We Performed a Third Revision Rhinoplasty Operation with Minimal Surgical Trauma

3rd Revision Nose Job

The patient seen in the image above had previously undergone rhinoplasty twice and applied to our clinic to eliminate the asymmetry that occurred afterwards. It is seen that the patient has an asymmetric swelling on the left in the supratip area. Although there is no serious asymmetry in the nasal bone, the C nose reflection appears when viewed from the front due to the asymmetry in the supratip region. The asymmetric soft tissue and cartilage grafts in the last supratip area were shaved using an open technique. The operation was concluded by placing limited rim graft on the patient's right nasal wings.

We planned a simple revision rhinoplasty operation for the patient, who had undergone two nasal aesthetic operations before, in order to have a limited amount of surgical trauma. The patient's problems with the nose detected before the operation:

- anterior view of the supratip region when viewed from the side

- crooked light reflection on the nose axis when viewed from the front

- a raised and asymmetrical appearance on the left side of the supratip when viewed from below

- an asymmetrical notch in the lower part of the right nasal wing when viewed from the front

We planned the tertiary revision rhinoplasty with the open technique to the patient. Asymmetric cartilage tissue, which is more prominent on the left side, was resected, partial removal was performed from the left alar cartilage outer leg. Right marginal rim graft and cup graft were placed.

At the request of the patient, care was taken not to change the nasal tip angle. The nasal bone was not broken and the upper nasal skin was not dissected. In order to speed up the healing, no operation was performed on the mucous membrane inside the nose. No intranasal packing was placed on the patient and only a simple bandage was applied to the outside. In this way, simple revision rhinoplasty operations that result in limited surgical trauma can be completed with very little discomfort to the patient.

Tertiary rhinoplasty is an advanced surgical procedure aimed at correcting through re-evaluation the shape of the nose, the nasal tip, the nasal bridge, or functional issues in a patient who has previously undergone two nasal surgeries. Unlike primary rhinoplasty, prior surgeries may have altered the anatomy of the nasal cartilage, bone structure, and soft tissues.

Therefore, in tertiary rhinoplasty procedures, the surgeon must consider not only the aesthetic outcome but also the preservation of existing anatomical structures and the support of nasal function to the greatest extent possible. Careful assessment of the remaining tissues is particularly crucial if excessive amounts of cartilage or bone were removed during previous operations.

Why Might Re-operation Be Necessary for a Nose That Has Already Undergone Two Rhinoplasties?

Following two previous rhinoplasty procedures, some patients may experience irregularities along the nasal bridge, deformities of the nasal tip, asymmetry of the nostrils, deviation of the nasal axis, or breathing difficulties. In other instances, a patient may seek revision surgery because the aesthetic outcome did not meet their expectations.

The goal of revision surgery is not merely to correct aesthetic issues resulting from the previous operation. Factors such as the stability of the nasal framework, the condition of the septum, nasal tip support, the nasal valve region, and the state of the soft tissues must all be considered comprehensively.

Why Is Minimizing Surgical Trauma Important?

In revision rhinoplasty, keeping surgical trauma as controlled as possible is crucial, particularly for noses that have undergone multiple previous surgeries. This is because scar tissue and anatomical alterations may be present in the tissues as a result of earlier operations.

Therefore, rather than removing more tissue during revision surgery, the aim may be to preserve existing structures as much as possible and perform necessary corrections in a controlled manner. Minimizing surgical trauma entails tailoring the scope of the surgery to the patient's specific needs and avoiding unnecessary tissue damage.

How Is the Nose Evaluated Before Tertiary Revision Rhinoplasty?

Prior to a third revision rhinoplasty, the patient's previous surgeries, operative reports, and current nasal structure are evaluated in detail. The nasal dorsum, nasal tip, septum, nostrils, nasal alae, and nasal airway may be examined individually.

Knowing which cartilages were previously used or removed is particularly beneficial for surgical planning. Any complaints regarding breathing must also be addressed independently of the aesthetic evaluation.

How Do Previous Rhinoplasty Surgeries Alter Nasal Anatomy?

Every rhinoplasty operation brings about specific changes to the nasal framework. After two or more surgeries, the shape and quantity of the cartilage, septal support, nasal tip support, and soft tissue planes may have changed.

Furthermore, fibrosis and scar tissue formed during the healing process can make it difficult to separate and reshape tissues during a third surgery. Therefore, a third revision rhinoplasty requires a personalized surgical plan that takes into account the anatomical changes resulting from previous surgeries.

