The emotional impact of a failed rhinoplasty can be devastating. Rather than gaining a long-awaited nasal enhancement, the patient is left with a disappointing and unfamiliar facial appearance. The resulting impact upon self-esteem and self-confidence can vary, but for some, embarrassment, insecurity and depression can affect nearly every facet of daily life.
Although the causes of a failed rhinoplasty are many, including non-compliance on behalf of the patient, one of the most devastating causes is technical incompetence. Instead of a natural-appearing nose with an attractive contour, substandard surgery can produce an unnatural and awkward appearance that is decidedly less attractive than the original (birth) nose. In addition to the initial cosmetic deformity, surgical destabilization of the nasal tissues often results in further deformity via a slowly progressive distortion of the nasal skeleton, usually with a corresponding deterioration in nasal function. In addition to cosmetic and functional deficits, the victim of technical incompetence must also cope with anger, disappointment and regret, all while seeking a trustworthy surgeon to rebuild the damaged and misshapen nose.
Repairing Damage from a Prior Rhinoplasty
While restoring a surgically-damaged nose may appear deceptively simple, the medical and artistic challenge is considerable — typically far more complex than the initial rhinoplasty. Thin and delicate skeletal components of precise three-dimensional shape must be recreated to strengthen or replace shredded, collapsed, twisted (or even absent) skeletal remnants. Each fabricated component must possess mirror-image symmetry that mimics the opposing counterpart, and the finished structure must be vertically aligned to appear visually "straight". Seams and joints must be invisible, and the entire structure must be harmoniously proportioned to fit the surrounding face. While the outer contour must be smooth and attractive, the air passages must also remain large enough to facilitate comfortable nasal airflow. Once assembled, the entire skeletal framework must possess sufficient strength to withstand the long-term forces of distortion commonly exerted by healing skin and soft tissues. Although swelling must be minimized to reduce unwanted scar formation, blood flow must also be optimized to nourish surgically-traumatized tissues and enhance immune function. All of this must be accomplished quickly before swelling, bleeding and anesthetic effects distort and obscure the surgical field. For this reason, restoration of the failed rhinoplasty, commonly known as revision rhinoplasty, is widely regarded among the most challenging of all cosmetic endeavors.
Several important differences between primary (first-time) rhinoplasty and revision rhinoplasty are worth noting. First, revision rhinoplasty takes far more time. Because of the obstacles posed by scar tissue and the increase complexity of surgery, revision cases require at least 4-5 hours of total operative time. By the same token, the more difficult dissection, the greater length of surgery, and the presence of pre-existing tissue damage also equate to a much longer period of recovery. Patients with thin healthy skin may require 6-12 months, whereas patients with thick scar-prone skin may require up to two years for all manifestations of inflammation to resolve.
Use of Cartilage Graft Material in Rhinoplasty
In addition to increased treatment time, revision rhinoplasty nearly always requires the use of graft material. Graft material is living tissue, usually in the form of cartilage, which is harvested from the patient's own body and then used to replace missing or damaged skeletal tissues. Even patients seeking a smaller, more delicate nose may require cartilage grafting. Depending upon the extent of nasal tissue damage, the surgeon's preference, and the patient's willingness to authorize graft harvest, cartilage grafts may be obtained from one or more locations. Because the human body has only three sources of surplus cartilage and because each source yields cartilage of different shape, size, and consistency, the use of graft materials varies widely from patient to patient.
The following summary describes the advantages and disadvantages of each cartilage donor source:
Scar Tissue (Fibrosis) Formation
Soon after the soft tissue blanket is surgically lifted to permit cosmetic modification of the nasal framework, scar tissue (or fibrosis) begins to develop. Special cells called fibroblasts deposit collagen and other substances to "glue" tissue layers back together and restore structural integrity to the nose. Without this miraculous healing response, surgery would be all but impossible. However, the extent of scar accumulation varies widely among individuals and the body's complex mechanism for controlling scar formation is poorly understood. Although the extent of scar accumulation is known to be genetically pre-determined, various external factors can also increase or decrease the amount of subcutaneous scar formation. While some scar formation is essential, excessive scarring results in overly thick and leathery skin which adversely affects nasal appearance.
Because severe swelling (or edema) after nasal surgery increases the risk of scar formation, supportive efforts are directed at minimizing or avoiding those external factors that contribute to prolonged swelling. For most patients, these restrictions are tedious and annoying, but are ultimately worthwhile as they often result in a far more favorable cosmetic outcome. Minimizing blood surges to the nose from blood pressure elevations avoids vascular congestion and trapping of additional fluids within the injured tissues. Patients are advised to keep the nose elevated high above the heart, to avoid elevations in heart rate from exercise or exertion, and to prevent further skin injury from sunburn or harsh skin products such as exfoliants, acne scrubs, etc. For those patients with stubborn swelling that persists despite all reasonable preventative measures, additional treatment options such as compressive taping, nasal steroid sprays, or steroid (Kenalog) injections may be necessary to prevent permanent subcutaneous scarring.
Patients with naturally thick sebaceous skin, acne, or a previous history of hypertrophic scar/keloid formation are at greatest risk for unwanted scarring, but even patients with a smooth, delicate complexion are at risk for scar contracture. Unlike fibrosis, scar contracture results from myofibroblasts, small cells that cause the overlying skin to tighten and shrink. As with fibrosis, some contracture is desirable since tightly adherent skin has a more pleasing surface definition. However, excessive scar contracture, known as the "shrink-wrap" phenomenon, can bend, buckle, shift or distort the underlying cartilage framework and cause contour imperfections. Thus, scar formation potentially affects skin of every type and scarring tendencies are increased in all revision surgery patients.