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Functional, aesthetic concerns drive rhinoplasty patients to seek new surgeons

Key iconKey Points

  • External approach to revision rhinoplasty improves critical exposure for optimal result, experts say
  • In revision rhinoplasty, reinforcing weaknesses becomes more central
  • Thick-skinned patients have distinct issues in revision rhinoplasty

Patients who present for revision rhinoplasty often complain of breathing problems as well as aesthetic problems.

"I almost never see a patient seeking revision rhinoplasty who comes in only to improve their breathing, even when the breathing is severely impaired," says Minas Constantinides, M.D.

"Almost every patient wants an aesthetic improvement and a breathing improvement, in that order," says Dr. Constantinides, director, facial plastic and reconstructive surgery, department of otolaryngology, New York University's Langone Medical Center, New York.

Oftentimes, these patients also feel as though their previous surgeon has betrayed their trust.

"Establishing a new trust with these patients is the biggest challenge that all of us who do a lot of revisions must face," Dr. Constantinides says. "They want another surgery but fear that another surgery will also result in more going wrong. They often blame their first surgeon for technical failures, but there often are none. Usually, the failure is from the first surgeon underestimating what structural support was required to achieve the desired result."


A 23-year-old female patient who had two previous rhinoplasties using ear cartilage before (left) and two years after revision surgery, which included excising a polly beak scar, repairing a transected right lateral crus, placing a left alar batten graft, placing bilateral spreader grafts for middle vault collapse, and placing a septal extension graft for tip support. (Photos credit: Minas Constantinides, M.D.)
ERRORS OF OMISSION Philadelphia-area facial plastic surgeon Timothy Greco, M.D., categorizes the reasons people present for rhinoplasty revision as either errors of omission or commission.

"Errors of omission are when certain surgical maneuvers were not performed in the primary procedure that would have enabled achievement of the desired refinement," Dr. Greco says. "Errors of commission are when too much surgery was done — For instance, if a patient has a dorsal hump and excessive removal of the hump results in a saddle nose deformity."

Sometimes, prospective revision patients visit Dr. Greco because they have a functional problem following their primary procedure, he says. "This is usually because too much cartilage was removed from certain areas of the nose. It can result in a postrhinoplasty obstruction that can either be due to a persistent deviated septum or collapse of the internal and/or external valve of the nose," he says.


A 58-year-old male patient who had a saddle nose deformity (left) from a septoplasty performed 20 years ago, followed by a traumatic injury, and the patient one year after Dr. Greco performed a rib graft to reconstruct the nose. (Photos credit: Timothy Greco, M.D.)
AN OPEN APPROACH Both Drs. Greco and Constantinides prefer an open, or external, approach to revision rhinoplasty. "This approach improves the critical exposure required for an optimal result," Dr. Constantinides says. "In most revisions, surgery is needed because structural support for the nasal cartilages has been severely compromised. Many renowned surgeons overcompensate by insisting on using rib cartilage for building a rock-solid framework. I believe that septal cartilage and ear cartilage are adequate for most revisions.

"I harness whatever inherent strength is left in the nose and supplement it, rather than completely rebuilding the nasal framework using rib cartilage," he says. "This is not to say that rib is never needed. It's just that I don't automatically go that route if I believe I can achieve adequate results with more modest measures. My results tend to be less structurally harsh, giving softer, more natural outcomes than those with rib."

Dr. Greco says he relies on the open approach to rhinoplasty revision because it gives him a greater opportunity to anatomically define the nature of the problem and correct it.

"The issue that's extremely important in revision rhinoplasty is to accurately diagnose what the deficiencies are and then make sure you have enough autologous material to correct the problems," he says.


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