Miami Revision Rhinoplasty Specialist
Dr. Andres Bustillo has practiced facial plastic surgery for more than ten years. He is double board certified in Facial Plastic and Reconstructive Surgery and Otolaryngology-Head and Neck Surgery. He only performs surgery in the face and neck. He devotes close 50% of his practice to rhinoplasty and revision rhinoplasty. Dr. Bustillo performs over 300 nasal surgeries a year. He is one of the most experienced nasal surgeons in South Florida. He believes in creating a beautiful nose that functions just as well.
Revision Rhinoplasty Before and After Photos
Dr. Bustillo is well known nationally and internationally for providing the most natural and conservative revision rhinoplasty results. He has an ability to re-create a natural nose from a previously unsuccessful rhinoplasty. Because Miami’s multi-cultural diversity, Dr. Bustillo has a vast experience in revision rhinoplasty with different ethnic noses, such as Hispanic, African American, and Middle Eastern.
Andres Bustillo currently instructs medical students, medical residents, and other physicians his techniques for rhinoplasty and revision rhinoplasty. Dr. Bustillo travels often to Central and South America, the Caribbean, and Asia, to teach plastic surgeons his innovative revision rhinoplasty techniques. He has written and published numerous chapters on revision rhinoplasty surgery. The information that follows was written by Dr. Bustillo to teach and educate patients about revision rhinoplasty.
What is Revision Rhinoplasty?
Revision rhinoplasty involves re-operating a nose to improve a previous poor result and can be one of the most difficult surgeries to perform in plastic surgery. Revision rhinoplasty can take two forms. The first is the small “touch up” revision of an acceptable previous result. The patient may be happy with the overall appearance of the nose, but may wish a small and slight improvement. For example, a small tiny bump was left on the bridge or a small visible edge on the tip. Revision rhinoplasty in this case is usually a less involved operation. The patient is typically content with having the surgery performed by the original surgeon since trust was not lost. Patients are typically not emotionally upset.
The second form is when the revision rhinoplasty is performed to reconstruct a previous poor result. A failed rhinoplasty can be one of the most devastating experiences a patient undergoing plastic surgery can have. Patients that undergo rhinoplasty have usually thought about the surgery for several years. When the result is a nose that is worse in appearance than the original nose, the patient can become extremely disappointed. Self esteem and confidence may decrease and affect the person’s social activities. I have a deep and personal understanding of the emotional distress that patients undergoing through this feel and I am committed to helping them.
There are several reasons why rhinoplasty can fail. However, the most common reason is technical error during the surgery. Surgical experience, pre-operative planning, and meticulous surgical technique are essential to a good rhinoplasty outcome. Improperly placed incisions, aggressive removal of cartilage and bone of the nasal bridge, and aggressive removal of nasal tip cartilages leading to poor structural support can all lead to an unnatural and awkward appearance. This in turn will draw unpleasant attention to the nose.
With the increasing numbers of cosmetic procedures being performed, there has been an increase in the demand for rhinoplasty surgery. While many surgeons perform plastic surgery throughout the body, few are specialists in the nose and face. A plastic surgeon that performs only 5 to 10 rhinoplasties a year may not be the best surgeon to perform a rhinoplasty. He may not have sufficient experience or the proper training to perform the rhinoplasty procedure. At the same time the rhinoplasty consumer has developed a sophisticated sense of nasal aesthetics. The delivery of poor surgical results and elevated expectations has resulted in an increase the number of revision rhinoplasty procedures being performed today.
Revision rhinoplasty can be one of the most difficult plastic surgery procedures to perform. The restoration of the damaged nose can be technically and artistically challenging. Often, the nasal cartilages have been removed and scar tissue has replaced much of the structural framework. The remaining nasal cartilages are often warped or misshaped. The nasal structure must be recreated using cartilage grafts to mimic the framework of a virgin, or non-operated, nose.
This reconstruction must be exact and flow together in a 3-dimensional fashion to give the appearance of a beautiful nose that will balance the patient’s facial features. Scarred and altered tissues must be placed back in the proper place by re-arranging the nasal framework. All this must be done while combating the distorting effects of a skin and soft tissues that have been scarred by the previous poor surgical result.
