D The most commonly cited revision rates of 5 to 10% are most likely underestimated. The revision rates for rhinoplasty are estimated to be between 5 and 10%; however, these rates are very likely to be underestimated.1–3 The main reason why these rates may be difficult to accurately assess is that these data are not well recorded. Surgeons may be cagey about discussing their actual revision rates or indeed have no idea of the true rates, especially when patients go elsewhere for their second or third procedure. There are a number of reasons why patients will seek revision rhinoplasty, and these may be functional, aesthetic, or a combination of both. A requirement for secondary rhinoplasty can be due to poor surgical technique, first time round, and can also be due to other factors such as incorrect technique selection, unpredictable scarring, or other complication such as hematoma, infection, or delayed healing. It may be that there are patient factors such as subsequent trauma to the nose or noncompliance with postoperative care such as continued smoking perioperatively. Of course, there are instances where patients request secondary rhinoplasty because they have unrealistic expectations about what can be achieved or has been achieved. These patients typically do not require secondary rhinoplasty and should not be offered this. There is no proven evidence that more revision surgery is required with a closed versus an open approach. Revision need will be affected by patient selection, surgeon experience, and the changes that are being implemented by any given approach.1–3
When considering secondary rhinoplasty for a patient, it is important to have a frank and open discussion preoperatively of what is possible and not possible to achieve for them. There are many factors to consider in general when deciding with a patient whether you should proceed with surgery for them. A key element of this is feeling that you and the patient are on the “same page” with what you would like to correct and have a similar aesthetic sense regarding what constitutes a balanced nose for them. Both the surgeon and the patient must understand that neither primary nor secondary rhinoplasty will ever create the “perfect nose.”1–3 If either surgeon or patient has unrealistic goals or expectations of surgery, surgery should not proceed.1 It is easy to be flattered by a patient putting their trust into you to correct another surgeon’s work, but one should always take a moment to pause and reflect, to be sure that you are likely to improve things and ask the question, “why is the original result suboptimal in the first place?” Knowing the competence of the original operating surgeon can be a useful piece of information here because if they are likely to have performed the surgery well, this should make you question whether you can really make it any better second time round especially when scarring is present, and the stakes are higher. Likewise, just because you have operated on the patient before, that does not mean you will necessarily have a great outcome for them in secondary rhinoplasty having been uninvolved before. That said, having insight into the patient’s background can be useful and hopefully shows you have a proven track record with them and a good working relationship. That their decision of not to take medicolegal proceedings is not necessarily of great significance, unless of course you have made a conscious decision to avoid such a case mix where claims have been made before. When patients bring photos of noses they like, this can be helpful but can also be a concern. If the purpose is to help the surgeon understand what the patient likes, then this is helpful. However, if the patient is unrealistic and wishes to create someone else’s nose, this is a red flag to avoid operating on them.
