What changes in revision rhinoplasty?

Revision does not always mean a mistake

The reason problems appear after a first operation is not always surgical technique. Tissue behaviour during healing cannot be fully predicted: scar tissue can thicken where it was not expected, cartilage can shift a little over time, and skin thickness carries the result differently in different people.

The revision rate that gets reported depends on what is being counted. In a database analysis of 175,842 patients published in JAMA Facial Plastic Surgery, the rate of revision septorhinoplasty performed in theatre after a primary operation was 3.1 per cent. Clinical sources that also count minor corrections and filler touch-ups cite around 15 per cent. In the same analysis, the rate of a second revision after a first one rises to 11.0 per cent — the numerical form of why revision surgery is harder than a first operation.

Why it is harder

At a first operation the surgeon works with known tissue planes. In revision those planes are disrupted: tissues have adhered, the blood supply has changed, and part of the cartilage support may have been removed.

Revision operations therefore take longer and are most often performed with the open technique. Seeing the structures directly allows safer work in altered anatomy.

Where the cartilage comes from

The first choice is still the septum, if it was preserved at the first operation. If not enough cartilage remains, two options arise.

Ear cartilage is easy to reach and suits smaller grafts, but its curvature limits it where a straight strut is needed. Rib cartilage provides stronger and more plentiful support, at the cost of an additional incision site and a few days of chest tenderness.

Which will be needed is discussed before surgery, because it directly affects the patient's recovery plan.

How long to wait

At least one year is usually left after the first operation. The reason is simple: a nose assessed before the swelling has resolved is not yet in its final shape, and an early decision can lead to an unnecessary second operation.

Where there is a functional problem such as obstructed breathing, that interval may be shortened at the surgeon's discretion.

Being honest about expectations

The aim of a revision is usually not a flawless result but the correction of the clear problem. Scar tissue and reduced cartilage support can limit corrections that would have been possible at a first operation.

A good revision consultation covers what cannot be improved as well as what can. The possibility that some patients need a second revision should also be raised at the outset.

Before your consultation

• Bring the operative note from the first operation if you have it
• Bring your pre-operative photographs
• Describe your complaint as concretely as you can: from which angle, and what bothers you
• Mention any breathing complaint; it changes the plan