Preservation of Existing Cartilage in Revision Rhinoplasty

Preserving existing cartilage tissue as much as possible can be a key surgical principle in revision surgery, as portions of the septal or tip cartilage may have already been used or removed in earlier operations.

If sufficient cartilage of suitable quality is available, it may not be necessary to harvest cartilage from another site for every patient. During surgical planning, a more conservative approach may be preferred after evaluating the quantity, integrity, and potential donor sites of the available tissues.

Nasal Tip Correction in Tertiary Revision Rhinoplasty

The nasal tip is one of the areas where shape changes are most noticeable following previous rhinoplasty surgeries. Issues such as drooping, asymmetry, excessive thinning, insufficient projection, or irregularities may be observed at the nasal tip.

Preserving existing cartilaginous support is crucial when reshaping the nasal tip during tertiary revision rhinoplasty. The goal is not merely to alter the appearance of the nasal tip but also to contribute to maintaining long-term structural support.

Nostril Asymmetry in Revision Rhinoplasty

Asymmetry in the shape and size of the nostrils can arise following previous rhinoplasty procedures. This asymmetry may stem from the structure of the nasal alae, the positioning of the nasal tip cartilages, or previous surgical interventions.

Accurately identifying the source of the problem is essential when correcting nostril asymmetry. Rather than simply addressing the nostril margin, it may be necessary to evaluate the underlying cartilage and soft tissue structures causing the asymmetry.

How Does Scar Tissue from Previous Surgeries Affect Revision Rhinoplasty?

One significant aspect of revision rhinoplasty is the potential presence of scar tissue formed during previous surgeries in the operative area. Such tissue can alter normal anatomical planes and make surgical dissection more challenging compared to primary rhinoplasty.

Therefore, in a third revision rhinoplasty, it is often crucial to perform controlled surgical work in specific areas of need, rather than unnecessarily expanding or traumatizing the tissues.

Aesthetics and Function Must Be Evaluated Together in Revision Rhinoplasty

Rhinoplasty is not merely a procedure to alter the appearance of the nose; the nasal airway and the nasal valve region are also vital components of surgical planning. Patients who have undergone previous surgeries, in particular, may experience breathing difficulties alongside aesthetic concerns.

Consequently, when planning a third revision rhinoplasty, both the external appearance of the nose and its internal structures must be evaluated in tandem. Aesthetic goals and functional requirements should be addressed within the same surgical plan whenever possible.

What Are the Advantages of Revision Rhinoplasty with Limited Surgical Trauma?

The primary objective of a limited and controlled surgical approach is to avoid unnecessary tissue manipulation while achieving the necessary corrections. Preserving existing structures especially in noses that have already undergone two surgeries can help maintain options for future surgical interventions.

However, "limited surgical trauma" does not imply that the exact same operative technique is applied to every patient. In revision rhinoplasty, the surgical approach varies based on the patient's anatomy, the outcomes of previous surgeries, and the specific issues present. 3. Recovery Process After Third Revision Rhinoplasty

The recovery process following a third revision rhinoplasty can vary from patient to patient. Since previously operated tissues may contain scar tissue and altered circulation, the resolution of swelling and the settling of tissue contours can take time.

In particular, the complete resolution of swelling at the nasal tip may take longer than a few weeks. Therefore, the appearance observed in the early postoperative period should not be considered the final result. Changes in nasal structure and the healing process are monitored during follow-up appointments.

When Do the Results of a Third Revision Rhinoplasty Become Clearer?

In revision rhinoplasty, it may take longer for nasal tissues to fully settle compared to primary rhinoplasty. Swelling can take time to subside, especially in the nasal tip and areas with thick skin.

Consequently, minor asymmetries or swelling may be visible in the early period following surgery. When making a final assessment, factors such as the healing process, skin characteristics, and tissue changes resulting from previous surgeries must all be taken into account.

Third Revision Rhinoplasty Performed with Minimal Surgical Trauma

In this case, the existing nasal anatomy of a patient who had previously undergone two rhinoplasty surgeries was evaluated in detail. During surgical planning, the changes resulting from prior operations were considered, with the aim of performing the necessary corrections in a controlled manner and with minimal surgical trauma.

Emphasis was placed on preserving existing tissues and avoiding unnecessary surgical interventions during the operation. A patient-specific revision plan was implemented by evaluating the nasal shape, nasal tip support, and the condition of existing anatomical structures. Patient-Specific Surgical Planning for Third Rhinoplasty

A third revision rhinoplasty is an advanced nasal surgery that requires careful planning due to the anatomical changes resulting from previous operations. Since each patient’s nasal anatomy and the outcomes of their prior surgeries differ, the surgical technique to be employed must be tailored to the individual.

