Complicated Revision Nose Aesthetic Surgeries

Understanding Complicated Revision Nose Aesthetic Surgeries: Challenges and Solutions

It may not be possible for a single operation to obtain a completely symmetrical and natural-looking nose in patients with recurrent nasal surgeries and severe tissue changes, or after a serious trauma to the nose, resulting in tissue loss in the nose, and with recurrent nose operations.  In the photo above, a patient who had severe tissue loss in the nasal bone and cartilage tissue after a traffic accident and then underwent recurrent rhinoplasty operations. You can see the photos before and after the complicated revision rhinoplasty.

Differences of Complicated Revision Nasal Nose Aesthetic 

Complicated revision rhinoplasty performed in patients with severe tissue changes, such as the patient presented above, has the following differences:

Generally not enough cartilage tissue on the nose for reconstruction

Since the cartilage tissue inside the nose is generally not sufficient during the operation, the patient may need to take graft (temporal muscle fascia) from his / her rib cartilage, cartilage cartilage, and muscle membrane in the skull. Sometimes irradiated cadaveric rib cartilages can also be used in complicated revision rhinoplasty operations. In some patients, it is not possible to eliminate the existing tissue loss with a single operation. Especially in cases of nasal cartilage and bone tissue loss, various tissue reaction and infections due to silicone nasal implants used in some Far Eastern countries have been reported. It is best to use horse or human tissues in complicated revision nose aesthetics and to avoid using industrial products as much as possible.

Difficulties in tissue dissection in the nose

During complicated revision rhinoplasty operations, due to the intense adhesion and healing tissues under the nasal skin, tissue dissection cannot be easily performed during the operation such as during simple rhinoplasty operation. Therefore, cartilage grafting is not easy and it can be noticed that there are bloodless and hard areas as if a thick cardboard was cut during the procedure. In order to stop bleeding areas in the subcutaneous areas, which do not require bleeding, cauterization is not performed and large cartilage graft applications should be avoided in order to prevent feeding problems.

All details can be understood during surgery!

During complicated revision rhinoplasty operations, current problems, asymmetric areas and details of the cause can be understood after removing the tissue. In other words, details about asymmetric cartilage skin edema, cartilage graft displacement, suture reaction or bone tissue changes can only be noticed during surgery.

Longer recovery time and edema than expected after surgery can be seen!

After complicated revision rhinoplasty operations, there may be a period of edema and recovery that lasts longer than normal as a result of recurrent tissue trauma.

Postoperative recovery problems and infection risk

Complicated revision nose aesthetic surgery is performed on an area with repeated tissue trauma. Unlike primary nasal aesthetic surgery, when the nasal skin is removed, it can be seen that there is no bleeding until normal nasal surgeries and sometimes there is a thick bloodless tissue. Dense adhesion, healing tissues, suture reactions can be seen in the subcutaneous tissue. After implantation of volume-increasing grafts to deformities or functional changes in these areas, infection and tissue loss may be seen due to poorly fed graft areas and insufficient blood supply. As a general principle, complicated revision nasal surgery operations, "Ending the operation with the least possible trauma of the tissue" is valid  instead of "the most possible surgical procedure for millimetric symmetry".

In other words, it is possible to expect a result such as in the animation of the rhinoplasty and to think that the operation consists of a simple and easy cartilage or bone shaping. Nose aesthetics animation "Complicated revision nose aesthetic operation" is different from each other. With the inanimate photo-processing computer program, changing the anatomy is not easy to give the same results as the live tissue shaping process.

In the beginning of the page, the description of the image: A car accident in the skull, severe bone fractures, nasal bone and cartilage tissue loss occurs, followed by a 2-time nose aesthetic surgery. The patient's nasal bone reflected on the nasal bone and the lower open roof deformity reflected light refraction areas, in her nose c defect, and endoscopic examination revealed a large perforation of the nasal septum.

- The skin scar area on the nasal bone was removed. Temporal muscle membrane (fascia) was taken and placed under the skin, augmentation of the nasal bone (enlarged - augmentation rhinoplasty)
- Using the irradiated cadaveric cartilage, a columellar strut graft, a head graft and a unilateral spreader graft were placed on the tip of the nose.
- repair of nasal septum perforation.
- pre-operative and 6-month follow-up are seen together.

