What Is A Revision Rhinoplasty?
Revision rhinoplasty refers to an operation on a nose that has been previously subjected to surgical changes. It is a surgery that involves the surgical reshaping of the nose along with alterations of the internal and external structures to improve the appearance and the function of the nose. This is one of the more challenging surgeries in plastic surgery and involves expert hands. Presence of scar tissue combined with surgical alterations of the natural structures of the nose makes it very delicate. Noses that require revision are at higher rates of complications including infection, skin necrosis (skin loss), and poor cosmetic outcomes.
What Is Different About A Revision Rhinoplasty From The First Surgery?
Because the nose has been altered by prior surgeries, often times the internal and external structures of the nose are different. Parts of the nose may be missing, or altered in size or shape. This difference in anatomy means that the surgeon must be equipped to replace, reshape, and restructure the nose to restore healthy anatomy, function, and aesthetics. Often times, surgeons must have the experience and skill sets to restore a nose. Such skills include the use of rib grafting and ear grafting, or free grafting, to integrate into the new nose. Also, depending on your primary complaint, surgeons must be skilled in the art of local and regional reconstruction. An armamentarium of skills and tools is needed in order to maximize outcomes. Fortunately, Dr. Mourad has advanced skills in both primary and revision rhinoplasty to provide the best services for his patients
This is a 41-year-old female who presented 1 year after rhinoplasty with complaints of 100% nasal blockage and unnaturally appearing nose.
Left Photographs: This photo shows her at presentation to Dr. Mourad’s office 1 year after her initial surgery. The black arrows show that she had an excessive amount of her nose removed externally, causing significant scarring and contracture. This scarring narrowed her nostrils and contributed to her inability to breathe. The blue arrows show that her nose has incomplete breaks in her nasal bones causing nasal valve collapse, further making her breathing worse. In the lower picture, the purple curved arrow also shows that she has a “droopy” tip that hangs low. The deformity is also from excessive resection of the internal structures of the nose. The blue star in the photo on the profile view also shows that the previous surgeon had left a bony hump, that also was made to appear worse by the droopy tip.
Right Photographs: This is a patient 1 year after surgery once the final healing has settled in. The purpose of the surgery was to restore her ability to breathe. The patient underwent a complete nasal reconstruction using her own rib. The orange arrow shows that her nasal tip was restored to a more natural, “higher”, position, no longer with a deforming “droopy” look. Her nasal tip has smoother contour. Her ability to breathe has been completely restored with improvement in her nasal valve structures.
Who Needs A Secondary Rhinoplasty?
Patients that have had previous surgeries with sub-optimal outcomes may require revision surgery. You may not like the way your nose looks, and think that more or less should have been done. This may happen often and be as a result of communication breakdown with your original surgeon. Some patients may also suffer complications from their original surgery such as nasal drooping, hooded nasal tip, nasal bone deformities, nasal asymmetry, infections, and excessive scar tissue formation. Patients who have had implants placed may also develop weeping infections that do not resolve with antibiotics. Other times patients may have developed difficulty breathing. This may result from an internal weakening of the nose, asymmetrical settling of the nose, or from excessive scar formation from the original surgery. Such cases require restructuring and restoration of the internal anatomy of the nose. Finally, patients that have had nasal surgery more than 10 years previously, may suffer subsequent weakening and changes in the nasal anatomy that is made worse as we age. Despite the variety of reasons you may need to have revision surgery, Dr. Mourad will individualize your treatment plan to provide the best outcomes.
Preparation For A Reconstructive Rhinoplasty
You will meet with Dr. Mourad where he usually spends an hour going over everything related to your nose. He will evaluate and make sure that he can specifically tailor a custom care plan to your exact needs. During the consultation, Dr. Mourad will determine the exact nature of your complaints and the exact causes. He may prescribe medications that will assist in your complaints. You will also have the opportunity to demonstrate exactly what it is you don’t like about your nose. He may examine the inside of your nose through a painless in-office procedure using a small camera. This will allow Dr. Mourad to visually map out all of the internal structures of the nose to create the best surgical plan. Once a tailored plan is made, Dr. Mourad and his staff will take you through all the necessary information needed to make sure that your surgery happens without issue. We take care of the details so that you can have the most enjoyable experience.
Dr. Mourad views treating his patients to be nothing short of a privilege and an honor and enjoys taking the time to get to know his patients and fully understand their issues. Dr. Mourad’s office provides a boutique experience that takes you out of the mindset of being at the doctor’s office. It is a warm, comfortable environment, providing a bespoke experience.
What Are The Approaches To A Revision Rhinoplasty?
Revision rhinoplasty may be performed in a similar fashion to the original surgery. This may be approached through an open or closed approach depending on what is required. An open approach is performed with a small incision at the base of the nose. The surgery involves gaining access to the internal structures of the nose and provides access to the nasal tip, bridge, and bones. Patients with severe complaints such as deformities or extreme nasal blockage may require this approach. A closed rhinoplasty is performed through the use of hidden, internal incisions inside the nose. This allows for minor modifications to the nasal tip and internal structure of the nose. This type of surgery is reserved for those patients with minor complaints that can be corrected without having to use an open approach.
