"As in primary rhinoplasty, the patient's aesthetic desires and the surgeon's assessment of the existing abnormalities influence the complexity of the revision surgery. However, insufficient septal and conchal cartilage for grafting is more likely when working on a previously operated nose, so that the need to weigh the risks and benefits of alternative graft materials may become part of the equation," Dr. Pearlman says.
While the majority (57 percent) of patients sought a second surgeon for the revision because they did not get the results they wanted, one-fourth of the patients did not return to their original surgeon because they felt he or she was insensitive to their needs and desires.
Another issue to consider in planning a revision rhinoplasty is that patients may not be seeking an ideal textbook appearance, particularly if their primary complaint is difficulty breathing, says Dr. Pearlman, who is also clinical associate professor of otolaryngology — head and neck surgery, Columbia University College of Physicians and Surgeons, New York.
"Although surgeons might identify multiple appearance defects, patients may be satisfied with the aesthetics of their new nose, even if the tip is too high or the dorsum too low," he says. "The surgery should not be planned to please the doctor, but should represent a mutual agreement taking into account the desired outcome and the effect of using different graft materials on the patient's needs, desires and tolerance for risk.
"All revision rhinoplasties generally involve some compromise because it is much harder to create the perfect nose in secondary cases," Dr. Pearlman says. "In addition, after considering the extra OR time and morbidity involved with opening the chest to harvest rib cartilage, some patients may be willing to compromise the amount of improvement achieved for a less complex procedure."