Secondary, or revision rhinoplasty, is very different than a primary rhinoplasty. Many challenging, complex secondary rhinoplasty cases in Newport Beach are referred to The Rhinoplasty Center by our colleagues. These cases range from complex congenital deformities (cleft lip noses, asymmetric noses), to post-traumatic crooked and twisted noses, to tertiary rhinoplasties (multiple failed rhinoplasties by multiple surgeons), which require aesthetic, reconstructive rhinoplasty. These operations are very difficult because of operative scar, lack of cartilage material, functional problems (difficulty breathing), and the element of surprise because often we do not know what was done during the initial operation(s). Although many principles of primary rhinoplasty do apply, revision rhinoplasty requires a much broader range of techniques focused on reconstructing the unoperated, normal anatomy of the nose. While we would prefer to confine the operation to the nose, oftentimes we must go to other anatomic sites to get graft material. This can include the ear or rib for cartilage, and the temporal hairline for fascia to thicken the soft tissue envelope of the nose.
Many of these complex cases require sophisticated surgical techniques, which Dr. Kosins and his former partner, Dr. Rollin Daniel, have developed. In 1996, Dr. Daniel gave a unique presentation comparing the use of different grafts on the nasal dorsum (bridge). It was clear that cartilage taken from the ribs was superior with regards to the amount of cartilage that could be obtained and the flexibility of the graft. However, most solid rib grafts (meaning a block of rib) had a tendency to bend and/or to become visible with time. Therefore, in 2004, Dr. Daniel published his revolutionary technique of “diced cartilage wrapped in fascia,” which allows the rhinoplasty specialist to use the patient’s own tissues to create a natural and smooth bridge. In 2006, he introduced the concept of “composite reconstruction” for reconstructing noses that had collapsed from prior surgery, trauma or cocaine use. This approach allows the surgeon to rebuild a nose by first stabilizing the support with rib graft reconstruction, and then building the aesthetics (tip and bridge) with soft grafts to achieve the desired nasal shape. Most recently in 2015, Dr. Kosins published and presented their use of Piezoelectric Surgery in rhinoplasty, which allows for nontraumatic bone and cartilage reshaping – ie. No need to “break” the nose. Piezosurgery is also used for rib graft harvesting, which allows for less risk and pain. In January 2017, Dr. Kosins will be lecturing on and moderating a panel in Paris, France on the structural approach to rhinoplasty. This forms the foundation for secondary rhinoplasty and he will be the expert discussing each surgeon’s lecture.
Similar to a primary rhinoplasty, at the initial consult we ask each patient the 3 things that he/she does not like about his/her nose and wishes to be changed. Common complaints include:
- My breathing is poor
- Lack of tip definition
- My smile has changed
- My nostrils are collapsed
- My nose is too wide
- My bridge is irregular
After defining your goals, standard photographs are taken and used as a teaching tool to better understand what you want to change about your nose. The nose is examined both internally and externally, previous operative reports are reviewed, and we can begin to detail an operation to achieve your desired goals. Importantly, I want you to understand our analysis so that any limitations in your operation are fully discussed as well as the technical details. Patients seeking solutions to their complex revision cases will absolutely benefit from my expertise in dealing with these difficult cases. My goal is to fit the best operation for you depending on your problems and goals. I do not believe in a “one size fits all” approach and almost every operation we do is different from the next. Each person’s anatomy and ideal nose are different, and therefore so are my surgeries.
When performing revision rhinoplasty in Newport Beach, preserving function is part of rebuilding your aesthetics. Unfortunately, I too often see noses that have been destabilized by destructive techniques to make a smaller, cuter nose. The nose may be smaller, but loss of structural supports leads to deformities including pinched tips, “pig nose deformity,” nostril asymmetry, and irregularities of the bridge. To have a truly successful revision rhinoplasty, your nose must look better and also breathe better without any signs of surgery.
In summary, secondary or revision rhinoplasty is likely the most challenging operation in aesthetic Plastic Surgery. Finding a specialist is a must, and having a close relationship with an experienced surgeon is the best way to achieve your desired result. I often recommend seeing more than 1 surgeon in consultation to find the specialist that is right for you.