Revision rhinoplasty(Secondary rhinoplasty)

Revision rhinoplasty (also called Secondary Rhinoplasty) is an aesthetic operation that is carried out for the correction of undesired results of the previous rhinoplasty (nose job). Unfortunately, rhinoplasty surgery may not be successful in every patient, and revision (correction) surgery is required at a rate of 5-15% after primary rhinoplasty (primary rhinoplasty). These rates are taken from the average of the publications on the results of aesthetic nose surgery in our country and in the world. Rates may vary depending on the experience of the surgeon, the complexity of the operation, or the surgeon's skill in handling complex cases. Nevertheless, there is a certain percentage of patients who need revision in the practice of each surgeon. 

Revision operations are divided into minor and major revisions. In the minor revision we have a satisfactory result of the first surgery and only small touch-ups are required. In these cases the patient is generally satisfied with the result and general appearance but may need only a little correction.
However, if there is a significant deformity as a result of previous rhinoplasty surgery, a major revision is required. Minor revisions often can be done in 30-40 minutes. Major revisions may take 3-6 hours depending on the scope of the surgery.
The Most Common Causes of Revision Rhinoplasty

The tip of the nose may be overly narrowed, wide, asymmetrical, low, drooping, or too shortened and raised (pig nose). The nostrils may be asymmetrical or wide. Collapse in the lateral walls of the nose (alar collapse) and breathing difficulties may occur. Existence of dorsal hump, collapse of the nasal dorsum, pollybeak deformity as a result of insufficient removal of the cartilage or a saddle nose due to excessive removal.The inverted V deformity, twisted nose, remaining deviation, irregularities along the nasal dorsum, excessive scar tissue development inside or outside the nose, skin and soft tissue problems. Difficulty breathing is observed in almost all cases requiring major revision. Congestion that remains after the first operation is mainly related to the remaining deviation, swelling of the nasal concha (concha hypertrophy), nasal valve insufficiency (internal and / or external), adhesions, septum perforation.


 When a Revision Rhinoplasty should be performed? What is the right time for secondary rhinoplasty?

During the first 1-3 months, it is not possible to determine the need for a second operation, since the swelling still remains. In some cases, the need for revision can be detected in the early period if there ise a pronounced asymmetry. It takes from minimum 6 months to a year to decide on a secondary operation and determine the scope of required correction. However, there are some exceptions. Right after the operation, noticeable defects can be corrected in the early period, preferably by the same surgeon. The revision can also be carried out in the early period in case of excessive reduction of the nose. In this case, the revision is carried out before adhesions and dense connective tissue are formed, and the skin does not contract.


 Why is Revision Rhinoplasty Surgery More Difficult?

Revision surgery involves differences from primary surgery. Tissues are very narrowed, cartilage and bone tissues, which are very valuable to us, have been removed excessively or asymmetrically, and the healing process has bended the weakened cartilage.This situation requires more careful and delicate work during surgery. Skin and soft tissue are very important in revision rhinoplasty. There may be a scar tissue on the skin. Besides, secondary rhinoplasty shows a more intense inflammatory tissue response than primary rhinoplasty. In addition, the cartilage of the nasal septum is often already used in previous operations, or its amount is insufficient. Deformities and the absence of normal anatomical structures make revision surgery more difficult than primary rhinoplasty.
At this point, the experience and patience of the surgeon are vital. Moreover, even if everything is done correctly in revision surgery, the healing response of the existing tissues and skin will also affect the result.

Although there are some differences in the preoperative evaluation, surgical process and postoperative recovery in Revision Rhinoplasty, it is the same as in primary rhinoplasty (first nose job).

“Pre-operative interview”, “Aesthetic and functional evaluation”, “Photo shooting and design”, “Pre-operative preparation” are as described in the Rhinoplasty title. For more details:
In the pre-operative interview and evaluation, the patient should have realistic expectations and the doctor must also make realistic promises.


 How is Revision Rhinoplasty Surgery Performed?

While minor revisions can be performed with local or general anesthesia, closed or open approach, almost all major revisions (except patients with skin problems) require general anesthesia and open approach. Minor revisions take 30-45 minutes, major revisions  takes around  3-6 hours. The duration depends on the degree and complexity of the deformity, the need for costal and ear cartilage. If there is no anesthesia-related risks, the result is always more important than the duration of an operation. 


What kind of Cartilage Grafts and implants Used in Revision Rhinoplasty?

I will try to give a little more detailed information on this subject, as we receive a lot of questions from my patients and social media.
Cartilage grafts used in primary and revision rhinoplasties are basically taken from the middle part of the nose (septum), ear and rib. The choice depends on the specific need.


