Revision Rhinoplasty New York
How do I select a surgeon for revision rhinoplasty?
Dr. Rizk has established the following criteria for selecting a surgeon for revision or secondary rhinoplasty
1. Be sure your surgeon has a history of success with revision rhinoplasty and ask to see pictures during your consultation. If the surgeon refuses to show you pictures then you should walk out. How do you know that the surgeon's aesthetic sense or ideal of an attractive nose is the same as yours. Even if your surgeon has an excellent reputation, his aesthetic sense may be different than yours and hence it is important to see pictures.
2. Be sure your surgeon is a nose specialist or facial plastic surgeon who specializes in the nose and not a general plastic surgeon. A nose specialist will do a lot of noses and at any given point in your visit to that surgeon's office, you should see patients who are having or have had rhinoplasty surgery. If you see patients in the waiting room who are getting breast implants or body liposuction, then you know your surgeon is not a nose specialist. It is important to select a nose specialist for primary or revision rhinoplasty since this is one of the most complex procedures in plastic surgery.
3. Be sure your surgeon is board certified by the American Board of facial plastic and reconstructive surgery. Board certification is important for a general knowledge and expertise in the face and nose and the board has developed criteria of requirements for competency.
4. Ask the facial plastic surgeon if he has some patients that you could speak with before your surgery.
What are the common anatomic problems found in revision rhinoplasty?
Dr Sam Rizk has identified the following anatomical abnormalities he typically finds in revision/secondary rhinoplasty
1. Having a functional breathing deficit resulting from an overaggressive rhinoplasty
2. Having asymmetries or a deviated/crooked nose
3. Areas of collapse secondary to overcorrection or an overly aggressive rhinoplasty
4. Areas of undercorrection in the area above the tip called pollybeak deformity
5. Drooping of the nasal tip secondary to not supporting it in the first operation with cartilage grafts if the tip had weak support to begin with.
6. Hanging columella (the middle center piece of skin in the nose separating the right and left nostrils).
7. Pinched Tip- resulting from overressected of the tip cartilages
8. Saddle nose deformity (scooped nose)- resulting from overresection of the nasal dorsum or bridge (cartilage and bone)
9. Inverted V deformity - resulting from overresection of the cartilages that form the sides of the bridge of nose (called upper lateral cartilages)
What is most important to establish in revision rhinoplasty during the consultation process?
It is most important to determine from the patient what were they trying to accomplish with the first surgery and what are their goals with the revision rhinoplasty. Dr Sam Rizk, a New York facial plastic surgeon and rhinoplasty specialist, points to the importance of the patient interview to determine if the patient's concerns/goals are realistic and if these concerns are attainable. The advantage the revision rhinoplasty surgeon has that the first surgeon did not is the knowledge of how the nose responded to surgery. Although most postoperative changes can be predicted, not all can: some soft tissue that appears to contract (shrink) will not, and some skeletal techniques work when they should not. Dr Rizk will sometimes choose not to operate on revision rhinoplasty patients if he feels the patient's expectations are not attainable.
When can a revision/secondary rhinoplasty be performed after the previous rhinoplasty?
Typically, it is necessary to wait 1 year for the swelling to resolve prior to doing a revision or secondary rhinoplasty. There are rare exceptions to the rule if there is an obvious deformity which may need to be repaired sooner.
What is done in the consultation for patients requesting revision/secondary rhinoplasty?
Dr Sam Rizk, does an extensive internal and external examination for a patient requesting revision rhinoplasty. Dr. Rizk also inserts a high definition telescope during his examination into the nose to assess the support structures, the septum, the turbinates and areas of inspiratory collapse. This is very important also to assess the existence of donor cartilage, which is typically needed in revision rhinoplasty. Very often, the septum (parting wall between right and left sides of nose) may be missing and may not be a good source of cartilage. Therefore, the revision rhinoplasty surgeon will have to look for other sources of donor sites for cartilage like the ear or external implants. The external examination should focus on areas of irregularities, skin thickness, asymmetries, areas of collapse or cartilage deficit, the support of the tip, tip droopiness, recurrence of a nasal bump, degree of tip definition, a hanging columella, adequate narrowing in the bony region of the nose, and finally the nostrils and asymmetries of the nostrils. Pictures are taken during the consultation and computer imaging may be performed as well as a CT scan of the nose being ordered.
How long does revision rhinoplasty surgery take?
Typically, it takes 2.5-3 hours but it may take longer depending on degree of defromity and the amount of work needed to obtain donor tissue. It should not take longer than 4 hours since the swelling in the nose will distort it to the point where the surgeon cannot judge subtle finesse aspects of the rhinoplasty adequately. Also the longer it takes, the more the skin stretches and some swelling may last for a very long time where it becomes replaced with scar tissue. Dr. Sam Rizk, therefore, does not feel it is necessary or prudent for a very prolonged operation such as 6-7 hours. Dr Rizk feels that if time is spent planning the revision rhinoplasty correctly before going into the operating room, intraoperative time is decreased. Additionally, hesitant surgeons may take longer to make intraoperative decisions. Some reconstructive rhinoplasty surgery Dr Rizk performs after cancer removal involving major flaps may take longer.
How does the patient prepare for revision rhinoplasty?
Dr Sam Rizk provides his patient with a nasal kit containing medicines which expedite the healing process. Dr Rizk also obtains blood work and recommends a medical clearance prior to the surgery. Dr Rizk also has specific pre/post operative instructions which must be followed carefully. Patients cannot take medicines which promote bruising or bleeding such as aspirin, motrin, alieve, etc. and also herbal supplements such as fish oil and vitamin E. Patients should also stop smoking before and after surgery as smoking can cause infections and the formation of scar tissue and swelling.
