Revision Rhinoplasty Specialist |
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Home > Procedures > Understanding Revision Nasal Surgery
If you are considering a second nasal surgery, it is important to understand that your goal should be an improvement rather than perfection. Any patient seeking a nasal revision should be aware that a first-time rhinoplasty is difficult enough, but a second surgery has extra problems inherent in the fact that the previous surgery has altered the tissues of the nose. Because every nose is different, there is no one correct technique for every patient. Additionally, concepts of beauty differ greatly, and what is a beautiful nose to one person may not be to another. One element of nasal surgery that should be kept in mind is that the nose cannot be shaped and revised into any form imaginable. A nose is not like a piece of modeling clay that the surgeon can mold into any shape he desires, nor can he be certain that it will remain in a certain shape forever. The nose is not like a piece of metal or wood that can be put on a lathe and made perfectly symmetrical. The nose is a combination of complex biologic tissues, with multiple functions including breathing, sense of smell, warming, humidifying and filtering air that goes to the lungs. Whenever the shape of the nose is changed in order to enhance its appearance, all of these functions must be considered, as well as the process of healing. Unlike clay, metal or wood, the nose, because it is a biologic living organ, must heal when it is operated upon. Healing is not always the same in all patients, nor is it always predictable. Since the nose consists of multiple biologic components including external skin, specialized internal membranes, various cartilage configurations, and bone (all of which interact dynamically), the final result will vary from person to person. Cartilage can buckle, bones can heal with irregularity, and swelling can persist. Noses also change in the post-operative period, and the final result may not be apparent for six months to two years after surgery. For many reasons, revision or secondary rhinoplasty is more difficult than primary rhinoplasty. First, consider this very important fact: Prior to any surgery, there are layers of tissue planes which are natural separations between the different types of nasal tissues, and as the surgeon operates, he can easily dissect or separate the layers to get to different structures. After a first surgery, though, these planes no longer exist, making any following surgery more technically difficult. It is almost as if someone has put glue into the nose, because the skin is stuck to the cartilage and to the bone. Additionally, the scar tissue itself (the glue) is very tough and hard to work through. There is the possibility of poking a hole through the skin or damaging the skin. This thick scar tissue also makes it difficult to make the nose as defined and thin as might be desired, and the scar tissue cannot always be removed. With each and every operation, the scar tissue becomes thicker and keeps the nose swollen longer. If your previous rhinoplasty was unsuccessful because not enough was done --- for example, if a hump is still there or is irregular --- your revision surgery will be less difficult because it is always easier to take away than to add. However, if your nose is too small, too short, turned-up or pinched, your revision surgery will be more difficult. Natural structures and specially shaped tissues may have been removed and will now need to be replaced with grafts from elsewhere. These grafts must be molded to take on not only the shape but also the function of the previously removed tissue --- sometimes a task that is next to impossible. The types of grafts that are necessary depend upon what structures are missing, whether they are bone, cartilage, external skin or internal lining. When tissues are missing, what you undergo is actually a nasal reconstruction rather than a revision rhinoplasty. Sometimes the damage is so great that we may need multiple grafts from many sources. We try to use the patient's own tissue first for grafts, but sometimes we need manufactured grafts or grafts taken from tissue banks. For all these reasons, expectations for revision rhinoplasty must be tapered, and improvement, not perfection, is the goal. Yet another area to be resolved in many cases of revision nasal surgery is dysfunction of the nasal airway. If you had difficulty breathing through your nose before your first surgery, or if the nasal airway was changed during your surgery, you may now be having trouble breathing through your nose, especially if your nose was made smaller or if you experienced a post-operative drooping of the tip of your nose. You may now need correction of a deviated or crooked septum (the partition between the nostrils), and trimming of your turbinates may be required (turbinates are structures deep inside the nose on the sides which warm and humidify the air going through your nose). Furthermore, you may need a graft to re-support the tip of your nose. Even though you may have already had surgery on your septum (called a septoplasty or a submucous resection) you may still be having trouble breathing, and a revision septoplasty may be needed. This is a more difficult procedure because again scar tissues must be entered. Unfortunately, this is too often the case if the previous surgeon was not an expert in the nasal airway. (Usually doctors trained in otolaryngology or ENT --- ear, nose and throat --- are experts.) An even more serious problem with the septum is a septal perforation, or hole in the dividing partition. This can happen after previous surgery, and the usual signs are bleeding, crusting, nasal obstruction and drainage. A perforated septum is very difficult to repair because it represents not just one hole, but actually three --- a hole through the septal cartilage, and a hole in each side of the membrane that covers the septum. Your nasal airway could also be blocked if, at your first surgery, the tissue lining was roughened in two opposing or touching areas and then later healed together, causing the formation of a scar band or web. In such cases, this web has to be opened, and thin, soft plastic sheeting is placed in the nose to prevent this web from forming again. This sheeting will need to stay in place for at least three weeks after surgery. Although revision nasal surgery is very difficult, there is also good news: Some new techniques, including those used by <b>Houston rhinoplasty specialist Dr. Kridel</b>, have made the operation more exacting, reaping better results than in the past. The open or external rhinoplasty approach allows the surgeon to see the prior defects, and grafts can be sewn into place under direct visualization. This operation requires an incision across the columella, or center-post between the two nostrils. During your visit, you can ask to see pictures of patients who have had such an incision, and you will note that it usually heals imperceptibly without leaving a noticeable scar. Even with this new technique, however, revisions take longer to perform in the operating room because we are often correcting problems that did not exist at the time of the first surgery. Typically, about three to four hours are allocated for a revision. Sometimes another operation can be necessary when, for structural reasons, we cannot make all the corrections at the same time. There will be an additional surgical fee should subsequent surgical revisions be necessary as well as facility and anaesthesia expenses. Despite the technical difficulty of the surgery and its length, we find that in most cases patients benefit from revisional surgery, and especially those whose expectations are realistic. We will not operate unless we feel an improvement is possible, but we cannot promise perfection. So much of what we can do depends upon what we find at the time of surgery. We have been very happy with our results, and hope that we can help you with your individual concerns. To brief you on my background, I am Certified by the American Board of Facial Plastic and Reconstructive Surgery, the American Board of Otolaryngology-Head and Neck Surgery and the American Board of Cosmetic Surgery. I am currently a Board Examiner for the American Board of Facial Plastic and Reconstructive Surgery and I have been a Guest Board Examiner for the Facial Plastic portion of the Boards in Otolaryngology. I received my initial training in General Surgery, Otolaryngology (ear, nose and throat), and Facial Plastic and Head and Neck Surgery. I did a fellowship in Facial Plastic Surgery, concentrating on the cosmetic procedures of the head and neck area, especially the nose. I feel that this double training helps me significantly in nasal revisions, because this procedure is a classic combination of both functional and aesthetic surgery. I am a full fellow of the American Academy of Facial Plastic and Reconstructive Surgery (AAFPRS), and have been on the Executive Committee and Board of Directors of AAFPRS, and have served as National President of the Academy and Chair of its Ethics Committee. I have been doing this kind of work for over 22 years, and I currently perform over 100 nasal surgeries per year. Because of this experience, many patients are referred to us for revisional surgery, and I do at least 50 revisional cases a year. Sincerely Yours, Russell W. H. Kridel, MD, FACS
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