WHAT IF THE FIRST OPERATION FAILED?
In a smaller, but still significant number of cases, there are unfavorable outcomes of nose surgery. This results in consequent disappointments, both in an aesthetic and functional sense. Secondary or revision rhinoplasty, i.e. correction of the nose, represents one of the most difficult challenges in aesthetic surgery. It is significantly greater than when it comes to the first operation. It may include simpler operations to repair minor defects of the previous operation (so-called lumps on the nose or minor depressions). More demanding procedures may be required, such as the revision of bad aesthetics of scars the revision of scars.
The typical patient presents a significant anatomical as well as psychological problem for the surgeon. After experiencing two or more failed surgeries, a patient’s frustration with surgery (or even surgeon) is often present when thinking about a possible additional surgery. When talking to patients, feelings such as anger, guilt, fear, nervousness, and frustration interfere with the course of the consultation.
Unfortunately, nose surgeries can have adverse outcomes in both aesthetic and functional terms. The option available is audit rhinoplasty i.e. correction of the nose. Prior to the final decision, it is crucial to identify opportunities for improvement.
POSSIBILITIES AND LIMITATIONS - REVISION RHINOPLASTY
Aesthetics, breating or both?
Any major revision also implies greater trauma to the already damaged nasal tissue. It creates a risk of further deterioration of appearance and unfavorable outcome. If the previous operation also disrupted the function, the improvement of breathing always takes priority. Fortunately, a revision surgery can most often improve both function and appearance.
Secondary rhinoplasty, ie. the revision includes some specificities. The scar tissue created by healing process after the first operation greatly influences the choice of the type of operation. This can be important factor in realistic possibility of “repair”.
The operator must make an important decision about the type of surgical approach:
- so called An “external” approach that allows a greater view of the operator or
- very limited access through a smaller incision inside the nose (endonasal approach) that reduces the risk of additional tissue trauma.
Regardless of the type of approach that the surgeon chooses, undoubtedly the most important part is the precise preoperative analysis of the nose. The goal should always be the same: to reach the most acceptable correction possible. As with the primary procedure, reshaping of the chin comes into play here as well. It can add improvement to the desired results even more.
Before a new operation, the surgeon must make a detailed plan on how to correct the resulting defects from the first rhinoplasty. Basically, such operations try to use the tissue that is still left. Other possibility is to add some new tissue in the form of bone or cartilage transplants/grafts. Most often they are taken from the ear. It is necessary to strive for simple techniques (which are not always possible). These help to achieve more predictable results. An aesthetically symmetrical nose and maintaining natural nasal proportions in relation to other regions of the face are ultimate goals.
Significant limitations are permanent tissue damage. Newly created scar, disruption of relationship between certain tissues of the nose and skin and impaired blood and lymphatic circulation are some obstacles. It is very important that the patient understands and accepts these potential limitations and/or risks.
The main goal of the operation is to improve the aesthetic appearance. The nose should be in a more correct relationship with the rest of the face. At the same time, we are thinking mostly of the central focus of the observer of our face, which are our eyes and, to a lesser extent, the external ear.
REVISION RHINOPLASTY - HOW TO ACHIEVE IMPROVEMENT
There are a few principles that a patient and operator should keep in mind before deciding on a revision rhinoplasty.
It is easy to make the mistake of operating on any nose with a postoperative deformity. It is not possible to correct every deformity after previous surgeons – it can even get worse.
It is obligatory to recognize which structures need to be repaired and which shall not to be manipulated (vital for the surgeon). Under no circumstances should there be a disturbance in function (breathing).
This task is sometimes more difficult than the technical planning of the operation. Unfortunately, a number of patients never reach complete satisfaction, no matter what improvement is achieved. If it is assessed that the psychological-motivational status of the patient is not suitable for revision, it is best to give it up.
The typical time between two operations, the second of which is revision, is about a year . This time is typically required for complete healing and maturation of scar tissue, and is essential prerequisite for undergoing additional surgery, without deterioration or new complications. However, there are exceptions to one-year waiting time when we can operate sooner, but also situations that require a longer wait for revision.
After a previous operation, a problem with difficulty breathing often occurs (or there is existing one that has not been solved). This is most often an unrecognized or neglected deformation of the nasal septum or the appearance of other deformities that compromise breathing.
In revision rhinoplasty surgery, it is not uncommon to have situations that surprise the surgeon during surgery and make correction more difficult. Therefore, there should be several “backup” variants in planning the dynamics when such unexpected situations arise.
The most common material available is septum cartilage, ears or, in more demanding cases, ribs. Such tissues ensure the longevity of the results because the chance of rejecting one’s own tissue is minimal. Other materials are also available (silicone implant, various dermal fillers).
Although rare, such cases still exist, in this situations it is prudent for the surgeon to abandon the plan for revision, since neither the patient nor the operator can achieve the desired result.
INSTEAD OF CONCLUSION - CAUTION
Revision rhinoplasty undoubtedly requires more careful preparation than in the case of the first (primary) rhinoplasty. After previous surgeries, patients frequently express dissatisfaction and anger and gain distrust towards further surgeries and/or surgeons.
It is up to the facial plastic surgeon to approach the frustrated patient carefully, to inform him objectively about the possibilities of a new operation, and to psychologically assess the patient. At the beginning of the conversation with the patient, it is important to emphasize:
- that a new operation cannot solve every problem with a full guarantee
- that in some cases more than one operation may be needed as well
- that, despite the surgeon’s effort, an unfavorable outcome is also possible.