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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

The preparatory work involved in revisional rhinoplasty is extensive, at least on the part of the surgeon. Operative notes should be collected from the patient’s previous surgeon, or surgeons, if possible. I say this with some hesitation because I’ve found that the notes are often of little value; it’s very difficult for most surgeons to put into words the exact changes in the cartilage and bone they made during each complex, technical step. The most valuable record a patient can provide is a photograph of the original nose. Studying the photograph and comparing it to the patient in person is extremely helpful to a surgeon planning revisional work.

Palpation tells the story about previous work done: whether a surgeon might have incorrectly performed one of the myriad steps involved in rhinoplasty, or whether he skipped a step or, perhaps, over- or under - estimated that amount of work that had to be done in the first place.

A visual inspection of the nose reveals important basic information about skin thickness, pigmentation and scarring. But the patient may also undergo testing for the possible presence of nasal, sinus or biochemical disease like allergies or infections. Patients who wear glasses present a special case; it has to be taken into account exactly where the spectacles fit on the nasal dorsum. (Glasses can affect the healing process by applying pressure on the recently fractured nasal bones, narrowing the vault too much. Patients should wait four weeks after the operation before wearing eyeglasses on the nose. It may be necessary to tape glasses to the forehead if the patient really can’t see without them or is unable to wear contact lenses.)

A final point to consider before launching into revisional rhinoplasty is the amount of time that has passed since the previous operation. No major revisional surgery should be undertaken before six months have e gone by and I usually like to wait a year. This is because rhinoplasty allows a patient to be up and around and back at work within a couple of weeks, but the true healing process takes a year or more. Problems that arise shortly after surgery might settle in and correct themselves after healing. I have treated at least one patient who nose took three years to fully heal and stabilize - due to extraordinarily thick skin - before we could start revisional work.

In the twenty years that I have been practicing, it seems tome that most revisional rhinoplasty centers around several basic dynamic (movable) parts of the nose: the relationship between the tip of the nose and its underside, and the relationship between the tip of the nose and the nasal dorsum. In other words, the relationship between the tip and various parts of the nose that support it.

As well, I’ve found that revisional work tends to fall into fairly predictable categories. People want the tip of their nose narrowed, or the “nasal base” narrowed - the area at the base of the nose extending across the width of the nostrils. Or they want the angle from the tip of the nose to the base of the nostrils made more acute, which as I explained is sometimes part of the technique to “shorten” the nose. Again, with regard to the tip, many patients want it to project out further, or they want it brought back toward the face a bit.

There are two ways to go about operating on the nose, whether it’s primary or revisional rhinoplasty. A surgeon can “open up” the nose by making a small incision across the columella and around the nostrils so that the soft tissue can be flipped back to reveal the structure of bone and cartilage underneath. Or the surgeon can take the “endonasal” approach. Endo is derived from the Greek word meaning “within”; the entire operation is conducted more or less out of sight as the surgeon works through the orifices of the nostrils.

Revisional surgery can be done endonasally, but in certain cases, the nose must be opened up even though it’s a more surgically intensive operation. This would happen, for example, if the surgeon hadn’t been able to determine exactly what went wrong with previous operation(s). For example, there may be a “twist” in the nasal dorsum. Or it would be necessary to open up the nose if any grafting of bone or cartilage had to be done. Sometimes, if excess scarring is to be removed, it requires this approach. I find, too, that if the patient is having trouble with a grossly asymmetrical nasal tip (due to uneven distribution of the cartilage), that I have to open up the nose to fix it.

Generally speaking, a surgeon has to make use of a wider variety of techniques for revisional rhinoplasty than might be necessary for primary surgery. But overall, the guiding principle is to inflict as little surgery as possible. For one, this reduces the likelihood that previously corrected problems will reappear. For another, limited surgery translates into less swelling after the operation, and less swelling means the patient will heal more quickly.

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