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About Face

Chapter Eight The Nose The Psychology of Rhinoplasty Patients Expectations Initial Surgery Making the Nose Smaller Saddle Nose Columella Deformity Revisional Treatment Recovery

Revisional Treatment

The most challenging task a cosmetic surgeon can be presented with is revisional rhinoplasty: operating on a patient who has already had one or more nose jobs. For a variety of reasons the rate of patient dissatisfaction with rhinoplasty can run as high as thirty percent. This represents a large pool of potential patients for an enterprising surgeon, but there is good reason to be cautious.

Again, the motives and psychological makeup of the dissatisfied patient must be carefully assessed before any work is done, but more than that, revisional rhinoplasty requires that the surgeon have tremendous confidence that the problems are actually correctable. Primary rhinoplasty is the most complex of all aesthetic surgical procedures; revisional rhinoplasty multiplies the complexity.

There are two types of patients that most cosmetic surgeons will avoid treating with revisional rhinoplasty: the perfectionist, and the patient who is vague about what exactly seems to be wrong with the nose. Sometimes the latter group will describe the new nose as “ugly” without giving any particular reason why. Both types seem unable to comprehend that cosmetic surgery improves so-called “deformities” but rarely corrects them 100 percent.

I can recall one candidate for revisional rhinoplasty who came to see me because he’d had a nose job done elsewhere, but found that the grooves at the bottom of his nostrils were not exactly the same. During the facial assessment, I took a measurement and found the grooves differed by one millimeter. The chances are good that if I’d gone ahead to try to correct a one-millimeter problem, I might have ended up creating a two-millimeter problem. Ours is not an exact art.

In a paper I presented to the American Academy of Facial Plastic and Reconstructive Surgery with Dr. K. Thomas Robbins and Dr. A.M. Rubin, we drew attention to the fact that any patient under-going revisional rhinoplasty should understand that there is a possibility of making the nose worse. This is called the “downside risk.” Things can go wrong when the patient’s original nose had a “twist” of some sort in the nasal dorsum, either in the bone or the cartilage; which has disappeared with the initial rhinoplastic surgery. This “twist” might reappear with revisional rhinoplasty, as though the nose had a memory for it. It’s an outcome almost impossible to predict.

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