Revision Rhinoplasty South Florida

Before & After Photos

Introduction
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.

Return to normalcy
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. 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 (Figures 1, 2, 3, 4).

A pre-operative lateral view of a female patient that had a previous rhinoplasty by another surgeon.			The post-operative view of the same patient after undergoing revision rhinoplasty by Dr. Bustillo
The pre-operative view of the same female patient seen in fig. 1.			The post-operative front view of the same patient after undergoing revision rhinoplasty by Dr. Bustillo.

Closed vs Open
For the last fifteen years there has been a great debate on whether the rhinoplasty operation should be performed in an open or a closed fashion. The "open" or external approach involves an incision in the columella, or the area under the tip of the nose. The "closed" or endonasal approach involves a series of incisions inside the nose. While I use both approaches for primary rhinoplasty, I almost always use the open approach for revision 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.

Grafts

An example of septal cartilage harvested for grafting.

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. Grafts are structural elements made of live tissue, typically cartilage.

One of the most common statements that I often hear is "I read 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 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.

An example of ear cartilage graft harvested for grafting.

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.

An example of rib cartilage harvested for grafting.

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).

A tip graft shaped from septal cartilage, used to reconstruct the nasal tip.

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 rounded and smooth 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.

An example of spreader grafts being used to correct a collapsed nasal bridge.

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.

Skin and Soft Tissue Envelope
The skin and soft tissue envelope is an important anatomical component of the nose. Understanding its importance in revision rhinoplasty is paramount. Often times the skin and the underlying soft tissues are 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 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.

Are you a candidate for revision rhinoplasty?
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.

The decision about having a revision rhinoplasty operation is a very important and personal one. You should consult with your surgeon and your family. 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. For most patients that undergo the procedure, the results are life changing. Patients describe an increase in confidence and boost in self-esteem. They can become more comfortable in social settings and feel better about how they photograph.

The patient must have the proper expectation before undergoing revision rhinoplasty. Although with modern revision rhinoplasty techniques, results are much better than in the past, there are still limitations. It is important that the patient have a good understanding of what can be achieved with the revision surgery. The communication between the patient and the surgeon must be clear. Computer Imaging can be a very important tool in helping me to communicate with the patient.

Surgeons are human and therefore are not perfect. While most revision rhinoplasty patients enjoy the benefits of an improved nasal contour and profile, it is important to remember that surgery, like all other human actions, is not perfect. A skilled revision rhinoplasty surgeon can achieve an improved nasal appearance, but may not be able to deliver a perfect result in some cases. The patient must be willing to understand that improvement, and not perfection, is sometimes the end result in revision rhinoplasty.

Consultation
The consultation process begins with a discussion about the specific issues and concerns regarding the appearance of the 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.

A thorough physical examination is then performed. The nasal cavities are examined. The septum is examined for any deviations and any inflammation or swelling of the turbinates is noted. The septum is palpated to determine whether any cartilage is present. The patient is asked to inhale through the nose to observe the internal and external nasal valves. Any collapse found here will be addressed in the surgery to improve the breathing.

The external nose is then carefully examined and palpated. The dorsum, or bridge of the nose, is examined for any humps that may have to be reduced. The nasal bones are then palpated for irregularities, asymmetries, or curvatures. The nasal tip is then examined and palpated. Occasionally, the tip cartilages are asymmetric, or pointing in different directions. The tip may have alar collapse or the ala may be retracted (Figures 11a, 11b, 11c, 11d). The collumela is examined to see if there is any hanging or retraction (Figures 12a, 12b). The tip projection, which is the length of the tip from the base of the nose to the end of the tip, is examined. Tips that are too projected, or long, need to be reduced and those that are to short, may need to be lengthened. Tip rotation, which is the angle of the tip in relation to an imaginary vertical line drawn at the base of the nose is analyzed. Tips that are under-rotated, or "droopy" need to be rotated up, while tips that are and appear "piggy" need to be de-rotated or brought down. Certain nasal tips that move when the patient talks or smiles may require strengthening.

