Revision
Rhinoplasty

First is the daunting analysis of what went wrong with the original (and sometimes second and third) rhinoplasty? More often than not, obtaining the old medical records is rendered difficult by either the reluctance of the patient in approaching the previous surgeon, or by the length of time separating first rhinoplasty from correction. If this is the case, the rescuing surgeon must depend on a sharp eye and a keen knowledge of anatomy to determine what is missing and what has been added. The reaction of the skin (degree of scaring) to the deforming forces is also assessed.

Second is the formulation of a plan of action for a secondary rhinoplasty. This step is best described as a “fantasy check” as the surgeon must check out ego and false confidence in favor of a sensible and realistic way of offering an acceptable outcome. This aspect of the treatment approach is the one that depends the most on experience. It is very similar to the establishment of a flight plan for a military rescue mission in enemy territory and demands courage, honesty, a realistic assessment of risk and a clear understanding of the chances of success with revision rhinoplasty. It is during this planning session that the patient will be informed of the possible need for obtaining additional tissue from elsewhere in the body (ear; scalp; ribs; skull) to aid in the reconstructive effort. The surgeon should neither mince words nor attempt to shield the patient from reality. A solid plan demands boldness.

Third is the surgical technique itself. To say that rhinoplasty revision is the most difficult operation facing the plastic surgeon is an understatement. It is not always that a supreme analyst and planner automatically translate into a superb rhinoplasty surgeon. Manual dexterity is the end result of exercise and eye/hand coordination. It is also a matter of self-control as the operating surgeon must continually be able to keep his/her nerves in check throughout the secondary rhinoplasty. This prevents the transmission of subtle tremors into the fingertips and keeps the head cool and devoid of foggy ideas liable to impairing judgment.

Finally is the matter of expectations. An individual who has been bodily and psychologically scarred by a previous experience is not always readily willing to pass on the reigns of control to another rhinoplasty surgeon who might compound the original injury. This is understandable. The surgeon must instill confidence in the subjects of such trauma, not by sweet-talking them into an unrealistic trap, but by realistically presenting a viable plan of action and by showing them examples of work previously done. The surgeon must convince by “tough love” that touches on the possibility of failure and present the chances of success based on grounded realistic facts. This is also where the physician removes the hat of surgery and puts on the one of psychiatry in order to assess the hidden trappings of the subject’s mind and chances of finding closure.