Francis R Palmer III MD. Rhinoplasty 101 part four: Revision Rhinoplasty.

Rhinoplasty Part Four will cover the topic of “Revision Rhinoplasty.” In my Beverly Hills Plastic and Cosmetic Surgery practice, Revision Rhinoplasty is as much a part as Primary Rhinoplasty, Facelifts. Minilifts and Breast Augmentation. Everything I wrote about Rhinoplasty applies to Revision Rhinoplasty with one exception! Revision Rhinoplasty is a quantum level more complex and difficult technically for the Plastic and Cosmetic Surgeon to perform…

When I approach a potential Revision Rhinoplasty case…when I think about what I can do as a Beverly Hills Plastic and Cosmetic Surgeon with about 20 years of experience doing Rhinoplastry Surgery. In Revision Rhinoplasty there are several important rules to follow as a Plastic and Cosmetic Surgeon: Worst case scenario:

1.Little normal anatomy will exist within the nose.

2. Excess scar tissue and lack of tissue covering within the nose will exist.

3. Have a clear plan of what you’ll do if you find various things wrong aesthetically once the nasal structures are revealed…ie. tip cartilages twisted, various pieces of cartilage are freely floating or there are deviations or fractures of the nasal bones.

In Revision Rhinoplasty, I often adopt a more conservative approach to the nasal structures. I try to save and modify the nasal bones and tip cartilages instead of tearing everything apart and replacing them, as is frequently done in a primary or first time Rhinoplasty. Why? Because, the nasal tissues can only take so much surgery…so much intervention and there are very real limitations to a PLastic and Cosmetic Surgeon if he/she tries to be overly aggressive to a nose that has previously undergone multiple Rhinoplasties. Things could go terribly wrong. The skin could die, cartilages could die and the result, of this, is a severly deformed nose that basically will never look normal…forget about good!

So, my staff is instructed to tell everyone that inquires about Revision Rhinoplasty to ask one all important question…..”do you have any ear cartilage”? Sounds strange but what we are asking is has a previous Plastic and Cosmetic Surgeon used one or both conchal cartilages during a previous Rhinoplasty or Revision Rhinoplasty Surgery? If there is at least one ear cartilage still intact, I have cartilage to rebuild the nasal tip. OK, I jumped ahead a little bit, let me digress.

In my Beverly Hills Practice of Plastic and Cosmetic Surgery, I perform a substantial amount of Rhinoplasties and Revision Rhinoplasties from patients that come here to Beverly Hills from all over the world. I have done many very difficult Revision Rhinoplasty cases and I know that there are two major areas of concern when thinking about Revision Rhinoplasty. The first is the nasal tip area: Is the nasal tip crooked, weak, bulbous, droopy etc. This translates to a problem with the nasal tip cartilages which may be uneven, or completely gone…and I have seen all that and then some.

The second area is the nasal bridge: does it have a hump, is it scooped out, is it crooked, are these any grafts and if so what are they made of…and are they dissolving partially? Once again, I have seen all of these scenarios and more.

In Revision Rhinoplasty, it’s all about making the nose look as natural and “unoperated” as possible. That means making things as even and symmetric as you can get them with an adequate amount of tip rotation, size and support. Since, I frequently can’t remove any more tissue from this area (because too much or all of the cartilage is already gone) placing a graft to take over the support and shape of the nasal tip is frequently required.

There are many different types of material that are used for tip grafts each with their pros and cons. Over almost 20 years, I have learned what works and what doesn’t…in my opinion. The premier nasal tip graft is one fashioned from conchal cartilage. It’s just the right strength and thickness to give the tip a very aesthetically pleasing shape. For the nasal bridge, I prefer a certain type of dorsal graft that’s made of silastic or solid silicone. No liquid or gel to leak out this implant will last forever and has just the right shape and strength for the nasal bridge.

No matter, well almost no matter, what has happened to your nose in the past, these two things can often give marked aesthetic improvement with a Revision Rhinoplasty….I know…I’ve done it many, many times.

Dr. Francis R Palmer, III