How long does the healing process take after revision rhinoplasty?
It takes normally 1 week to look presentable and most patients return to work or their regular daily activity at 1 week. It takes 1 month to return to exercising, and 1 year on average to attain the final result. Dr Rizk points out that the nose continues to change even after 1 year and more refinement occurs, especially after revision rhinoplasty where swelling may persist longer than 1 year. Patients with thicker skin take longer for the swelling to diminish than a year and may require steroid injections to help decrease scar tissue formation. The steroid injections are done in the nose and have no systemic side effects because these are very low dose injections in the scar tissue only, not the blood stream.
If I have collapse in different areas of my nose causing either a scoop or saddle or a pinched tip deformity or a drooping nasal tip where will surgeon obtain grafts or implants to correct deformity?
Very often in revision rhinoplasty after a previously overaggressive rhinoplasty, it is necessary to use pieces of cartilage to support or augment areas of collapse. Dr Rizk states that he first looks for donor sites in the nasal septum followed by the patient's ear followed by rib cartilage from a rib bank. Other options include medpor implants which can work very well in thick skin patients. Medpor is a biocompatible synthetic implant which has a long safety history in the US. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant. Different types of cartilage is appropriate for different areas of the nose. Rib and septal cartilage is good for reestablishing nasal tip support because a flat strong piece of cartilage is needed. Ear cartilage is good for the tip of the nose to establish projection because it has a rounder, softer shape. Ear cartilage is also useful for areas of asymmetries that require a camouflage graft. Ear or conchal cartilage is not adequate for reestablishing tip support.
Can a previous rhinoplasty make my lip appear longer and flatter?
If too much was removed from the bottom part of the nasal septum, the columella (middle piece of skin separating the right and left nostrils) becomes pulled up too much or retracted, the upper lip can then appear flatter and longer. To correct this, an implant or nasal graft called a plumping graft or subnasal graft may be used to push the columella down and lift the upper lip region.
If my nose became crooked after a rhinoplasty, can a revision rhinoplasty fix that?
There are many reasons why a nose may become crooked after a rhinoplasty and each require a separate treatment, according to Dr Sam Rizk. Revision rhinoplasty is aimed at correcting deformities that either were not addressed in the first surgery such as a deviated nasal septum, which may make the nose appear crooked, or correct a deformity created by poor healing or a bad rhinoplasty. In addition to an uncorrected septum, scar tissue on one side of the nose more than the other may make a nose look crooked and that would need to be asymmetrically removed in the revision procedure. A crooked nose may also result from overresection of cartilage on one side of the nose more than the other and to correct this will require a cartilage graft to make the nose appear straighter. It is important for patients to be realistic and to aim for improvement and not expect a perfectly straight nose after the revision procedure. Most noses are not 100 percent straight.
How does Dr Rizk's techniques for revision rhinoplasty differ?
Dr Rizk has 2 innovations that allow for a more precise result and smoother more natural result in revision rhinoplasty. First, a 3d high definition telescope/camera system, pioneered by Dr Rizk, is used during the revision rhinoplasty to view the nasal bridge (dorsum) and more accurately modify it. Errors in rhinoplasty can occur with either overresection or underresection of the nasal dorsum in the primary procedure and can create nasal dorsal deformities. Dr Rizk believes that these errors can be reduced by using this telescope system to visualize the nasal dorsum in high definition views instead of the traditional method of looking at the dorsum from a distance and attempting to judge its reduction or augmentation. Because of intraoperative swelling, which can distort the skin and make the nose look like it has a bump when in reality it is swelling and the surgeon would then make a decision to resect more dorsum_this could have been preventable by looking at the nose's dorsum internally with much more accuracy.
Second, as most revision rhinoplasty surgeries resulting from overresection of tissue causing a crooked nose or pinched nasal tip will require cartilage grafts, Dr Rizk has developed a method of better sculpting cartilage grafts or nasal implants to create smooth edges, which are not palpated as a sharp edge. Traditionally, the surgical knife is used to sculpt the cartilage grafts or implants, but the surgical knife invariably creates angeled edges, even in the best of hands and these angeled edges eventually become palpated by the patient. Dr Rizk uses a specialized micro-sanding powered tool to round out the edges of the cartilage grafts or implants to achieve a smoother non-palpable and more natural result. Dr Rizk believes that the cartilages in the nose in their natural state are rounded and thus to create the most natural appearance it is necessary to round out their edges with this tool. Through this technology, Dr Rizk has advanced the art of science of graft sculpting, an important skill for a surgeon to possess in performing revision rhinoplasty.
If my nostrils have been pulled up from a previous rhinoplasty, so-called alar retraction, how does Dr Rizk correct this deformity?
Alar retraction, which makes the nostrils appear pulled up usually results from a rhinoplasty where too much cartilage and mucosa was removed during the previous surgery. Dr Rizk points out that it is important to make sure that a hanging columella does not exist. A hanging columella can give the illusion that the nostrils are retracted and if so it needs to be corrected first prior to evaluating the nostrils. If a true alar or nostril retraction exists, this can be corrected either with a cartilage graft, typically from the septum or ear, or a composite graft of skin and cartilage from the back of the ear. A composite graft is used if there is a deficit of mucosa or skin creating the retraction inside the nose.
- "Correcting the Drooping Tip and Hanging Columella in Revision Rhinoplasty" Chapter in Rhinoplasty Medical Textbook
- The Drooping Tip
- The Hanging Columella
- How Does Dr. Sam Rizk Treat Internal/External Valve Collapse Or Stenosis?
- Spreader Grafts In Rhinoplasty
If you would like to read more about Dr. Rizk's approach to revision rhinoplasty, click here.
For more information about rhinoplasty, click here.