Front view of a female patient with a previous rhinoplasty demonstrating alar retraction.			Post-operative view of the same patient after undergoing revision rhinoplasty by Dr. Bustillo
Lateral view of the same patient demonstrating alar retraction.			Post-operative lateral view of the same patient after undergoing revision rhinoplasty by Dr. Bustillo
Pre-operative lateral view of a patient with a previous rhinoplasty demonstrating a hanging columella.			Post-operative lateral view of the same patient after undergoing revision rhinoplasty.

Computer Imaging
Pre-operative pictures are then taken and computer imaging is done. Computer imaging involves the digital manipulation of the patient's picture to evaluate various nasal and tip contours. This is a fantastic communication tool that allows the wishes of the patient to be aligned with the surgeon. In fact, I want the patient to participate in the process, so that I can have their input when making the computer-generated image. I will always give the patient a computer-generated image that I believe is achievable. Using computer imaging will allow me to have a clear understanding of the patient's aesthetic goal and allow the patient to have a clear understanding of what I think is surgically possible.

Preparation
Patients are required to obtain pre-operative labs prior to surgery. Some patients, depending on age or medical condition, may be required to obtain a medical clearance before the surgery by their primary care physician. All aspirin, anti-inflammatory products (naproxen, ibuprofen), and vitamins such as A, ginkgo biloba, and St. John's wart should be discontinued ten days before surgery because they may interfere with blood clotting and cause bruising. Alcohol should also be avoided for five days before surgery to avoid swelling. Patients are required to start on high dose vitamin C two weeks before and two weeks after to help with the healing and to reduce bruising.

Anesthesia
The revision rhinoplasty surgery is performed on an outpatient basis in an AAASF-certified surgical facility. Because I believe that patients recover best outside of a medical environment, they are allowed to allowed to return home or to their hotel room the same day after they recover. All surgeries are staffed by board certified anesthesiologists, which are part of the Baptist Hospital Anesthesiology Department.

The revision rhinoplasty operation is performed with general anesthesia. I believe that this is a safe technique that allows me to focus on the surgery while you are safely asleep under the care of an anesthesiologist. General anesthesia allows the anesthesiologist to protect the airway. In this way, any blood or secretions that may travel to the back of the throat do not enter the lungs and cause irritation. IV sedation anesthesia, on the other hand, does not protect the airway during nasal surgery. Any secretions that travel towards the back of the throat may enter the lungs and cause irritation and coughing. The surgery usually takes about 2 hours to perform.

Risks
Like every surgical procedure, there are some possible complications that can follow the revision rhinoplasty operation. Bleeding after the surgery is rare, but if it occurs, it can be controlled with measures such as cauterization or packing. The risk of post-operative bleeding is about 1%. There is also the risk of infection, which extremely rare, and occurs less than 1% of the time.

The risks of revision rhinoplasty are almost always higher than those associated with primary rhinoplasty. The surgeon must recreate the structural framework and deal with the consequences of soft tissue scar formation. That being said, most patients that have realistic expectations are happy with an improved nasal appearance.

Recovery
The night of the surgery should be spent relaxed. Activity should be kept to a minimum. A liquid diet is best for the first eighteen hours after anesthesia. The head should be kept elevated using two pillows to help reduce swelling. Patients should place small zip lock bags with frozen peas on the eyes 10 minutes, for every hour spent awake for the first 48 hours. This is done to help reduce swelling around the eyes, which typically resolves in five days.

The post-operative period after revision rhinoplasty is not painful. Tylenol is usually enough to control any minor discomfort. You will be provided you with additional pain medication, in the event that you need it. Occasionally, a small cotton is placed in the nose, which is removed on the first day after the surgery. There is a small cast that is applied to the bridge of the nose. This is removed in the fifth or sixth post-operative day.

There is a variable amount of swelling that occurs on the nose after the revision rhinoplasty operation. About seventy percent of the swelling resolves in the first three weeks. It is recommended that physical activity, such as running or lifting be resumed only after the fourth week. The remainder of the swelling after revision rhinoplasty can take up from twelve to sixteen months to completely resolve.

While the final results of the surgery may not be completely evident until several months after the surgery, most patients look better than before surgery right when the cast comes off. Patients that undergo revision rhinoplasty are, by enlarge, extremely happy.

Click here to contact Dr. Bustillo.

Click here to view Dr. Bustillo Book Chapters and Published Articles