Revision Rhinoplasty FAQs

Dr. Hilinski is "Double Board Certified" in Facial Plastic & Reconstructive Surgery.

Featured Case
Rhinoplasty Case Example

The current Featured Rhinoplasty Case Example was chosen because of the many complexities involved with her surgery. This is an otherwise healthy young lady who desired reshaping of her nose due to several areas of concern. She had no prior surgery on her nose.
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Q - What is revision rhinoplasty?
Revision rhinoplasty, also referred to as secondary rhinoplasty, is a surgical procedure designed to further reshape the appearance of the nose following a prior rhinoplasty surgery.

Q - Who is a good candidate for revision rhinoplasty?
Patients who have realistic expectations and desire refinement and reshaping of their nose following prior rhinoplasty surgery may be good candidates for revision rhinoplasty. Revision rhinoplasty patients must realize that revision procedures are significantly more complex and difficult than primary rhinoplasty. In general, patients should allow at least ten to twelve months of recovery after their last surgery before proceeding with revision rhinoplasty.

Q - Where is the revision rhinoplasty procedure performed?
Most revision rhinoplasty procedures are performed in the outpatient surgery center.

Q - What type of anesthesia is used for revision rhinoplasty?
Deep sedation or general anesthesia can be used in most revision rhinoplasty procedures.

Q - How is revision rhinoplasty performed?
Revision rhinoplasty involves an entirely different approach compared to primary rhinoplasty. Revision cases are, in general, considerably more challenging and complex to perform, due in large part to the presence of abnormal scar tissue not seen in primary cases as well as some degree of undesirable tissue distortion which prompted the decision to proceed with revision rhinoplasty.

The closed technique can be used in some cases of revision rhinoplasty where additional selective reduction of the bone and/or cartilage is indicated. It can also be used in cases where the bridge requires augmentation due to over-reduction during prior surgery. Unfortunately, revision rhinoplasty of the tip using the closed technique is significantly more challenging because of excessive scar tissue in this region. In most cases of revision rhinoplasty, an open technique is utilized because of the more complete and direct exposure that is afforded using this approach.

The following summarizes the most common techniques used in revision rhinoplasty for the most frequently seen deformities: In many cases of revision rhinoplasty, the nasal bones (bony vault) have not been narrowed and/or aligned properly. In these cases, the bones require further narrowing to achieve a more refined appearance on the frontal view. If the bones are still improperly aligned (crooked), the vault requires additional mobilization to achieve a more symmetric frontal view alignment.

Middle vault (the middle one-third of the nose) collapse is a commonly seen deformity following prior rhinoplasty which usually results from an over-aggressive reduction (lowering) of the bridge and subsequent separation and collapse of the cartilage. This appears nine to twelve months later as a visible inverted V deformity on the frontal view of the bridge (below the nasal bones) and also manifests as breathing difficulty on one or both sides of the nose due to a compromise of the internal valve of the nose (one of the most critical cross sectional areas of the nose when it comes to breathing). Techniques to repair a collapsed middle vault usually involve the placement of spreader grafts which are hidden grafts made of the patient’s own cartilage. If there is sufficient septal cartilage remaining, the spreader grafts can be fashioned from this material. If there is insufficient septal cartilage remaining, which is often the case, ear (auricular) cartilage can be used as a substitute. Spreader grafts are placed parallel with the bridge in between the upper lateral cartilage and the dorsal septal margin. This helps to widen the middle vault and reinforce the structural integrity of the bridge across this region.

If the nose requires augmentation (addition) for a bridge that was excessively lowered during prior rhinoplasty, cartilage grafting is the first choice and this includes using either septal cartilage, ear cartilage or rib (costal) cartilage grafting. Rib cartilage grafting is usually reserved for those cases of revision rhinoplasty where there is at least a moderate amount of loss in bridge height.

In many cases of revision rhinoplasty, the support of the tip has been comprised due to improper technique used during prior surgery. If this involves a compromised septum and tip junction, it can result in a tip that is insufficiently projected, or under projected. In these cases, cartilage grafting is often required in the form of a strut graft (columellar strut graft) which is sutured to the edge of the septum to restore proper tip support. The actual tip is then reshaped with the use of a shield-shaped tip graft that is sewn over the native cartilage to help redefine the tip. In other cases, the tip support has been compromised as a result of excessive removal of the actual tip cartilage. This usually involves excess removal of the cephalic (upper) margin of the tip cartilage which can result in a tip that scars upward excessively and leads to over rotation, often referred to as a pig nose deformity or a short nose. Revision rhinoplasty techniques to repair this deformity involve the use of cartilage grafts to counter-rotate the tip back down to a more natural position. In other cases, excess removal of the tip cartilage can lead to a weakening of the nostril side walls. This manifests as unwanted pinching of the nasal tip and also requires reinforcing cartilage strut grafts to restore a more natural convex tip contour.