In some patients, there may be many different problems such as permanent skin tightening and incision scars, changes in the subcutaneous tissue, serious asymmetries in the nasal bone and cartilage tissue loss. It may not be possible to eliminate all problems in these patients with a simple surgical intervention. Mutual communication with patients is very important in complicated revision rhinoplasty surgeries. In particular, it is appropriate to talk to the patient in advance to understand whether the surgical result will actually meet expectations and to plan the surgery if a common point can be reached. In some patients, infection, gangrene and tissue nutrition problems that occur after previous rhinoplasty surgeries may cause the surgeon to panic and limit the procedures he will perform. Although this issue is controversial, various scientific articles have been published on PRP injection or massage of the nose before complicated revision rhinoplasty surgery. Especially in patients with severe asymmetry on the nose who will undergo augmentation rhinoplasty, perhaps the most innocent and beautiful tissue that can be used is the temporal fascia. This tissue can easily be taken from the patients' temple area before surgery. A 2-3 cm incision is made to reach the fascia and excise it. The temporal fascia can be used both at the end of the nasal dorsum augmentation and to camouflage asymmetric cartilage areas. If you type "complicated revision rhinoplasty" in the search box on this website, you can reach before and after photos of patients with very different nasal deformities who have undergone surgery. Please do not underestimate revision rhinoplasty surgeries and do not see them as a simple photo illusion. Because revision rhinoplasty surgeries are a group of surgical procedures that are more complex than primary rhinoplasty surgeries and whose results cannot be easily understood. Sometimes we prefer to perform limited procedures in order to protect patients from complications. In patients who do not have enough cartilage tissue left in the nose, patients' auricle cartilage, patients' rib cartilage or rib cartilage obtained from another human cadaver can be used. I have not used non-human industrial tissues in revision rhinoplasty surgeries for a long time. Previously, very different materials such as pediatric vascular graphics and artificial abdominal membranes could be used in revision rhinoplasty surgeries. However, the main disadvantage is the use of non-human tissues, tissue reaction and increased risk of infection. The information given to you by your examining doctor regarding technical details is the most accurate. Interpreting the information you obtain on the internet by combining it with animation as if it were a pre-visualization process by a presenter may cause you to be seriously disappointed. Especially in very thick skin and revision rhinoplasty surgeries, the animation result and the actual surgical result may not match. The recovery period after complicated revision rhinoplasty surgeries is usually much longer than simple rhinoplasty surgeries. Therefore, the procedure should be completed with the least possible surgical trauma.

A patient of ours who came from Australia many years ago had had rhinoplasty surgery 5 times before. He stated that he had serious problems in the temple area, behind the ear and rib areas where grafts were taken, and that there was a collapse in the tip of the nose. In the examination of the patient, there was serious support tissue weakness in the nose. And we planned the sixth revision rhinoplasty surgery after explaining all the risks to the patient. During the surgery, after making the incision in the columella, we cut the nasal skin upwards and we realized that although we cut the nasal skin almost to the nasal bone, there was very little blood and that we cut a very hard tissue as if we were cutting a thick paper tissue or cardboard tissue. Unfortunately, in patients with such poor blood circulation during the surgery, the surgery may need to be terminated or the procedure should be performed as soon as possible with the smallest possible procedure. It was very lucky that the patient did not have any serious problems after the procedure. In the near future, a protocol for evaluating nasal circulation with Doppler USG may be provided to patients who are planned to undergo revision rhinoplasty in order to understand whether the nasal circulation is sufficient or not. Link to a few recent articles recommending Doppler evaluation of nasal blood flow before complicated revision rhinoplasty operations >>

• https://pubmed.ncbi.nlm.nih.gov/40255966/
• https://journals.lww.com/prsgo/fulltext/2024/02000/high_resolution_ultrasound_for_diagnosis_and.65.aspx?
• https://www.thieme-connect.com/products/ejournals/pdf/10.1055/s-0043-1770078.pdf?

How long should I wait for a complicated revision rhinoplasty operation?

Although this question is controversial. Previously. Patients who have had a complicated rhinoplasty operation should not have the operation earlier than 6 months. However, waiting 9 to 12 months is more beneficial for the patient's nasal circulation to normalize and the result to be seen definitively. Some patients may need to wait longer than a year. Especially in patients with thick skin characteristics. And in patients who have had a complicated procedure, as much as possible. It may be appropriate to wait longer than a year in order to evaluate the result and for the patient's nasal circulation to normalize.

Search result link where you can find articles prepared by Dr. Murat Enöz about Revision Rhinoplasty and published on this website (you can also reach previous articles by clicking "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=Revision+Rhinoplasty

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon - ENT Doctor in Istanbul

Private Office:

Address: İncirli Cad. No:41, Kat:4 (Dilek Patisserie Building), Postal code: 34147, Bakırköy - İstanbul
Appointment Phone: +90 212 561 00 52

E-Mail: muratenoz@gmail.com
Mobile phone: +90 533 6550199

Fax: +90 212 542 74 47