The structure must be strong enough to withstand the tremendous scar formation forces that are sometimes present during the healing period of previously operated noses. The function of the nose, that is breathing, must be maintained or, in many times, repaired. This is done by strengthening those elements of the nose that are responsible for maintaining the air passages open.
My philosophy when confronting severely distorted noses is the following: to return the nose to normalcy, so that the nose appears normal and is no longer the center of attention. Often, the noses have an operated or surgical appearance that attracts attention. My goal is to give the nose a natural and non-operated look, so that it is no longer the center of attention.
In other words, to remove the surgical appearance and make the nose normal. There are noses that because of the damage they suffered, may never achieve perfection. However, I strongly believe that if they are brought back to normalcy, they well blend with the facial features and will not attract undue attention.
In the past, there has been great argument on whether revision rhinoplasty should be performed in an open or closed fashion. The external or “open” approach is done through a small incision in the columella. The endonasal or “closed” approach is done through incisions made inside the nose. While I use both approaches for primary rhinoplasty, I almost always use the open approach for revision or secondary rhinoplasty. In most cases of revision rhinoplasty, there is a great deal of asymmetry of the nasal tip cartilages that may require rebuilding and recreating the individual components of the nasal tip. I can best reconstruct the nasal tip through an open approach. In this fashion, I can see the exact areas that are causing deformities in the nose and repair them.
I have been using state of the art techniques to recreate and rebuild the structural framework of the nose since I began practice. One of the techniques that I sometime employ in revision rhinoplasty is the use of grafts. As far as rhinoplasty is concerned, grafts are structural elements made of live tissue, typically cartilage. One of the most common statements that I often hear is “I read in the internet that grafts show through the skin.” This can happen when they were made and placed in the wrong way or they were used in a patient that should not have had the graft placed. When grafts are properly and judiciously used, they should not be visible through the skin.
The cartilage used for grafts can be acquired, or harvested, from the septum, which is inside the nose (Figure 5). The septum is a “wall” between both nostrils. In some cases the septum can be deviated. In these cases, a septoplasty may be performed to straighten the septum. The procedure involves removing the deviated portion of the nasal septum. The harvesting of septal cartilage is done the same way as a septoplasty. The only difference is that in the septoplasty, the cartilage is discarded. When I harvest it, it is re-used to make the grafts. Septal cartilage is the ideal cartilage for the making of grafts. It is strong, thin and is resistant to warping. It is my preferred grafting material. However, oftentimes patients undergoing revision rhinoplasty may have had septal cartilage removed during their previous surgery.
In the absence of septal cartilage, cartilage may be harvested from the ear (Figure 6). This is done through an incision behind the ear. The ear does not change in appearance after the cartilage is taken. Ear cartilage can then be used to make the grafts. Ear cartilage is thick, shaped in a curvilinear form, and can crack easily. These characteristics make it less than ideal for grafting. It is a good substitute in the absence of septal cartilage.
Rib cartilage is another option (Figure 7). The rib is harvested through a small incision in the right chest. In females, this is done through an incision just under the right breast. The risk with harvesting rib, although rare, is injury to the lining of the lung. Although there is enough rib cartilage available, this is by no means the ideal cartilage for grafting. The rib cartilage has a tendency to warp or change shape after it has been placed in the nose. Although the rib is carved in a certain fashion in order to avoid warping, this can occur, especially when the graft is made thin. I often use rib grafts to rebuild a collapsed nasal bridge or to augment a nasal bridge that has been overresected (when too much of the bridge was removed).
Tip grafts can be used to define a nasal tip (Figure 8). There are two types of tip grafts that I use. The shield-type tip graft can be used to rotate or project the nasal tip. They are also used to recreate the nasal tip cartilages when they have been removed by the previous surgery. Cap grafts can also be used to define the tip. When using grafts to define the nasal tip, the surgeon must be very meticulous in shaping the graft and camouflaging it to avoid any showing through the skin. Extreme care must be used when using tip grafts to rebuild the tip in patients with thin skin. The grafts must perfectly carved, with smooth and rounded and edges. In addition, the grafts are often covered with soft-tissue to avoid any visibility.
