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Compromise is key to rhinoplasty revision surgery

Key iconKey Points

  • Revision rhinoplasties generally involve compromise because it is more difficult to create 'perfect' nose in secondary cases
  • Common complaints after primary rhinoplasty include assymetric nasal tip, symptomatic nasal obstruction, irregularity of upper-third of nose
  • Dorsal reconstructions involve use of only grafts, require material that is long and strong

Dr. Pearlman
Unique issues relating to graft selection and management of patient expectations make surgical planning much more complex for revision rhinoplasty compared with a primary procedure, according to Steven J. Pearlman, M.D.

"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.


A male patient before (left) and after a tertiary revision rhinoplasty with spreader grafts, alar strut grafts and a dorsal onlay graft with diced cartilage in fascia for a saddle nose correction. Cartilage came from the patient’s rib. (Photos credit: Steven J. Pearlman, M.D.)
"Furthermore, patients seeking revision surgery are already traumatized, which makes managing their expectations even more critical and more challenging," he says. Dr. Pearlman is director, division of facial plastic surgery, St. Luke's-Roosevelt Hospital and the Head and Neck Institute, New York. Speaking at Vegas Cosmetic Surgery 2011, Dr. Pearlman noted that data from a recently published study he co-authored (Yu K, Kim A, Pearlman SJ. Arch Facial Plast Surg. 2010;12(5):291-297) reviewing 100 consecutive patients seeking revision rhinoplasty highlights the heightened emotional state of the revision rhinoplasty patient.

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."


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