3. Bouaoud J, Loustau M, Belloc JB. Functional and aesthetic factors associated with revision of rhinoplasty. Plast Reconstr Surg Glob Open 2018;6(9):e1884
4. Sedaghat AR. Chronic rhinosinusitis. Am Fam Physician 2017;96(8):500–506 Although the focus of consultation with primary rhinoplasty patients is centered around what the surgeon can do, the discussion with secondary rhinoplasty patients is about what the surgeon cannot do and cannot improve. It is critically important to make it clear from the outset what cannot be done and why you feel this is the case, so patients are not under any illusion that these things can be provided when they cannot. This ties in with patient expectations. Patients who desire perfection will be disappointed regardless of how successful the surgeon believes the operation has been and how ideal the outcome is. Because of this, such patients should not undergo revision rhinoplasty, as they stand to be further disappointed and yet will have been subject to additional risk and financial costs. The other things are also important to cover in both primary and secondary rhinoplasty; i.e., what can be done, then how it will be done intraoperatively. For example, if a patient has a pinched tip deformity, then to discuss the fact this can be improved and that the surgery might involve cartilage grafts and suture placement to support the lower lateral cartilages would be an appropriate discussion. One should avoid stating what “should” be done as, it is in most cases, there just needs to be a two-way discussion about options and plans, which the patient must drive forward. Telling patients, they “should” do something might be construed as encouraging them down a particular pathway.1,2
deformity? The pollybeak deformity is one of the most common complications after rhinoplasty. It is characterized by fullness in the supratip area with derotation and caudal displacement of the nasal tip. This effect is said to resemble a parrot’s beak. Common causes of the pollybeak deformity following primary rhinoplasty include a lack of tip support leading to underprojection of the tip, excess scarring in the supratip creating excess fullness, and over resection of the nasal dorsum more cranially. The principles of correction for a pollybeak deformity are to address the underlying causes on an individualized basis. Therefore, the tip support likely needs to be reinforced and the tip scar tissue may need to be reduced. The tip then typically needs elevation with or without upward rotation and the dorsum may also need correction with grafts to build it back up.1,2 Other common deformities in secondary rhinoplasty include the inverted-V deformity, dorsal irregularity, saddle-nose deformity, a pinched tip, and a hanging columella.3,4 A saddle nose deformity corresponds to a loss of projection of the cartilaginous and or bony structure of the nasal dorsum and may be caused by trauma, rhinoplasty, infection, or autoimmune disorders such as Wegener’s granulomatosis. The inverted-V deformity is observed at the keystone area of the nose where there is separation of the upper laterals from the dorsal septum and the caudal margin of the nasal bones. A pinch-tip deformity is as it sounds, where the tip appears to be pinched. This deformity can present when there has been over-resection of the lower lateral cartilages. The hanging columellar can be a developmental or acquired issue where the soft tissues of the columellar area protrude and appear to hang beneath the columella.5
Secondary rhinoplasty may require additional cartilage grafts in order to correct underlying nasal deformities such as an inverted-V, saddle nose, pollybeak, or pinch-tip deformity. Unfortunately, patients who have undergone previous rhinoplasty may be cartilage deficient if key sites have been overly resected and the septum has been used before. Therefore, it is vital to plan for needing additional cartilage and there are a number of potential donor sites for this. These include the ear and the ribs. In addition to cartilage, fascia may be required, for example, to create a “pillow of diced cartilage” to help build and recontour the nose. Facia may be obtained from the temporal scalp, mastoid area, or thigh (fascia lata). Cadaveric tissues can also be used such as irradiated rib and fascia.1–3 The mouth tends to be a donor site where buccal mucosa is required, and this perhaps is more likely in some nasal and eyelid reconstructions rather than rhinoplasty. When autologous tissue is not sufficient, alloplastic material such as polyethylene and polydiaxone may be used.