A columellar strut is a narrow graft used to provide support to the nasal tip. This provides the support necessary to counteract the healing forces that may attempt to drop the nasal tip. It is also used to straighten a hanging columella. The columella is the central column between both nostrils. Spreader grafts are grafts used on the dorsum, or bridge (Figure 9). They can be used to help straighten the bridge or to correct narrowing of the bridge. They can sometimes be used to help open a narrow airway. Alar rim grafts are tiny grafts that are used to bring down a retracted ala. A retracted ala is one that has arched and retracted due to the previous removal of excessive alar cartilage. Alar batten grafts are small grafts used to help reshape a narrow or pinched nostril. These are also typically used to help elevate a collapsed nostril, which may impede nasal breathing.
The skin and soft tissue envelope is an important anatomical component of the nose. Understanding its importance in revision rhinoplasty is paramount. As a result of previous surgery, the skin and the soft tissues are often scarred to the remaining nasal framework. This scar tissue can replace the cartilage that was removed during the original surgery.
The dissection must be meticulous to avoid damage to the skin, which is often thin. In addition, one of the main differences between primary and revision rhinoplasty is the intense inflammatory response seen in the nasal soft tissue that occurs after the revision surgery. While the normal inflammatory reaction seen after a primary rhinoplasty is mild, the nasal soft tissues may react very differently after a revision rhinoplasty.
This reaction is more intense with an increasing number of surgeries. This can damage an otherwise good cosmetic result. It is imperative that the surgery be performed in an atraumatic and meticulous fashion to prevent inflammation and scar tissue formation.
Patients with thick skin must be dealt with in a very different way than those with thin skin. There are several issues that must be considered. First, patients with thick skin need very strong nasal tip support to help keep the tip in the ideal position. Because thick skin is heavy, the tendency is for the weight of the skin to pull the nasal tip down.
Secondly, the nasal tip must be strengthened to “push” through the thick skin in order to provide definition. Failure to establish the support for the nasal tip will give a round, non-defined nasal tip. By stretching the skin by building a strong nasal tip, the tip will gain maximum definition. The third difficulty with thick-skinned patients undergoing revision rhinoplasty is the prolonged swelling.
Patients with thick skin will have prolonged swelling as compared to thin-skinned patients, and when these patients undergo secondary rhinoplasty, the swelling can take a longer time to resolve. I have seen swelling take up to two years to resolve. Luckily, this does not happen often.
Patients that have very thin skin have other problems with rhinoplasty. In these patients, any small irregularity will show. Therefore, all of the underlying work that is done on the bridge or tip of the nose must be carefully polished to avoid any imperfections showing through the thin skin. It is advisable to not use grafts in patients with thin skin. When necessary, any graft should be carefully carved and covered with fascia to prevent any show.
Why does the Tip Swell in Revision Rhinoplasty?
The tip of the nose can swell for a prolonged time after a revision rhinoplasty. The reason is that after normal tissues are operated on, the normal lymphatic drainage is altered and a new one needs to develop. Scar tissue formation after surgery can also lead to prolonged swelling in the nasal tip. In addition, the thickness of the skin has a considerable effect on the swelling after a revision rhinoplasty. For example, a nose with thick skin may take more than a year for all of the swelling to dissipate. Noses with thin skin will swell less and the swelling will resolve in a shorter time than those with thick skin.
The ideal candidate for revision rhinoplasty is a healthy person who is not content with their previous rhinoplasty result. The timing of revision surgery should be approximately a year after the previous surgery. Although patients may feel compelled to undergo the surgery at an earlier time, patience is a real virtue here. Allowing adequate time for the post-operative swelling to completely subside will help to avoid a surgical error.
Patients that suffer from a poor previous rhinoplasty result often feel uncomfortable with the appearance of their nose. They may feel embarrassed or insecure with themselves. In addition, they may have difficulty breathing. It is for these two reasons, aesthetics and breathing, that the decision of having a revision rhinoplasty procedure is an extremely important one. This is because every time that the nose is operated, the probability of having a satisfactory result decreases. Most patients that undergo a revision rhinoplasty with Dr. Bustillo are extremely happy. They feel better about how their nose looks and feel more confident.
