Secondary Rhinoplasty

 What is a secondary rhinoplasty?

The first rhinoplasty should also be the last ...

Rhinoplasty is the one of the most complex operations in plastic surgery for many reasons, including the technical nature of the act. Moreover, the slightest defect can be seen and can not be hidden.
Secondary rhinoplasty is even more complicated because it rebuilds or repairs a nose that was already operated on. Sometimes it is impossible to know in what condition the bones are and especially the cartilaginous structures under the skin.

  • Skin and subcutaneous tissue of the nose may have been damaged, weakened or indurated.
  • The cartilages are often weakened or altered, distorted, diverted.
  • The bones may have been pressed too close together or not close enough, or could pressed asymmetrically.
  • The structures involved in nasal breathing may have been damaged.

Finally, psychologically, patients are no longer under the same conditions as before the first operation. A lack of confidence, an excess of information, or exaggerated expectations can make it difficult a to operate a second time.
Secondary rhinoplasty are still common and account for about two thirds of the activity of Dr Gerbault.
Secondary rhinoplasty is meant to correct previous mistakes from previous nose surgeries. The operation is much more complicated and requires a surgeon who is an expert in secondary rhinoplasty.

 

The different types of problems requiring a secondary rhinoplasty?


  • Resections of excessive bone (nose too hollowed) or not enough (persistent bump, nose that’s too wide, etc). The bones were sometimes broken in places that were not desired: it is even more common in people over 40 years, or in women with thin bones UNLESS THE PROCESS OF ULTRASONIC RHINOSCULPTURE is used. Indeed, ultrasonic rhinosculpture does not damage the bones in the same way as most methods used to break bones.
  • Resections of excessive cartilage (a nose that's too narrow, deformation of the middle of the nose, inverted V shape, pinched tip, retraction of the nostrils, etc) or not enough  cartilage (too broad tip or too prominent, visibility inside the nostrils, etc)
  • Asymmetries of the nose can occur at all levels. They may be related to surgical steps performed asymmetrically or to pre-existing asymmetries not taken into account.
  • Visible and/or palpable hollow bones or cartilages
  • Disharmony between parts of the nose, or between the nose and the rest of the face

These operations are often long, usually around 3 hours, and sometimes can last up to 5 hours in the more complex cases.

 

What happens during the consultation?


The consultation for a secondary rhinoplasty is generally the same as that for a primary rhinoplasty, but with some particularities.

  • First, we ask patients to come up with a photo of their face, if possible large enough, and under different views before their operation and between operations if there were several rhinoplasties. These photos are very important to evaluate the nose at each stage.
  • Furthermore, you are also asked to come with a document describing what the previous surgeon has done in each operation to evaluate the situation.
  • They are also asked to come with all the reviews that have been made before or between rhinoplasty: scan of the nasal cavity, rhinomanometry …
  • The examination of nasal breathing is essential: comprehensive analysis, evaluation of the different nasal valves,inspection of the nasal septum, turbinates
  • Palpation is also an important step to analyze the localization of bone fractures and to look for bone or cartilage irregularities, evaluate the strength of the remaining cartilage and the supports of the tip.
  • A cone beam scanner or examination is often required to complete clinical analysis.

Two factors may interfere with the assessment and treatment of various problems at a secondary rhinoplasty:

A first critical factor is the notion of injections performed after the operation. Two types of injections may have been practiced and it is essential to inform the surgeon:

  • hyaluronic acid, to hide defects or increase excessively reduced areas; AH interfere with the accurate perception of defects and it is preferable to wait for it to disappear before operating
  • corticosteroids, to reduce postoperative swelling; these products can create an exaggerated thinning of tissues, telangiectasia (reddening) persistent on skin, a melting of adjacent cartilage…

The second key factor is smoking, which can create serious problems during the healing in secondary rhinoplasty. It is imperative to stop smoking at least six weeks before any secondary rhinoplasty.
Finally, in rare cases, a nasofibroscopy is performed under local anesthesia in the office, in particular to evaluate a very posterior nasal septum deviation.

 

What happens during a secondary rhinoplasty?


Secondary rhinoplasty should be prepared as meticulously as primary rhinoplasty, but it is essential to warn patients that they can be faced with different unpredictable factors, for example:

  • Cartilages that were severely damaged
  • Areas of the nose that were excessively reduced and partially corrected by placing grafts
  • Foreign bodies placed in the nose to camouflage or hide defects
  • A septum that has been damaged and weakened (loss of the function of support)

Thus, it is necessary that the surgeon adapts the operating plan when faced with unpredicted surprises. This means that any type of graft can be harvested: ear cartilage, costal cartilage, deep temporal facia... Indeed, it is almost always necessary to rebuild at least some part of the nose, and this would be impossible without grafting.
Ultimately, secondary rhinoplasties are particularly complex, delicate operations that should be performed by experienced surgeons in this type of surgery to maximize the chances of success.

 

After a secondary rhinoplasty


First, edema is usually extended after a secondary rhinoplasty, making the evaluation of final results late. It is also common that the respiratory discomfort is prolonged. Still, a well-made secondary rhinoplasty should allow the patient to see quick improvement as to the preoperative appearance.

The appointment and postoperative instructions are essentially the same as for a primary rhinoplasty.
In cases of very complex secondary rhinoplasty, be aware that the need for additional retouching is not uncommon.

 

The risks of a secondary rhinoplasty


  • Risk of infection, which is slightly more common for a primary rhinoplasty, although this is very rare.
  • Risk of perforation of the septum, that depends essentially of previous interventions, which should normally not be seen after a primary rhinoplasty.
  • Skin slough risks that may exist after a rhinoplasty or more when the skin of the nose was undermined too superficially, but also in smokers. This is why it is imperative to stop smoking within 6-8 weeks before a secondary rhinoplasty.
  • Risks of an imperfect scar, especially if you have to use a previously made scar.

But the greatest risks by far are those of aesthetically or functionally unsatisfactory results. They are closely linked to interventions made earlier, and the experience of the surgeon.

Finally, secondary rhinoplasty procedures are still sometimes technically and psychologically complex, which generally produce good results when performed by rhinoplasty specialists who know perfectly all the aesthetic and functional aspects of rhinoplasty.

Secondary rhinoplasty cases are demonstrated in the Clinical Cases section.

Information Sheet SoFCPRE (Société Française de Chirurgie Plastique Reconstructrice et Esthétique)

Last update of this page : 06-06-2019