PREOPERATIVE DIGITAL SIMULATION IN RHINOPLASTY Standardized preoperative photographs are a vital component of any rhinoplasty consult whether for primary or revision surgery. They serve many purposes including supporting the discussions between patient and surgeon, providing objective evidence of the starting point before/after surgery, and medicolegal purposes. The standard rhinoplasty views should include frontal, lateral, oblique, basal, bird’s eye, and any additional views that may be required to better show specific deformities. It is possible to take this to the next level and use simulation technology to show what the planned changes in surgery may look like postsurgery. Some surgeons and patients feel this is a helpful practice, but others do not as a computer-generated image may not be effectively replicated in life following surgery, no matter how well the surgery is performed. It is therefore best indicated to facilitate the preoperative discussions on goals of surgery between the patient and their surgeon. Preoperative digital imaging can give the patient an idea of the possible surgical outcome, but its use should be limited to providing a dialogue between them and the surgeon. It should be used to represent the surgical goals, not the final result and so may be helpful to discuss expectations and to provide education regarding the proposed operation.1 Patients cannot select images of other individuals and expect a rhinoplasty to give them such a nose. Use of patient’s preferred images can, however, still help the preoperative discussions to guide what they like and dislike. Simulation technology does not provide patients with images of the exact final outcome, nor enable them to request and expect subtle changes they would like. Indeed, one should be wary of a patient who requests multiple simulations and miniscule alterations to these images, as these patients likely have unrealistic expectations of what surgery can deliver. There may be little medicolegal benefit in showing a proposed image; in fact, it may be unhelpful if the result does not match it as the patient may claim they were promised such a result.1–4
There has to be an emphasis on realistic expectations in all aesthetic surgery, perhaps none more so than in secondary rhinoplasty. Taking time to find out what specific elements of the nose patients are unhappy with is the first step. Then assessing which of the changes will not be possible and which may be possible to effect should come next. During this discussion, it is paramount to ensure patients have understood and have realistic expectations. Multiple consults are often required to do so with support from patient information leaflets. Without this, the surgeon and patient are at risk of postoperative disappointment and conflict. It may be that the primary surgeon did nothing wrong and, in some cases, this warrants exploration. In other circumstances, this may not be known and may have no place for discussion. Some patients are disproportionately bothered about what friends and family say and need to have reassurance from them about results. This response from others is completely unpredictable and patients should be reminded of this. The term “perfection’ should not be used in rhinoplasty and in fact expecting imperfection is the right approach even following high-quality surgery, especially in complex revision cases in the same way that this is highlighted to patients undergoing nasal reconstruction. Things will never return to an unscarred normal. A real technical issue for surgeons undertaking revision surgery, particularly of the nose is that the underlying anatomy will be distorted, and the intraoperative findings may be unpredictable. They must therefore prepare 1042 Part VII ■ Aesthetic Surgery for this and consider what tricks and techniques might be required so that they can be incorporated at the time. Patients must be made aware of this during the consenting process, as this will have an impact on likely outcomes and the potential need for grafts and specific techniques.1–3
One of the main issues in rhinoplasty in general is ensuring patients have realistic expectations about the possible outcomes following this procedure. There is a large amount of media coverage and extensive online information ranging from reliable scientific clinical data to forums for open discussion by patients and surgeons. It is easy for people to review such data and develop unrealistic expectations for surgery. This can range from wanting to change subtle, barely noticeable irregularities and imperfections as they see them to wanting nasal shapes that are not achievable nor would suit their face shape. It seems this patient has had improvements in her nasal appearance and probably just needs a fresh pair of eyes to review things with her and provide honest feedback about the current status of things. She may also benefit from clinical psychology input to help her obtain a more balanced perspective on things. Revision rhinoplasty should be reserved for patients who have an identifiable problem that has the potential for improvement and that outweighs the risk of further surgery. It is key to remind patients considering undergoing revision surgery of any sort that the process may actually make things worse, rather than better, especially if the benefits are marginal or they experience a postoperative complication. While some patients will have psychological issues relating to their nasal appearance combined with deeper underlying personal issues, it would be wrong to conclude this patient has significant psychological issues based on the information provided. In general, it is preferable for patients to see their primary surgeon in the first instance to discuss and review outcomes and this patient may have already done so. One should be cautious with patients who focus on the previous surgeon’s inadequate abilities or incompetence or who persist in blaming the previous surgeon for the result. In general, revision following rhinoplasty should be delayed until 1 year postsurgery, as this allows time for the soft tissues to settle fully. Therefore, in this case if a further revision was indicated, she has waited sufficient time already.1–3
