Revision Rhinoplasty

Revision Rhinoplasty. A situation neither the patient nor the surgeon wishes to have to face. Yet, even in the best of hands, revision rates can reach 10-15%. How can a patient considering rhinoplasty avoid or decrease the chances of having to face this unhappy scenario?

Revision rhinoplasty is considered when the patient is dissatisfied with the results of the primary rhinoplasty. It is therefore important to choose an experienced surgeon before going ahead with surgery.

While aesthetic sense can be very nuanced and subjective, many revision rhinoplasties are also performed to correct or undo problems and complications arising from the first rhinoplasty. To understand this better, let’s illustrate with 2 examples of commonly used materials:

1) L shaped silicone implants are easy to insert, and gives a nice contoured dorsal aesthetic line that is much sought after.

However, the presence of the silicone implant triggers formation of a capsule around it. Over years, this capsule can calcify and contracts. As this capsule contracts, it pulls the nasal skin with it, resulting in nasal shortening. This means the nose becomes excessively upturned, as it slowly takes on a snoutlike appearance.

The angle of the “L” shaped silicone gives a nice shape to the tip. The short limb of the “L” becomes the “support” that helps to push the shape of the silicone against the skin over the nasal tip.

This creates the 2^nd problem – under enough pressure, this silicone tip can compromise the blood supply to the tip skin, causing the skin to slowly thin out and eventually give way. The implant thus eventually pokes through the skin, otherwise known as implant extrusion.

Now consider the first problem of shortening compounded with the second problem of extrusion. Even if the initial placement does not cross the critical physiologic threshold leading to extrusion, as the nose shortens over the years, pressure over the nasal tip can gradually increase leading to eventual extrusion.

2) Fillers are very popular as a “quick fix” alternative to a more invasive procedure such as a rhinoplasty. While fillers are less invasive, their complications are anything but simple. Severe comlications such as skin gangrene and blindness can occur, but lets focus the discussion on how fillers lead to “revision” rhinoplasty.

Migration. Filler materials are injected in a gel-like form, into the nose – which is an irregularly shaped structure. You can be almost certain that the gel under the skin over this irregular terrain will move. Due in part to gravity and in part to facial movements during smiling or frowning, the filler material can spread to other sites instead of where they were intended to be. This is especially so for permanent fillers, which are notoriously difficult to remove. Even supposedly temporary fillers trigger tissue response causing adhesions and skin thinning, causing rhinoplasty to be difficult.

Fillers have another problem when injected over the nasal tip– they do not contribute to tip support. Imagine that the tip is a table and filler material is added to the top of the table to increase the height. As more and more filler is injected, the legs of the table begin to buckle under the tension from the overlying stretched skin. The inexperienced practitioner may inject even more filler to compensate. Unfortunately, this just leads to more buckling of the legs without increasing tip height. Eventually you have a bulky looking nose and start considering rhinoplasty.

All alloplastic materials, be it silicone, fillers, medpor or goretex have their advantages. More importantly, however, we should understand each of their unique problems and potential complications. Be sure to discuss them in detail with your surgeon before deciding what to use. Ultimately, autologous (from our own body) material is always going to be the safer choice. While it is important to choose your revision surgeon carefully, you are better off choosing your primary surgeon wisely. Your first chance is always your best chance!  — TRC