Revision Rhinoplasty

Secondary rhinoplasty corrects the results of previous operations

A sense organ, the first part of the airway, and also an important facial feature, the nose is crucial in determining our identity, aesthetic harmony, and quality of life. Due to these peculiarities, rhinoplasty is considered the most demanding operation in facial surgery. Its growing popularity among men and women of all ages does not make rhinoplasty a routine operation. On the contrary, any correction of the nose requires a set of skills that the specialist must continually refine throughout his career.

The constant search for improvement proceeds hand in hand with the application of dependable and tested techniques. Above all, safety and predictability of results should distinguish rhinoplasty and septorhinoplasty, and prevent the excesses of surgery. Moreover, while operating on the internal and external structures of the nose, the surgeon must also take care of the psychological and emotional wellbeing of the patient. Empathy and humanity from the first contact are as strategically important as the surgical plan.

The initial consultation is highly emotional both for the patient and the surgeon. The specialist must pay close attention to the human aspect following previous rhinoplasty. To overcome the unsuccessful result of previous surgery, the specialist must make an accurate pre-operative diagnosis and then design a tailor-made nose operation. For more information on surgical revisions, please make an appointment with the secondary rhinoplasty specialist at Clinica del Viso or Casa di Cura La Madonnina in Milan.

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The complexities of primary rhinoplasty: minimize risks and complications through an accurate pre-operative diagnosis

In the last decade, the requests for revision rhinoplasty procedures have gained momentum. The increase in demand is partly due to the rising popularity of nasal surgery. However, reducing rhinoplasty to “routine surgery” has also played a part. Inexperienced surgeons sometimes think of rhinoplasty as a mere removal of the hump, when the harmony of the profile results from many factors: among these, the position of the root, rotation, and projection of the tip are as essential as a straight septum.

The mind and the hands of the surgeon must always pursue equilibrium and proportion. Even when the request only concerns the hump excision or the repositioning of the tip, the nose specialist knows that a natural and pleasant result depends on many balanced modifications. The harmony of the profile results from the adjustment of surgical techniques to accommodate individual variables. Tailor-made surgical manoeuvres are absolutely necessary in revision cases.

Proportion and consistency of the nasal ensemble are crucial factors in determining a successful outcome. Disregarding them will enhance the risk of disappointing, unnatural, and detrimental outcomes and therefore increase the chances of revision rhinoplasty. Dr Palma’s experience spans more than 25 years of specialist surgical practice in rhinoplasty and septoplasty. In this period, Dr. Palma and his team have had the opportunity to address a wide range of aesthetic and functional problems, both simple and complex, including extreme situations of reconstructive rhinoplasty revision.

Causes of unsuccessfulness in rhinoplasty and possible remedies

Failure in rhinoplasty is often due to the inexperience and over-confidence of the operator, especially if he underestimates the importance of an accurate pre-operative analysis. A novice surgeon may feel pressured to agree with unwise, unrealistic, or hazardous requests. For example, a nose that is in sharp contrast with natural anatomy can distort the features of the patient and lead to post-operative dissatisfaction. The use of cartilage grafts in primary rhinoplasty is ill advised, as their utility in supporting the osteocartilaginous skeleton is highly questionable. Their use should be limited to a few, selected cases.

Deconstructing the nose to excise unnecessary cartilage is dangerous as it can lead to an excessive reduction of the nasal support structures. Subsequent defects, including the imbalance between the skin cover and the skeleton, are destined to become more evident in the long term. Dr. Palma’s experience shows that septal cartilage – generally taken from the same patient – is useful in defining the various aesthetic subunits of the nose, and creating an interaction between the natural light and shadows in specific areas of the nose. These “autologous cartilaginous micro-grafts” are most effective when reserved for the final part of a minimally invasive endonasal rhinoplasty. They make the result more predictable, while increasing the safety margins of the surgery.

Further causes of revisions after open rhinoplasty

The intrinsic dissection that characterizes the open approach can lead to atypical scar formation. A Polly-tip deformity consists of tenacious scar thickening located immediately above the tip, between the septal cartilage and the skin cover. Imprudent reduction of nasal support (bone and/or cartilage) or inadequate osteotomies can lead to harmful consequences, including the so-called dorsal ridge, due to the excessive removal of osteocartilaginous material. Insufficient or improper resections can compromise the natural appearance of the profile with the formation of notches in the dorsum or sides. The V-shaped inverted deformity, distinguished by an open roof and disarticulation between the bone and cartilage of the nasal spine is amongst the most undesirable complications of structural demolition of the dorsum.

Revision cases where the loss of structural support (back or tip) is associated with the deficiency of septal cartilage are technically highly demanding, as septum t is the ideal material in almost all graft procedures. During primary surgery, the septum must be preserved as much as possible, avoiding all unnecessary grafting procedures. Otherwise, the revision surgeon will have to take the cartilage from locations other than the nose (i.e., ear or ribs), increasing the difficulty of the procedure and the risk of side effects in the donor areas. Further consequences are longer operating times and higher surgical costs.

Revision surgery in Milan with Dr. Pietro Palma

There is no room for approximation and improvisation in surgery, especially in rhinoplasty and septoplasty. Having received numerous requests for revision surgery, we have become convinced that rhinoplasty should not be one of the many arrows in a surgeon’s bow. The ideal practitioner for this delicate specialty is not the general surgeon, but the specialist. This specialist-led approach prevails in modern medicine. There are specialist surgeons for the knee, the hand, or the spine. The nose also needs its experts.

Rhinoplasty, with its length and pitfalls, in addition to aesthetic and functional repercussions, demands total commitment to achieve the best result with the smallest number of manoeuvres. The surgeon’s educational background requires further consolidation with technical updates, continuous technical training, and maturity in the decision-making processes. Dedication, passion, and natural inclination are the pillars of Dr. Palma philosophy. More than 25 years of operational, academic, and research activity entirely focused on rhinoplasty have led to the fine-tuning of YOUnique Rhinoplasty™, the made-to-measure approach to nasal surgery. 

Thanks to his super-specialization, Dr. Palma has the competence required to handle extreme revisions. Even in the most challenging situations, he can always achieve significant improvements. Every decision is made in the best interest of the patient; for this purpose, in the highest-risk cases, Dr. Palma could recommend minimally invasive alternatives or even advise against further surgical procedures. Pietro Palma will not accept requests for surgery based solely on photos sent via the Internet. The decision to operate can only be made after an accurate and systematic pre-operative screening and diagnosis. For more information about revision rhinoplasty, we invite you to set up an interview with Dr. Palma at Casa di Cura “LA MADONNINA” (Via Quadronno, 29/31 – Milan – Tel 0258395555) or Clinica del Viso (Piazza Repubblica, 21 – Milan – Tel 0263611932). We will assess the situation and establish the best strategy to correct an unpleasant surgical look or a dysfunctional problem requiring surgical revision.