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From Dr. Gross

Thoughts on Revision Rhinoplasty

Surgeons in every specialty understand that a second or revision surgery is generally more difficult than the original or primary procedure. That is indeed true for plastic surgery in general, but for revision rhinoplasty in particular. There are several reasons for this including the fact that there is scar tissue and some loss of normal anatomical landmarks following each procedure, as well as the emotional issues associated with not achieving the desired result. For these reasons, some patients (and surgeons) considering revision rhinoplasty decide it is perhaps best not to do the surgery. Wisdom suggests at times it may be best to accept a minor imperfection rather than risk the possibility of worsening the appearance.

Surgeons with minimal training, less experience, and a lack of what we call "aesthetic sense" are more likely to generate an inadequate result, an unhappy patient, and a "botched nose job". On the other hand, those surgeons who are highly focused in cosmetic nasal surgery, who have had the intense and long training and a high volume of rhinoplasty experience, have relatively few problems. However, even in the most experienced hands, problems and the need for revision rhinoplasty can occur. Presently, about 30% of our rhinoplasty patients are for revisions referred from other surgeons

In revision rhinoplasty surgery, the key to preventing complications is the pre-diagnosis of potential anatomical and functional abnormalities. For example, you desire a hump reduction and we identify short nasal bones and a narrow middle vault. A thorough nasal evaluation indicates you are at risk for upper lateral cartilage subluxation from the nasal bones (inverted V deformity) as well as internal valve collapse. In primary nasal surgery, the previous surgeon missed these telltale potential anatomical abnormalities and now we're in charge of repairing the problem. We always perform a detailed anatomic and functional evaluation of the nose using Computer Imaging, followed by a diagnosis of the nasal deformities and/or nasal obstruction. After the problems and potential complications are identified, we create a surgical plan while studying the preoperative computer images and prepare to use everything in our surgical armamentarium--since we must always prepare for the unexpected.

The most important attribute that you, the patient, can possess following revision nasal surgery is PATIENCE and REALISTIC EXPECTATIONS. It may well take one year for all the swelling to completely resolve and you may have some persistent areas of concern. However, I can promise you that I will do my best to educate you on the risks and benefits of surgery to help you improve the health and appearance of your nose. Call us today at 407.333.30340 to see if you are a candidate for revision rhinoplasty surgery with Edward J. Gross, MD, a specialist in Facial Plastic Surgery .

Commonly Asked Questions

What are some of the common problems that can occur after rhinoplasty? I had a 'bad nose job' and may need more surgery to correct my nose.
Complications in rhinoplasty may be categorized as functional (related to breathing) or aesthetic (related to appearance); often, there are elements of both. Problems after rhinoplasty commonly are due to under resection (not enough taken off), over resection (too much taken off), and/or asymmetry. Also, sometimes abnormal scarring is a problem after rhinoplasty or even revision rhinoplasty.

"In general, it is easier to fix problems relating to under-resection, because they can be fixed by going back and taking a little more," according to Dr. Gross. Rhinoplasty problems caused by over resection can be a little more complicated because material needs to be added, and technical factors arising from the need to add tissue must be considered. Asymmetries can usually be improved, but with less certainty. "I find the computer imager to be essential in diagnosing and formulating a treatment strategy based on the unique anatomy encountered in each patient's case I review," says Dr. Gross.

If you need to use grafting material to correct or rebuild my nose, what kind of materials are used?
Various materials are used. Most commonly, cartilage is taken from inside your nose, specifically the nasal septum, (or from your ear). I also use Medpor or silastic silicone implants. These are selected based on your unique anatomy and customized to correct the area in need. They generally stay in for life and are not anticipated to be changed out or removed. The use of FDA approved implants has proven to be a safe and effective method of treating bridge, side-wall, or tip deficiencies in revision rhinoplasty.

My skin is very thin. Do you take any special measures in my revision rhinoplasty?
Yes. In patients with very thin skin, even the slightest irregularity may be felt or even seen. In these cases, I consider the use of Gore Tex sheeting (1-2mm), Alloderm or Enduragan. Of course, if this is a consideration for the patient, I will discuss this in advance of surgery.