It is important for the patient to understand exactly what Dr. Bustillo will be doing to the nose to improve the aesthetics and breathing, if necessary. Although Dr. Bustillo is an expert in revision rhinoplasty, there are things that cannot be completely corrected with surgery. Dr. Bustillo uses computer imaging as a tool to communicate with patients, so that they may have a clear understanding of what surgery can achieve.
While most revision rhinoplasty patients enjoy the benefits of an improved nasal shape and profile, it is important to remember that surgery is not perfect a perfect science. Even though Dr. Bustillo is a highly skilled revision rhinoplasty surgeon and can achieve an improved nasal appearance, the result will not be perfect in some ways. The patient that is undergoing a revision rhinoplasty must understand that an improvement, and not perfection, is sometimes the end result in revision rhinoplasty.
Dr. Bustillo will begin the consultation for your revision rhinoplasty with a thorough talk about the concerns that you may have with the appearance of your nose. Occasionally, patients with previous nasal surgeries may suffer from severe nasal obstruction, due to an aggressive removal of cartilage. This should also be discussed, as this can be corrected during the revision rhinoplasty.
Next, Dr. Bustillo will perform a complete physical examination of your nose. He will examine the both the inside and the outside of your nose. The septum is checked for any deviations and palpated for the presence of cartilage. This is very important, since it will help plan whether septal cartilage, if present, will be used. If septal cartilage is not present, Dr. Bustillo will have to decide where cartilage will need to be harvested from. The internal and external nasal valves are checked by having the patient inhale through the nose. Any collapse of the valves during inspiration, will require correction during the secondary rhinoplasty procedure.
The outside of the nose is then completely examined. The nasal bridge is carefully felt for any humps, irregularities, or depressions. Both nasal bones, one on each side, are then examined and palpated for any deviations, irregularities, or asymmetries. The tip of the nose is then touched to feel for any asymmetries or any irregularities.
The sides of the tip, known as “ala”, are examined for any collapse or retraction. (Figures 10, 11, 12, 13). The columella is then inspected for any hanging or poorly healed. (Figures 14, 15). The projection of the tip, defined as the distance from the base of the nose to the end of the tip is checked. Overprojected tips may have to be reduced. A common problem with previously operated noses is the lack of projection. This happens when the previous surgeon failed to properly strengthen the nasal tip.
As a result, Dr. Bustillo often has to strengthen the nasal tip to establish proper nasal tip projection. Another consequence of failure to strengthen the nasal tip is the loss of tip rotation. Tip rotation is defined as the angle of the tip in relation to an imaginary horizontal line drawn at the base of the nose. Weak tips tend to be “droopy” or under-rotated. Over-rotated tips may have to be dropped to an adequate rotation.
Revision rhinoplasty by Dr. Bustillo demonstrating the correction of alar retraction. (Same patient fig. 10)
The cost of a revision rhinoplasty with Dr. Bustillo ranges from $7300.00 to $ 8300.00 including operating room and anesthesia. Dr. Bustillo performs his surgeries in his state of the art certified facility with board certified anesthesiologists (M.D.) which work for the Baptist Hospital Department of Anesthesiology.
Does Computer Imaging Help with Revision Rhinoplasty?
During the consultation, Dr. Bustillo will take pictures of your nose. He will then use computer imaging to give the patient an idea of what the nose will look like after surgery. This is an excellent tool that allows the patient to communicate with Dr. Bustillo. It is important that the patient communicate with Dr. Bustillo, so that together they can agree on the exact look that the patient wishes for the nose. The image that Dr. Bustillo finalizes will be something that he thinks is possible and achievable with surgery. This is one of the key factors with computer imaging for revision rhinoplasty. Is the surgeon’s computer image realistic and similar to the result of the revision rhinoplasty? Dr. Bustillo guarantees that the computer image he produces will be extremely close to the actual result.
The patient will have to obtain pre-operative labs several weeks before the surgery. Patients older than 45 years of age or with medical conditions will have to obtain a medical clearance prior to surgery. Patients taking aspirin, Non-steroidal anti-inflammatory products (naproxen, ibuprofen), and vitamins such as A, ginkgo biloba, and St. John’s wart will need to stop these ten days before surgery. These products can interfere with blood clotting and cause bruising. Alcohol intake should be stopped five days before surgery to avoid nasal swelling. Dr. Bustillo recommends that all patients take to take 2000mg of vitamin C a day one week before and two weeks after the revision rhinoplasty to improve healing and lessen bruising.
