1.1 Revision Rhinoplasty: Why a Separate Topic?

Sooner or later, every surgeon who practices functional and aesthetic nasal surgery must face the issue of revision surgery. Surgeons should be concerned first and foremost with their own revisions. Often they are not dealing with a major disaster but with “minor complaints,” which are just as challenging. The more subtle the problem, the greater the importance that the patient attaches to his or her physical appearance. This blurs the distinction between “mild” and “serious” revisions. Every nose is “serious” because rhinoplasty is an all-or-nothing operation. The most important factor in judging its success is the subjective satisfaction of the patient. ¹ It is not unusual for the patient and surgeon to disagree in this respect. Everyone wants an optimum result and everyone has an opinion. But what is a realistic expectation when all factors are taken into account? The ability to predict a realistic outcome of revision rhinoplasty and communicate it to the patient beforehand is an important prerequisite for achieving patient satisfaction. Whether and when a surgeon performs a revision or refers it elsewhere will depend on his or her experience and success rates.

Is there really a need for a book on revision rhinoplasty? Do primary rhinoplasties differ from secondary and tertiary operations? We believe the answer is yes! There are psychological, biological, and certainly technical aspects that distinguish revisions from primary operations. Because the expectations of revision candidates were not met in the previous operation, all hopes are centered on the revision procedure and on the surgeon, who must decide whether, when, and by whom the revision should be done based on a precise morphological and psychological evaluation.

1.2 The Myth of Michael Jackson′s Nose

The most famous rhinoplasty patient of all time is the “King of Pop,” Michael Jackson. He never personally acknowledged having facial and nasal surgery, and we shall not offer analysis or commentary on that point. But the fact remains that his name comes up in almost every consultation visit with a rhinosurgeon; he is “always there.” Michael Jackson underwent extreme changes during the course of his life. The dark-skinned youth with an “Afro” became progressively lighter-skinned, his nose more slender. The human being morphed into an art figure. Was it a quest for his personal ideal of beauty? Or did he simply no longer want to look like his father, who often teased the young Michael for having a “wide nose.” ² Perhaps we will never know why this transformation took place. It is certain that Michael Jackson had multiple surgeries and entered a virtual Neverland between all ethnic and aesthetic norms, in the process becoming as unmistakable as his music. Fig. 1.1a–f illustrates the phenotypic changes that marked different stages in the life of Michael Jackson.

1.3 Special Problems of Revision Rhinoplasty

Fundamental differences exist between a primary rhinoplasty and a revision. While the surgeon in a primary septorhinoplasty seeks to locate the “surgical plane” that will afford elegant access with minimal bleeding, this plane is not available in revision surgery because it has been obliterated by scarring ( Fig. 1.2 ).

The ideal surgical plane for septal surgery is located between the mucoperichondrium and cartilage of the anterior septum, while the ideal plane for surgery of the nasal dorsum is located below the superficial musculoaponeurotic system (SMAS) of the facial muscles and the perichondrium of the upper lateral cartilage. In revision rhinoplasties these planes are either obliterated or difficult to define. The surgeon is always faced with anatomic changes and a loss of elasticity or stability in cartilage that has been weakened by incisions or excisions. Circulation is usually poorer than in primary rhinoplasties because of scarring, and the soft tissues covering the nose have usually not “forgotten” the trauma of previous surgery. ³ As a result, revision surgery always carries an increased risk for both the patient and surgeon, despite all available options and possibilities. ⁴ Access requires a sharper dissection technique. Bleeding tends to be heavier and may obscure visibility. The blood flow to scar tissue is relatively poor, areas of soft-tissue elevation may show delayed or asymmetric healing, and repeated undermining of the soft-tissue envelope may lead to cutaneous telangiectasia and trophic changes. As in any rhinoplasty, the surgeon must enter the operation with a well-devised plan of action. But revision surgery also requires a talent for improvisation in cases where, say, anticipated structures are not found or cannot be realigned or trimmed in the usual way. Scars are bradytrophic and hamper the uncomplicated healing of implants. This is why only autologous tissues should be used in revision rhinoplasties. Richard Goode′s advice to “replace what is missing with like material” is a sound rule to follow. ^{5 , 6} For these and other reasons, revision rhinoplasties belong in the hands of experienced surgeons. ⁷ Fig. 1.3 illustrates a hemitransfixion incision for a primary septorhinoplasty. Even this approach can be problematic in revision cases.