Septal Cartilage 

The septal cartilage is an  ideal choice because it has a smooth, thick and strong structure and is located directly in the surgical site.
Complication (resorption, infection, rejection , bending) rate is low. In a large study of more than 2,000 patients with septal cartilage grafts, it was reported that there were no cases of rejection for 17 years.

Resorption  rate varies between 12-50% according to the results of different studies. Excessive crushing or shaving of cartilage increases resorption possibility. However, resorption is not clinically noticeable since it replaces itself with fibrous tissue (connective tissue).
Disadvantages: Since at least 1 cm of L-shaped cartilage support must be left, the amount of septal cartilage we can take is limited, and uneven septal cartilage may bend over time due to "cartilage memory".


Conchal cartilage (Ear Cartilage)

As it is easy to be taken, it is an ideal graft for supporting and raising the dorsum of the nose in revision rhinoplasty. Conchal cartilage  can also be used to camouflage small defects and irregularities. Besides,a crushed conchal cartilage can be used by wrapping it in a membrane. Ear cartilage is difficult to shape as it is elastic and curved. It can be easily broken, sometimes we have to use two layers or fix it by stitches to get a flat shape.
Its ideal use is in cases where collapses on the nasal dorsum, valve reconstruction and contouring are required. After the skin incision, the required amount of cartilage is taken from the anterior or posterior part of the ear and then the skin is sutured again. Compression dressing is required for a few days after the procedure. After healing, the scars are completely invisible. If correct technique is used, ear shape will not be distorted. The procedure does not have any negative effect on hearing.

 Costal Cartilage (Rib Cartilage)

 Perfect choice for severe deformities or in secondary cases if a large amount of cartilage is required. Although the most important disadvantage is bending, this problem has been minimized by the oblique split method. Postoperative pain may last up to 1 month in the area the graft was taken. Average complication rate is 11%. The cartilage of the 7th rib is achieved by cutting the skin under the breast by an average of 2-3 cm, the cartilage of the required size is removed and the incisions are sutured again. The graft collection takes 30-45 minutes, which prolongs the operation time.

Diced Cartilage

It can be prepared with all 3 cartilages (septal cartilage, conchal cartilage, costal cartilage). This technique provides great flexibility to the graft. Membrane wrap reduces the rate of resorption and provides better results. We can also use sergicel or alloderm for wrapping. In addition, tissue adhesives (platelet rich plasma plus fibrin glue) can be combined.


Cadaveric Costal Cartilage

First of all, I do not use cadaveric cartilage. Cadaveric cartilage is especially used to support-raise the nasal dorsum. Advantages: no additional intervention needed, reduction of operation time, the ability to supply in any quantities. The main disadvantages are resorption and buckling. The rate of resorption in many studies is indicated differently. During preparation, the cartilage is exposed to radiation of 30-50 thousand Gy.
It is believed that as the radiation rate increases, damage of collagen and resorption increases accordingly.

We can list the problems seen in the studies of  rib cartilage (Irradiated Homologous Costal Crtilage-IHCC) taken from the cadaver as follows;

- Resorption Research data on this topic is quite contradictory.Long term resorption rates (5 years or more) are reported from 1 to 75%. The amount of resorption may be mild-medium-complete. Frankly, some studies do not reflect the truth in my opinion.

According to the experience of my friends who honestly share results of observations and my own experience, there is 30-50% resorption in the long term. It is not possible to foresee the resorption process for each patient individually. Resorption is most pronounced in grafts used as structural support. Although there is resorption in the grafts used for camouflage, the resorbed cartilage is replaced by fibrous tissue, so we don’t observe the loss of volume.
For these reasons, I always recommend using the patient's own cartilage for low nasal tip or saddle nose deformity.


- Infection; It can be seen between 1-9% and often can be controlled with antibiotics. Rarely, it may be required to remove the graft.

- Deformation; Deformation happens rarely, mostly if it was used the central part of the cartilage or grafts were prepared with the oblique split method. It should be kept in saline for about 45 minutes and checked.

- Displacement; Rare

-Ossification; Rare

There is no HIV or Prion infection due to cadaveric cartilage reported in the researches. However, the fact that prion infection (the causative agent of mad cow disease) is very difficult to detect may be one of the reasons why it has not been reported.

Implants are synthetic materials. 

Implants used in revision rhinoplasty: Silicone Gore-Tex, Medpor and PDS. Synthetic implants are not preferred in our country, Europe and America due to the high rate of complications and the fact that these complications persist throughout life, regardless of the postoperative period.
It is especially used in Asian Nose type to raise the nasal dorsum.

To sum up; in rhinoplasty and revision rhinoplasty, I recommend using septal, conchal or the person's own rib cartilages if cartilage grafts are needed.

More detailed information about Revision Rhinoplasty

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