Dr. Bustillo performs the revision rhinoplasty procedure in his certified surgical facility. The anesthesia is provided by board certified anesthesiologists (MD), who are part of the Anesthesia Department at Baptist Hospital. The revision rhinoplasty surgery is performed using general anesthesia. General anesthesia is a very safe technique that allows Dr. Bustillo to focus on the revision rhinoplasty surgery while the patient is safely asleep under the care of an anesthesiologist.
The advantage of general anesthesia is that the airway is protected during the surgery. In this way, any secretions or blood in the back of the throat do not go into the lungs and cause irritation. On the other hand, IV sedation anesthesia does not protect the airway during the revision nasal surgery. If there are secretions or blood in the back of the throat, these will go into the lungs and may cause coughing and irritation. Dr. Bustillo takes approximately two hours to perform the revision rhinoplasty surgery.
Every surgical procedure has certain risks. As far as a revision rhinoplasty is concerned, there are some possible complications. Bleeding after surgery occurs less than 1% and is rare. Most of the time it can be controlled with cauterization or light packing. Infection is rare and also occurs less than 1% of the time. If it does occur, it can usually be treated with oral antibiotics.
The risks of revision rhinoplasty are almost always higher than those associated with primary rhinoplasty. The surgeon must recreate the structural framework of the nose that was removed during the original rhinoplasty. In addition, Dr. Bustillo must deal with the consequences of soft tissue scar formation and airway compromise. Even when the surgical operation is properly executed, there are factors that can affect the final result. Scar tissue formation, graft failure, graft shifting, or warping, and prolonged swelling can turn a otherwise successful result into a les than perfect outcome. That being said, most patients that have realistic expectations are happy with an improved nasal appearance.
Dr. Bustillo would like for his patients to spend the night of the revision rhinoplasty in a relaxed atmosphere. Patients should rest and relax. The patient should maintain a liquid diet for the first twelve hours after anesthesia. Two pillows should be used to keep the head elevated. This helps to reduce swelling. Small zip-lock bags filled with frozen peas should be kept on the eyes every ten minutes an hour for the first forty-eight hours. This will help to reduce the eye and nasal swelling.
Most patients that undergo revision rhinoplasty do not experience any pain. In fact, most patients do not take the pain medication that is given to them. Occasionally, Dr. Bustillo may place a small cotton ball in the nostrils. If this is done, they are removed the next day in the office. A small cast is always placed on the bridge of the nose. This is removed on the fifth or sixth day after surgery. Most patients can return to work on the sixth day after surgery. Patients may fly home on the sixth day after their revision rhinoplasty if they wish. Exercise is allowed three weeks after surgery.
The nasal swelling after a revision rhinoplasty varies. About seventy percent of the swelling resolves after the first month. The last thirty percent may take up to a year or more, depending on the thickness of the skin. In individuals with thick skin, the swelling may take a year and a half to fully disappear. Even though the swelling after a revision rhinoplasty takes some time to resolve, most patients look much better than before surgery right when the cast is removed on the fifth or sixth post-operative day. At the twelfth month, Dr. Bustillo will take after photographs and will give them to you along with the pre-operative photos. The great majority of patient that undergo revision rhinoplasty with Dr. Bustillo are very happy.
Who is the Best Revision Rhinoplasty Surgeon in Miami?
The reality is that there is no best revision rhinoplasty surgeon. Any good surgeon can have complications or a less than perfect result. I think that a patient should consult with a board certified facial plastic surgeon that has vast experience performing revision rhinoplasty, has an aesthetic that the patient likes, and that there is chemistry between the patient and surgeon. I firmly believe that Facial Plastic Surgeons have a significant advantage over Plastic Surgeons when it comes to revision rhinoplasty. Facial Plastic Surgeons have been trained in Otolaryngology-Head and Neck Surgery as well as Facial Plastic and Reconstructive Surgery and know the nose better than any other surgical specialty.