Alloderm is a non-cellular human dermis taken from an organ donor and treated with a patented, FDA-approved treatment. Alloderm is used in a number of facial cosmetic applications, including lip augmentation, scar revision, and rhinoplasty. In revision rhinoplasty in patients with extremely thin skin, Alloderm or Enduragan may be placed between the skin and the graft to thicken the skin and thereby provide additional camouflage for the graft.

If you need to take ear cartilage, how will that affect my ear?
The good news is that if you need ear cartilage for your revision rhinoplasty, taking that cartilage should not alter your ear's shape or function.

The septum is usually our first choice for grafting material. However, if you have already had a septoplasty or septorhinoplasty, then this source of grafting material may have already been used, in which case we turn to your ear.

The incision is usually placed behind your ear where it cannot be seen. I prefer to make the incision on the front side of your ear in a location where it is well-camouflaged and difficult to see.

The cartilage taken from your ear works well in rebuilding your nose. The good news is -- when performed properly, removing this cartilage should not change the shape of your ear!

What about breathing problems?
Nasal breathing problems are not uncommon. I find that breathing issues are usually caused by nasal valve collapse, which requires physically lifting and adding volume to the lateral tip and alar areas. I tend to correct these nicely w/ spreader grafts or the use of thin implants such as Medpor (at the time of surgery). However, if breathing is the main concern, I refer to ENT specialists to address, as our office does NOT accept or participate with Medicare or insurances.

I have problems with the tip of my nose. What kinds of problems can occur at the nasal tip?
Asymmetries of the nasal tip may be present preoperatively and may have been overlooked by both the patient and the surgeon. Since rhinoplasty in Orlando in some ways is like "two operations" (a left and a right side), the surgery must be performed with great attention to symmetry. Asymmetries can also be caused surgically, for example by unequal sizes or treatment of the lower tip cartilages. It may also be caused by unequal scarring that can occur during the natural healing process and may not be evident for months or even years after surgery. Shifting, settling, sliding, scarring, or sinking of the skin or cartilage may occur after well-performed surgery. These are known as the 5 "S's".

What is a pollybeak?
A pollybeak refers to fullness of the region above the nasal tip, giving the nose the appearance of a parrot's beak or "pollybeak." An example is shown here. To correct this, I usually reduce or resect the fullness of the tip and augment the bridge w/ either cartilage or a small implant to provide balance and harmony.

Treatment of the pollybeak deformity depends upon the cause. If the cartilaginous hump was under-resected, then I can resect additional tissue here. Adequate tip support must be ensured or a pollybeak can occur. If a pollybeak is from excessive scar formation, Kenalog injection or skin taping in the early post-operative period may be undertaken prior to any consideration of surgical revision. If this doesn't help, I may excise some scar tissue, followed by skin taping, Pulse Dye Laser, and possible Kenalog injection(s). Massage usually helps these problems, along w/ time.

What kinds of problems can occur in the middle and upper nasal thirds?
I divide these into categories: over-reduction, under-reduction, asymmetry, and scarring.

What kind of problems result from over-reduction of the middle and upper thirds?
Over-reduction of the upper portion of the profile results in a flattened appearance. If extreme over reduction occurs then the patient may have an overly concave, operated appearance. Over-reduction may lead to iatrogenic saddle nose deformity (also known as "boxer's nose.") When undertaking profile reduction, great care must be taken to preserve support of the middle nasal vault - failure to do so can lead to complications such as nasal valve collapse and inverted-V deformity.

What kind of problems result from under-reduction of the middle and upper third?
Under-reduction leads to a persistent deformity. Under-reduction may not only leave a persistent dorsal hump but may also create a pollybeak deformity, or alternatively an unsightly prominence at the upper nasal third. Nevertheless, this deformity is preferable to over- reduction because it is easier to correct the under-reduction secondarily when indicated.

Asymmetric resection may lead to unsightly appearance. Correction of this deformity is challenging. This may be treated with onlay grafts, through a precise pocket placement via an external or open-approach revision rhinoplasty in Orlando, FL.