In many revision rhinoplasty cases, the skin is notably thin, due in part to incorrect elevation of the tissue planes during prior surgery. In other cases, contour irregularities along the bridge have resulted from prior surgery and easily show through a thin skin layer. In these cases, temporal fascia grafting is frequently used to thicken the overlying nose skin to minimize the chances of visualizing minor contour irregularities during the healing process. Temporal fascia harvesting uses a hidden incision within the hair-bearing scalp (without shaving the hair) and this incision heals relatively quickly. Once the nose has been reshaped, the fascia is placed over the bone and cartilage framework and below the skin. This provides an additional ‘cushion’ layer that helps the nose to look smoother and more natural as it heals. Fascia grafting is usually not required during revision rhinoplasty for patients with thicker skin.

After achieving the desired changes, the incisions are closed with meticulous technique. To minimize soft tissue swelling, the nasal skin is taped. An external nasal cast will be placed for additional stabilization in cases where the nasal bones have been reshaped.

Q - How long does the revision rhinoplasty procedure take to perform?
Surgical times for revision rhinoplasty range anywhere from two and a half to four hours. In patients requiring a rib graft (costal cartilage graft), the length of surgery may be up to six hours.

Q - Where are the incisions made for revision rhinoplasty?
If a ‘closed’ rhinoplasty approach is chosen for the revision rhinoplasty procedure, hidden incisions are made entirely inside the nose along the inner nostril rim and septum (the wall which separates the left and right nasal passages). If an ‘open’ rhinoplasty approach is chosen for the revision rhinoplasty procedure, a short incision is made on the skin between the nostrils half way between the nasal tip and the upper lip. Shaped as an inverted V, this incision is less visible than a straight line incision. In addition, proper technique allows this incision to be essentially imperceptible once it has healed. Though the closed technique can be used in some cases of revision rhinoplasty, the open technique is more commonly used due to the more complete and direct exposure afforded by this approach.

Q - Are there scars after revision rhinoplasty?
There is no visible scarring if a closed approach is used for the revision rhinoplasty procedure as all incisions are hidden on the inside of the nose. Patients undergoing an open approach will have a small scar on the underside of the nose between the nostrils. However, the incision is shaped as an inverted V which makes it less visible than a straight line incision and proper technique allows the resulting scar to be essentially imperceptible once healed.

Q - Is the revision rhinoplasty procedure painful?
Pain is not a significant component of the healing process after revision rhinoplasty.

Q - What is the recovery like after revision rhinoplasty?
Revision rhinoplasty patients can expect five to seven days of initial recovery during which time the bruising and swelling may be more noticeable. We instruct all of our rhinoplasty patients to use Arnica Montana prior to and after surgery which can significantly minimize the degree and duration of bruising and swelling. Pain is generally not significant. Most patients will begin to look presentable in public within seven to ten days after the revision rhinoplasty surgery. However, a majority of the soft tissue swelling will take several months to disappear and the nose will continue to undergo healing and remodeling of the shape for upwards of a year and beyond in some cases. Swelling tends to resolve faster in patients with thinner skin than those with thicker skin because thicker skin generally doesn’t ‘shrink wrap’ around the new nose as quickly. In cases involving realignment of the bridge for a crooked nose deformity or narrowing of the bones, patients will need to be seen more frequently during the first six to eight weeks after surgery. Some patients will be instructed on how to perform ‘digital exercises’ which help to maintain a proper alignment and position of the bones.

Q - When will I be able to return to work after undergoing revision rhinoplasty?
Work can usually be resumed within seven to ten days after the revision rhinoplasty procedure.

Q - When will I be able to exercise after my revision rhinoplasty procedure?
Aerobic activity (reconditioning) can usually be resumed within ten to fourteen days after the revision rhinoplasty procedure while more strenuous activity (resistance workouts) can be resumed in about three to four weeks. After resuming their workout routine, some patients may note a temporary increase in swelling.

Q - When are the stitches removed after the revision rhinoplasty procedure?
The stitches are removed within five to seven days after the revision rhinoplasty surgery.

Q - What are the risks or complications of revision rhinoplasty?
As with all types of surgery there are potential risks associated with revision rhinoplasty. In general, the risk of infection and bleeding is very low. The most common complication following revision rhinoplasty is related to a less than optimal aesthetic result. Asymmetries and/or unwanted contour changes can result despite execution of a technically sound revision rhinoplasty procedure and every revision rhinoplasty surgeon has had their share of patients with less than optimal cosmetic results.

Q - Does insurance cover the revision rhinoplasty procedure?
Revision rhinoplasty procedures performed for cosmetic purposes are typically not covered by insurance, though patients will need to consult with their own insurer.

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