhinoplasty surgery are similar to those of your primary rhinoplasty. Just like any surgery, infection is always a risk. Undesired cosmetic outcome is a common risk that we see with rhinoplasty. Revision rhinoplasty is a little bit different because again, we're operating in a scarred field, so there's a lot more scar. There's an increased risk for infection in revision rhinoplasty.

(07:51):
So these patients always get antibiotics in the postoperative setting to reduce the risk of infection. Infection is very important in rhinoplasty surgery and can be catastrophic to the outcome because infection can cause resorption of cartilage can cause increased scar and can really be detrimental to the outcome of our rhinoplasty surgery. So I would say infection is, to be honest, the biggest risk when it comes to revision rhinoplasty surgery. When I do revision rhinoplasty surgery, patients get IV antibiotics, they also get post-op antibiotics, and anytime we put cartilage grafts in revision rhinoplasty patients, all those grafts are soaked in antibiotic solution. Again, all of these things in order to really reduce the risk of postoperative infection.

(08:39):
Does it take longer to recover from revision rhinoplasty? Yes, it does. You can expect that the soft tissue is going to be swollen a little bit longer than it was during your initial surgery. So usually it takes three to four months for you to really start to see the shape of the nose. Sometimes can take up to six months depending on the amount of cartilage and the amount of fascia and the different types of grafts that we use. But if you're undergoing a revision rhinoplasty, you have to be a little bit more patient in the recovery process because it does take a little bit longer for you to see those improvements. In the contours specifically of the nasal tip, do you make the same incisions during revision rhinoplasty as you do during your primary rhinoplasty? For me, I always do an open approach when I do a revision rhinoplasty.

(09:28):
Again, that is because it allows me to see all of the cartilage, all of the nasal framework, and it maximizes my ability to achieve the patient's goals. So every time I do a revision rhinoplasty, even if their primary was done with a closed approach, I always do an open approach for revision rhinoplasties. When are rib cartilage or other types of grafts needed for rhinoplasty or revision rhinoplasty? So for me, I always use rib cartilage as well as fascia, specifically temporalis fascia, when I'm doing a revision rhinoplasty, because typically in a rhinoplasty surgery, most of the cartilage has been removed from the nasal septum and the cartilage of the nose, specifically the nasal tip cartilage, has usually been cut or augmented to some degree, and we need to have extra pieces of cartilage in order to reshape the septum as well as the cartilages of the nasal tip in order to get that ideal aesthetic or ideal shape.

(10:29):
So for me, anytime somebody gets a revision rhinoplasty, they're always consented for rib cartilage as well as temporalis fascia. How long does the revision rhinoplasty procedure take? So typically primary rhinoplasties can be anywhere between two to four hours depending on the desired changes of the nose that we want to make. With revision rhinoplasty, I would say a minimum it's going to be about four hours. Again, because in my revision rhinoplasties, I'm always using rib grafts. I'm always using temporal fascia grafts. So these things will prolong the surgery a little bit, but also we have to be much more delicate with opening the nose in a revision setting because one, there's scar tissue and two, we don't know the quality of the nasal cartilage when we're opening it for a second time. So you have to be much more careful. The tissue planes don't open up as nicely or as easily.

(11:23):
There may be slightly more bleeding in a revision setting. All these things can make the surgery take a little bit longer. Is the revision rhinoplasty more expensive? So typically a revision rhinoplasty will cost more. That's because we have to utilize cartilage in pretty much every single revision rhinoplasty case. We also always take temporalis fascia grafts in each of these revision rhinoplasty surgeries. Again, because we want to have as much grafting material as possible to maximize the patient's outcome. So these things make the procedure longer. When do you tell a patient no to revision rhinoplasty? So when looking at a patient who's interested in revision rhinoplasty, we have to take several things into account. One of the most important things is the quality of the patient's skin or if they had a history of infection after their initial rhinoplasty surgery. One of the most important things is to make sure that you don't revitalize the skin of the nose, because if the skin has poor blood supply and you lose skin over the nose, it dramatically increases the risk for infection in the postoperative setting, and it can have a pretty catastrophic effect on the overall outcome of the nose, meaning that you can have scars on the soft tissue of the nose, which really is something that's very hard to control. If the patient's very concerned about very small or minor things in the nose, maybe a one millimeter difference here in the nostril, or a one millimeter difference in the nasal bridge on one side versus the other.

(12:55):
Now these things are a lot harder to manage and harder to control in a revision setting. There's other things that can be utilized for patients that have these subtle asymmetries, such as filler in the appropriate place, in appropriate amounts in order to achieve a more symmetric shape. But those patients, I always steer away from a revision rhinoplasty, because if they're small, subtle changes that they're looking to make with a revision surgery, those are much harder to control in a revision setting. So you also want to wait at least 12 months after your initial rhinoplasty, before you even entertain having a revision rhinoplasty. Again, that's because within the first 12 months, you still have remodeling of the scar tissue under the skin, and you can continue to have changes in your nose, those first 12, 18, even up to 24 months. Patients that are interested in revision rhinoplasty, I say you have to wait a minimum of 12 months after your initial surgery. Sometimes I say you have to wait longer depending on the changes that you're looking to make. But again, we kind of tailor our approach to each specific patient and their desired concerns and goals.

Announcer (14:03):
Basu Plastic Surgery is located in Northwest Houston in the Towne Lake area of Cypress. To learn more about the practice or ask a question, go to basuplasticsurgery.com/podcast. On Instagram, follow Dr. Basu and the team @BasuPlasticSurgery. That's BASU Plastic Surgery. Behind the Double Doors is a production of The Axis, theaxis.io.