The approach of minimizing surgical trauma focuses on preserving existing nasal tissues as much as possible while performing the necessary corrections. Particularly for patients who have undergone multiple rhinoplasties, it is crucial to avoid unnecessarily expanding the scope of the surgery and to carefully evaluate the existing anatomical structures.

Why Is Revision Rhinoplasty More Challenging for Noses with Thick Skin?

In noses with thick skin, it may take longer for minor changes made to the underlying cartilage and bone framework to become visible from the outside. The thickness of the skin and soft tissue can cause edema to persist for a prolonged period, particularly in the nasal tip and supratip regions.

Therefore, when planning revision rhinoplasty for patients with thick skin, one must consider not only the correction of the cartilage and bone structure but also the characteristics of the overlying soft tissues. The patient's skin structure is a significant factor when evaluating asymmetry and swelling observed during the early postoperative period.

What Is Supratip Asymmetry?

The supratip region is the area located just above the nasal tip, where the nasal dorsum transitions into the tip. A noticeable difference in shape or contour between the right and left sides in this area can be defined as supratip asymmetry.

Supratip asymmetry may be associated with cartilage and soft tissue changes resulting from previous rhinoplasty surgeries, irregular healing, scar tissue, or asymmetries in the nasal framework. Identifying the source of the asymmetry is crucial for planning the surgical approach in revision rhinoplasty.

Correcting Supratip Asymmetry in Third-Stage Revision Rhinoplasty

Correcting supratip asymmetry in a nose that has undergone two previous surgeries requires a careful assessment of the existing anatomical structures. Cartilage and bone interventions performed during earlier surgeries may have altered the natural contour of the supratip region. Therefore, the surgical approach evaluates the underlying structural causes of the asymmetry rather than simply correcting superficial irregularities. The goal is to create a more balanced transition in the supratip region while preserving existing nasal tissues as much as possible.

Thick Skin and Edema in the Supratip Region

In patients with thick skin, postoperative edema may remain noticeable for a prolonged period, particularly in the nasal tip and supratip regions. This can cause nasal contours to appear more irregular or asymmetrical than they actually are during the early postoperative phase.

Consequently, the assessment of nasal shape following revision rhinoplasty should not be based solely on the appearance immediately after surgery. The reduction of edema and the adaptation of soft tissues to the new nasal framework occur over time.

The Importance of Nasal Tip and Supratip Contours in Thick-Skinned Noses

For patients with thick skin, a natural-looking transition between the nasal tip and the supratip is a key aesthetic factor. In addition to the shape and projection of the nasal tip, the bilateral symmetry of the supratip region and the transition from the nasal dorsum to the tip must also be evaluated.

Particularly in tertiary (third-time) revision rhinoplasty, reshaping this transition zone may require more precise surgical planning due to anatomical changes resulting from previous surgeries.

Correction of Supratip Asymmetry with Minimal Surgical Trauma

In this patient, the supratip asymmetry present following two previous rhinoplasty operations was evaluated in conjunction with the patient's thick skin. The surgical plan aimed to achieve the necessary correction while preserving existing tissues as much as possible.

It is crucial especially in noses that have undergone multiple prior surgeries to avoid unnecessary surgical dissection and to operate in a controlled manner only where required. Therefore, an approach prioritizing the preservation of existing anatomical structures in line with the principles of minimal surgical trauma was adopted for this case.

Evaluating Revision Rhinoplasty Outcomes in Patients with Thick Skin

When assessing postoperative outcomes in patients with thick skin, one must consider not only changes to the nasal framework but also soft tissue healing. Since the resolution of edema—particularly in the supratip and nasal tip regions—can take time, it is essential to distinguish between the early postoperative appearance and the long-term result.

In this case, the patient's thick skin and history of two prior operations must be taken into account when evaluating changes in the nasal contour following the third revision rhinoplasty.

The link group you can browse to read the articles I have prepared about tertiary revision rhinoplasty on this website >> https://www.ent-istanbul.com/search?q=tertiary+revision+rhinoplasty

Source links >> Tertiary Revision of a Failed Nasal Reconstruction : Dermatologic Surgery (lww.com) / Use of Bone-Cartilaginous Unit in Revision Rhinoplasty | Aesthetic Surgery Journal | Oxford Academic (oup.com)

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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