After Surgery and Recovery
Depending on the type of surgery you have, you will likely have nasal packing/splints in your nose. These are placed by Dr. Mourad to allow for proper healing of the internal nasal structures, like an “internal cast” for the nose. These typically are removed at your first postoperative visit, one week later. You will also likely have a nasal cast on the outside of the nose. This also helps reduce swelling and keep everything in place. This remains on the nose also for 1 week following surgery. Depending on your work, Dr. Mourad typically recommends taking a minimum of 3 days off before returning to work. He also discourages his patients from any heavy lifting as this can alter the structure of the nose through straining. If you wear glasses, you may require some alterations as to not provide pressure on the nasal bones. Dr. Mourad will provide you with pain medications, ointments, nasal sprays, all to help maximize your results.
You will see Dr. Mourad one week after surgery where he will remove all casting materials and splints. Your nose may be swollen for a temporary period of time, so don’t stress! The nose is a small area, and all that surgery causes swelling that eventually is reduced with time. Depending on the patient this swelling typically lasts for 2-3 weeks but can last up to two months in rare circumstances. To help reduce the swelling Dr. Mourad will re-apply tape to the nose that will be there until your second post-operative visit. This pressure dressing reduces the amount of swelling. The second postoperative visit will involve removing all the tape. Dr. Mourad will then see you in visitations two weeks later, and then one month after that. Dr. Mourad enjoys the continued visitation of his patients and will see them in follow up for many years thereafter.
- Anesthesia: Depending on the type of anesthesia administered, patients may have a reaction. This is exceedingly rare, and it is important to discuss your personal risk with your anesthesiologist.
- Infection: In rare circumstances patients may develop an infection following rhinoplasty procedures. These are usually managed with intraoperative and postoperative antibiotics.
- Bleeding: Although rare, patients may have bleeding episodes following nasal surgery. Your surgeon will likely order blood work to make sure you are healthy enough to undergo the procedure. Your surgeon should also go over all medications and supplements that you take to minimizing bleeding risk.
- Need for secondary and revision surgeries: Depending on the complexity of the surgery, sometimes multiple surgeries are required to ensure the best aesthetic and functional outcomes.
- Scarring and Poor wound healing: Some patients with underlying medical conditions or more prone to poor wound healing and scarring. It is important to understand these risks prior to embarking on a treatment strategy.
- Local Reactions: Sometimes you may experience local reactions to the ointments, sutures, taping material, and nasal packing used during surgery and postoperatively. This is rarely seen, but may occur. If you have any allergies to certain materials or adhesives you should discuss with your surgeon.
- Changes in nasal sensation: Patients may experience altered sensations in their nose (pain or numbness). This is exceedingly rare, and if it occurs it is most often temporary.
- Persistent, New, or Recurrent Nasal Airway Obstruction: Altering the nose may result in changes to breathing. Sometimes patients may develop new, persistent or recurrent airway problems. This is rare, but oftentimes is due to poor wound healing or scarring (see above). This may require secondary surgeries to optimize outcomes.
- Continued need for medical therapies: If you have breathing complaints related to medical causes (e.g. allergies), then you may continue to require medical nasal therapies (e.g. nasal steroids and sprays).
- Swelling: Swelling is a common part of the healing process. Sometimes this swelling may persist for a prolonged period of time.
- Poor Aesthetic Outcome: Although the goal of rhinoplasty is to enhance the aesthetics of the nose, sometimes patients may have an unsatisfactory result. This may occur due to poor communication and understanding of the goals by the surgeon. Other times, it may be due to poor wound healing, scarring, and swelling (see above). It is important that you spend a significant amount of time with your surgeon in order to outline the exact goals and desires of surgery to minimize the chance of a poor outcome.
- Nasal Septal Perforation: A hole in the septum may develop. Oftentimes these do not cause any problems. Other times however, they may cause crusting, bleeding, and breathing difficulties. These require secondary surgeries for repair.
Does Insurance Cover A Reconstructive Rhinoplasty?
Depending on your complaints, insurance companies may, in fact, cover your revision rhinoplasty. If you suffer specifically from nasal breathing problems made worse by your original surgery or have a significant nasal deformity, insurance companies will cover your revision surgery. Dr. Mourad and his staff work very closely with insurance companies to make sure that all resources are made available to you, minimizing financial burden.
Why Should You See Dr. Mourad?
Dr. Mourad is an expert not only in the fields of rhinoplasty and revision rhinoplasty but also in the field of advanced facial reconstruction. Dr. Mourad treats some of the most challenging congenital, traumatic, and oncological deficits of the head, face, and neck. This has given Dr. Mourad a broad skill set that can handle even the most challenging of cases. There is no case too small, or too large that Dr. Mourad has not been trained to handle. No matter how severe your complaints are, Dr. Mourad is well versed in all of the skills needed to maximize your outcomes.
Select Relevant Publications
Kadakia S, Mourad MW, and Ducic Y. Supraclavicular Flap Reconstruction of Cutaneous Defects Has Lower Complication Rate than Mucosal Defects. Journal of Reconstructive Microsurgery. 2017 May; 33(4):275-280. Link to Article.