Revision Rhinoplasty

How often a revision happens

Where the operation counted was itself already a secondary septorhinoplasty, the rate was 11.0 per cent: 386 revisions in 3,518 such patients. That is roughly three and a half times the primary figure, in the same cohort.

A population figure is not a prediction. Studies differ on what counts as a revision, how long patients were followed and whether small adjustments counted.

Why the wait is at least twelve months

Swelling and scar tissue are still changing through the first year. Operating before they settle risks correcting a shape that would have settled on its own.

In the same cohort, the median interval between the first operation and the revision was 1.2 years.

1. Through the first yearSwelling comes and goes, and the tip refines last. The day by day timeline sets out the stages.
2. At twelve monthsThe usual earliest point at which a second operation is planned. Heavily scarred or contracted noses need longer.
3. Beyond eighteen monthsScarred tissue holds swelling longer, so a revision result is judged later than a first one.
4. The exceptionAn early functional or structural problem may be dealt with sooner. A surgeon will assess whether that applies.

What a revision can correct, and what it cannot

A revision addresses an identifiable fault, aesthetic or functional. It cannot produce a refinement that the remaining tissue will not hold.

• Tip asymmetry and contour irregularity. The tip settles last and is where support is most easily lost, which makes it the hardest area to correct.
• Blocked breathing. Often lost support at the nasal valve, judged by internal examination rather than from photographs. See nasal valve collapse.
• A collapsed middle third. Where a dorsal hump was reduced without the support beneath it being rebuilt.
• Saddle nose. A bridge that sags once cartilaginous septal support is lost. Recognised causes include trauma, previous nasal surgery, septal haematoma or abscess, autoimmune disease and intranasal drug use.

Because an altered framework has to be seen to be rebuilt, many surgeons prefer open access for revision work, case by case rather than as a rule.

Where the cartilage comes from

Septal cartilage has often already been taken, so a revision usually needs a second donor site.

One single-surgeon series compared 53 primary rhinoplasties with 49 revisions. Revision cases used ear cartilage in 67.3 per cent and rib in 42.9 per cent.

Rib gives the most volume and the straightest grafts, and adds a chest incision. A meta-analysis of 20 studies and 1,648 patients pooled its complications:

• Overall complications, 15.13 per cent.
• Warping, the commonest single problem, 3.05 per cent.
• Hypertrophic chest scarring, 2.08 per cent. Contour irregularity, 1.53 per cent.
• Infection 1.45 per cent, resorption 1.2 per cent.
• Pneumothorax pooled at 0 per cent, though the confidence interval reaches 0.46 per cent, so the risk is low rather than absent.

Before agreeing to a second operation

A revision is planned from what an examination and the previous operative notes show, not from an account of what was meant to have been done.

Skin that has been lifted once does not always redrape as it did before, and further reduction rarely solves a revision problem. Each operation leaves less to rebuild with.

A surgeon who calls a revision straightforward, or who promises a particular result, is a reason for caution rather than reassurance. A consultation should end with a list of limitations.