There will continue to be debate about the advantages of the open and closed approaches in rhinoplasty with proponents for either approach. However, for secondary rhinoplasty, there are potential benefits of using an open technique over a closed approach. These advantages include binocular vision, the ability to use both hands, a more effective evaluation of the deformity without distortion and subsequent precision in deformity correction. The deforming forces from soft-tissue scarring can be released and scar tissue can be removed. The options for both graft and suture techniques are increased over a closed approach and bleeding can be well controlled under direct vision. The disadvantages of an open approach are minimal but include the transcolumellar scar which will not be present if the primary rhinoplasty was performed closed, problems with wound healing, continued tip edema, and a greater potential for devascularization of the soft-tissue envelope. For these reasons, an open approach is more popular for secondary rhinoplasty in most people’s practice.1–4
One of the main caveats of an open approach to rhinoplasty is the presence of a transcolumellar scar, which can be a giveaway that rhinoplasty surgery has been undertaken. However, if done well, in most cases, the scar will be subtle and imperceptible in the longer term. When faced with patients requiring revision surgery, making decisions about scar placement can be complicated by where they were placed by their previous surgeon. This applies to any aspects of plastic surgery, not only the nose, and in some cases, it will be best to excise the original scars and thereby reuse the same approach, while in other cases it will be better to ignore them and use incisions at the ideal place. Deciding about the transcolumellar incision for a secondary rhinoplasty is a challenge because if the scar was too low or too high previously, then trying to correct this risks potential compromise of the skin and soft-tissue vascular supply and subsequent problems with necrosis and poor wound healing, which in a rhinoplasty can make a huge difference to outcome. It may also be that the shape of the scar is suboptimal. A recent retrospective study reviewed 100 cases of secondary open rhinoplasty from a single center over a 10-year period where the original transcolumellar scar had been ignored and a new preferred incision made. There were no problems with wound healing, tissue necrosis, or poor scars by taking this approach. The authors suggested that unless the patient has high-risk factors for wound healing problems such as diabetes and smoking, this is a safe and reliable approach to take even when the original incision was placed too high on the columella. They do suggest caution though in terms of patient selection and would not advocate this in patients undergoing surgery at less than 1-year post rhinoplasty or in active smokers. Most surgeons would not operate on active smokers for revision rhinoplasty or on any patients earlier than 1-year postsurgery.1
tissue envelope. Soft-tissue fillers can be very useful for correcting subtle imperfections of the face due to ageing or following previous surgery. The “liquid rhinoplasty” has been marketed as an alternative to surgery for many patients and certainly does have a place for patients with contour deformities and volume deficiencies of the nose. Unfortunately, the vast majority of patients wishing to improve their nasal shape will need volume reduction and reshaping that only surgery can achieve. Many would also prefer a permanent result. The patient with residual dorsal excess would be better served with further surgical revision to reduce the cartilaginous excess rather than trying to mask it by building up other areas. 1044 Part VII ■ Aesthetic Surgery There is, however, a role for using injectables either before or after surgical rhinoplasty for certain cases. These include the following: • Patients who do not want to undergo further surgery to correct a nasal deformity. • Patients who are awaiting the appropriate time interval before undergoing further nasal surgery. • Patients who want to “wear a secondary rhinoplasty” before committing to surgery. • Patients who are not surgical candidates for rhinoplasty due to health reasons. • Patients with subtle irregularities that may not be predictably treated with surgery. Hyaluronic acid–based soft-tissue fillers are preferred because of their characteristics and safety profile. A variety of hyaluronic acid–based soft-tissue fillers are available and range in characteristics such as gel hardness, hydrophilicity, and dwell time. Complications are generally low with hyaluronic acid filler; however, even in the best hands, complications can occur. Aside from the risks of blindness, tissue necrosis can occur where skin and soft-tissue vascularity is compromised, and the tissues are thin with altered blood supply such as a patient following multiple surgical rhinoplasties. Tissue necrosis may occur following injection because of inadvertent direct intravascular injection of the product or, more likely, secondary to pressure ischemia by the product on adjacent tissues. If blanching is observed during injection of hyaluronic acid fillers, the injection must be stopped and Hyalase may need to be injected if it does not recover. Other components of the management plan when tissues are felt to be compromised by intravascular injection or severe soft-tissue compromise would include aspirin and nitro paste. Hyperbaric oxygen may also be considered for more extreme cases.1–3