What is a saddle nose deformity?
Saddle nose or "boxer's nose" refers to the appearance of the nose after loss of support of the nasal vault with collapse. This deformity has been described after over-resection. Other causes of saddle nose deformity include septal hematoma, car accidents, cocaine use, and severe nasal trauma.

Mild to moderate saddle nose deformity may be treated by onlay grafting to effectively camouflage and restore the nasal profile, or alternatively in experienced hands by conservative profile reduction. Severe saddle nose deformity may require major reconstruction with bone grafts.

What is an inverted V deformity?
In this deformity, the lower edge of the nasal bones are visible to the naked eye. This edge or line forms an upside-down or "inverted" V. Feel your own nose and recognize the inverted V - this is just at the lower edge of your nasal bones. Inadequate support of the middle portion of the nose after removal of the nasal "bump" can lead to collapse of the middle portion of the nose (specifically, the upper lateral cartilages) and the "inverted V" may be visible to the naked eye, causing the "inverted V deformity." Inadequate in fracture of the nasal bones is another significant cause of inverted V deformity.

This patient has an inverted V deformity. The middle portion of her nose has collapsed, and you can see a line on either side of the nose that joins in the middle to form the inverted V.

What is nasal valve collapse?
The external nasal valve refers to the area delineated by the nostril and lower side wall of the nose. Excessive narrowness or flaccidity in either of these locations may cause nasal obstruction.

Weakness at either of these locations may result in collapse with the negative pressure of inspiration, resulting in nasal airway obstruction. Nasal valve collapse may be due to over-resection, scarring, or thickened heavy skin that can't be support by the underlying thin cartilage.

Treatment of nasal valve collapse may include the use of spreader grafts, and also relies on nasal sidewall grafts to re-support a weakened area. Nasal sidewall grafts (known by surgeons as alar batten grafts) may be placed in such a way as to correct nasal valve collapse.

What about persistent deviation or curvature of the nose?
Persisting deviation after rhinoplasty in Orlando, FL may occur at the upper third, middle third, or tip of the nose, or may occur postoperatively in a previously straight nose. Pre-operative anatomic diagnosis is a critical component of successful treatment. This is the subject of a separate Rhinoplasty chapter unto itself. A number of surgical maneuvers are available to address the deviated nose. A deviated nose can often be improved, but this can be one of the more difficult problems in primary and revision rhinoplasty. Deviation or twisting of the nose may persist despite the best efforts of a skillful surgeon.

I have small irregular bumps on my nose since my rhinoplasty. What are they, and can you fix them?
These are small irregularities (bossae) in the bone or cartilage that persist or were not perfectly smoothe. In my experience, these can usually be improved, but seem to become less noticeable over time. If they are cartilage they can be shaved off, and if they are bony they may be rasped or "filed.' I also, use Radiesse® filler successfully to smoothe out small irregularities on the bridge and sides of the nose without the need for surgery!

My nasal bridge is still wide after my first surgery. What is this, and can it be fixed?
After your bony profile is lowered, the experienced surgeon performs osteotomies (cutting or "breaking" of the nasal bones) and shifts the bones inward to make the nose a little narrower. This "closes the open roof" created by taking off the top of the nasal bridge. If the nasal bones are not completely closed, then you may feel the free edges of the nasal bones and/ or see a wide bridge. This is called an "open roof" deformity and I correct this by performing (or repeating) the lateral osteotomies (i.e. narrowing the bridge).

Ask Dr. Gross a question about revision rhinoplasty in Orlando, FL or arrange your computer imaging consultation by calling (407) 333-3040. You may also e-mail us at: info@wedofaces.com. If you are considering, Revision Rhinoplasty in Orlando, FL, a board- certified Facial Plastic Surgeon is strongly recommended.

Before & After's

Patient Testimonials

Dr. Gross, I just wanted to say thank you so much, so much, for the wonderful care you took in doing my surgery. Even now, after only a few days of the reveal, I am extremely happy and so is my husband. I wish we, I, would have known about you and your staff years ago. Your staff, by the way, is absolutely awesome! I just have to say one more thing, I was not able to weare my cross during the surgery, but my mind was put at ease when I noticed that you wore a cross. It meant a lot. "God Bless You"
Andrea M.