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Revision rhinoplasty surgery is the most challenging, and often, ungratifying procedure that facial and general plastic surgeons perform. I am sure you have all experienced the pit in your stomach when one of your primary rhinoplasty patients enters your office with postoperative nasal obstruction and ovbious iatrogenic external valve collapse. You are overwhelmed with feelings of disappointment and bewilderment, wondering how this happened when all you did was perform a conservative cephalic trim (leaving 7 mm) and place domal sutures. Why did this happen? Because you did not diagnose the flaccid, weak lateral crura. As a result, and manipulation of the cartilage without placement of lateral crural strut grafts might cause this easily preventable mishap.
Perfecting surgery with this 3D structure can take years to improve the master. Rhinoplasty maneuvers performed today could cause disastrous results 3 years from now. In rhinoplasty surgery, you learn from your mistakes.

My fellowship director, J. Regan Thomas, MD, told me something that I will never forget-”You have not learned anything about rhinoplasty until you have performed at least a thousand procedures and followed them for many years.” This statement epitomizes why fellowships are so valuable. Some of the needed experience and potential pitfalls are circumvented by first-hand observation, which includes studying the analysis, judgment, techniques, complication management, and most importantly, results from a seasoned rhinoplasty surgeon. The training catapults you years ahead of your colleagues that are not fortunate to have postgraduate training.

Many of us are taught that aggressive cartilage removal is a procedure of the past. Today’s concept: less is more. Less cartilage excision, cartilage repositioning, camouflage techniques, structural grafting, and suturing techniques are being taught in most rhinoplasty courses and at our national meetings.

In primary rhinoplasty surgery, the keys to preventing complications are prediagnosis of potential anatomical and functional abnormalities. For example, a patient desires a dorsal hump reduction and you identity short nasal bones and a narrow middle vault. Your thorough evaluation will warn you that this patient is at risk for upper lateral cartilage subluxation from the nasal bones (inverted V deformity) and internal valve collapse. In revision nasal surgery, the previous surgeon missed these telltale potential anatomical abnormalities, and now you are in charge of repairing the complication. Always perform a detailed anatomical and functional evaluation of the nose followed by a diagnosis of the postoperative nasal deformities and/or nasal obstruction. The incidence of postoperative nasal obstruction is approximately 10%. After the potential complications are identified, create a surgical plan while studying the preoperative photographs and prepare to use everything in your surgical armamentarium since nothing goes as planned.

Consultations

Below is my algorithm for a revision rhinoplasty consultation, which makes up approximately 60% of my practice. When the appointment is made, ask patients to bring copies of their medical records and operative reports from their rhinoplasty surgery or surgeries, in addition to photographs of their native nose. Initially, review the notes and photos while the prospective patient discusses surgery with your patient care coordinator. This will give you a head start on identifying the problem, assuming that a problem exists. Next, perform a detailed history while listening carefully to the patient’s wishes. Does the patient have realistic expectations? This is by far the most important detail that surgeons need to attain from the history. What is the patient unhappy with-a pinched tip or Polly break deformity? Additionally, listen to the patient and see if negative comments about the prior surgeon are made or if potential law suits are mentioned. If this is the scenario, you may want to think twice about operating on this patient. If the patient is not happy with the results with you, there is a good chance that the patient will be saying unkind words about you in the subsequent surgeon’s office. Does the patient fit the SIMON profile (Single, Immature, Male, Obsessive, and Narcissistic)? If so, be cautious because these patients are difficult to please and are litiginous. During the initial 5 minutes while acquiring the patient’s history, surgeons should know if the patient is a good candidate for revision surgery. Poor patient selection can lead to an unhappy patient and physician.

Another important detail is to ascertain if the patient has nasal obstruction. Determine if the nasal obstruction was present preoperatively. If the obstruction is a result of the surgery, a number of questions need to be answered. Did the patient have reductive rhinoplasty surgery? Have the patient point out where the obstruction is. Is it static or dynamic? Does it present with normal or deep inspiration? What alleviates and worsens the nasal obstruction? What are the characteristics of the nasal obstruction? Was septal surgery performed? health information