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Revision Rhinoplasty FAQ

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Because rhinoplasty is such a delicate procedure, patients are sometimes unhappy with their results. One way to lessen the risk of complications or unsatisfactory results is to have surgery performed by a rhinoplasty specialist. However, patients can also rely on such a specialist if they previously had surgery elsewhere and are now ready for a second procedure to fix resulting problems. These patients can trust Dr. Edward J. Gross' experience in revision rhinoplasty in the Orlando area. Here, we provide answers to some of the most common questions our Orlando patients ask about revision rhinoplasty.

Dr. Gross is a double board-certified facial plastic surgeon who is committed to patient education. Request a consultation today, or call our office at (407) 333-3040.

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Common Questions

What are some of the common problems that can occur after rhinoplasty? I had a bad "botched" 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), scarring, deviations, bumps, curvatures, collapse, and asymmetry. Also, sometimes abnormal scarring is a problem after rhinoplasty or even revision rhinoplasty. Various terms have been used to describe these problems: "nose job nightmare" or "botched nose job." Suffice to say, for revisions or repairs, it is best to consult with a dedicated rhinoplasty specialist, such as Dr. Edward J. Gross.

"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," Dr. Gross says.

If you need to use grafting material to correct or rebuild my nose, what kinds 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. "Tip plasty" involves reshaping the tip of the nose.

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 cartilage grafting, GORE-TEX® sheeting (1 to 2 mm), AlloDerm®, or ENDURAGen® to cushion the skin. If this is anticipated for the patient, I will discuss this before 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, patients with thin skin are treated with cartilage grafting, AlloDerm, or ENDURAGen. These may be placed between the skin and the graft to thicken the skin and thereby provide additional camouflage.

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 nasal 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 in a hidden crease in 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.

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 well with spreader grafts of cartilage or the use of thin implants such as MEDPOR. However, if breathing is the main concern, I refer to ear, nose, and throat specialists to address the issue, as our office does not accept or participate with Medicare or insurance.

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. Becuase rhinoplasty in some ways is like 2 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, scarring, or sinking of the skin or cartilage may occur even after well-performed surgery. These are known as "the 4 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." To correct this, I usually reduce or resect the fullness of the tip and augment the bridge with 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 postoperative 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 with 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 kinds 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-on appearance. Over-reduction may lead to the 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 the inverted-V deformity.

What kinds 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.

Asymmetric resection may lead to an 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.

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 is visible to the naked eye. This edge or line forms an upside-down 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.

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 supported 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 may occur at the upper third, middle third, or tip of the nose, or may occur postoperatively in a previously straight nose. Preoperative anatomic diagnosis is a critical component of successful treatment. 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. The rule of thumb is a 90% chance of reducing the curvature and a 10% chance for recurrence/ persistence.

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 smooth. 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® dermal filler successfully to smooth out small irregularities on the bridge and sides of the nose without the need for surgery!

I have a wide nose after my rhinoplasty. What is that from?

A wide nasal bridge results from taking down a profile bump without performing the needed osteotomies to narrow the bridge. Many surgeons are inexperienced with this osteotomies and simply avoid it. The resulting cosmetic problem is known as an "open roof deformity" and can be corrected with resetting the nasal bones and closing the open or wide bones. Dr. Gross performs osteotomies routinely in both primary and revision nose surgery and has a great deal of experience with this maneuver. Additionally, a refined nasal bridge that matches the tip is aesthetically more pleasing.

I have a bump on my nose after surgery. Is that scar tissue, and what can be done?

The nose may have scar tissue and/or regrowth and thickening of cartilage or bone is small areas. The treatment for these minor problems usually involves a series of steroid injections called Kenalog-10, which help to reshape the nose without further surgery. These are usually done 6 to 12 months after the procedure to allow swelling to resolve before the injection. The injections are spaced 2 months apart, and the results begin to take effect in about 4 weeks. In this way, we are able to straighten the profile, make the nose more symmetrical, and reduce scar tissue.

Is financing available for Revision Rhinoplasty?

Yes. Financing can be arranged through CareCredit®.

"The most important attributes that you, the patient, can possess following revision nose surgery are patience and realistic expectations."

– Dr. Gross

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