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Facial Plastic And Reconstructive Surgery Specialist

Baltimore, Lutherville, Maryland 410. 502 .2145
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 Revision rhinoplasty, Secondary rhinoplasty,  rhinoplasty expert

 Maryland, Virginia, Washington DC, New York , Pennsylvania

If you are seeking a revision rhinoplasty then you are not alone. At least 10% of all patients who have undergone  rhinoplasty undergo a secondary procedure to acheive their desired result." The best revision rhinoplasty surgery everperformed was the one that was never done" That is to say,

it is best to get it right suring the first surgery. Most of the time, when the primary rhinoplasty is performed by an experienced facial plastic surgeon, only minor touch up surgery is needed to further refine your results. However in some cases, major revision nasal surgery is needed and slight changes are just not enough. If this is your case, then you have come to the right place. First educate yourself about revision rhinoplasty before undergoing another nasal surgery.

 

Common reasons for revision rhinoplasty  

  • an over-operated, unnatural  looking nosebreathing difficulty
  • overly up-turned nose
  • assymetric, twisted, disproportionate nose
  • no facial balance 
  • nasal tip problemsnose remains too wide
  • nose too thin
  • crooked  nose
  • nostril assymmetry
  • undesirable scars
  • too pinched
  • lost of ethnic features
  • infected or exposed implant

 Understanding  the basics of rhinoplasty

In a simplified way, the nose is made up of an internal mucosal lining, a supporting structure of cartilage and bone and an outer lining of skin and muscle. Most changes done in rhinoplasty are made by altering the shape of the underlying nasal cartilages and nasal bone. Occasionally the skin requires some minor alteration. Over time, the nasal skin adapts to the restructured cartilage and bone. Minor changes to the structure of the nose — often measured in millimeters — can make a large difference in how your nose looks.   It can take up to one year for your final result to show. The nasal cartilages and bones provide structural support to the nose preventing nasal collapse during breathing. Thus, overzealous violation of these structural elements without compensatory techniques often results in a bad nose job that requires revision.

 

The nasal skin can be thin or thick. Thin skin adapts quicker and better to  alterations made to the underlying nasal bone and cartilages. Individuals with thin nasal skin will see their final results quicker as swelling and adaptation occurs faster. One disadvantage with the thin nasal skin is that any irregularities in the nasal structure is also obvious and difficult to hide. Patients with thicker skin have slower healing and skin adaptation but they hide any irregularies better. Thicker skin needs more structural support therefore overzealous alteration of the cartilages without compensatory measures will eventually lead to an amorphous nose that just does not work well. It is not too uncommon to have people tell us that their rhinoplasty looked great for 6 months then things begun to change. To avoid these predictible changes of wound healing  and the need for major rhinoplasty revisions, we carefully evalaute each patient to determine their nasal skin type, nasal bone structure and strength of their nasal cartilage.  We have found that creating highlights and shawdow points on the nose by reshaping the nasal cartilage and bones and actually adding more structure provides an natural looking, balanced result that withstands the forces of wound healing.

 

 

Timing for revision rhinoplasty

Revision rhinoplasty can be done at any time followiing the primary surgery  but the timing should be selected to optimize the result. When major structural changes are needed, waiting too long before undergoing a revision may not be helpful as contraction and scarring of the skin and nasal lining may make the revision surgery more difficult. On the other hand, it is best to wait at least 6 months when minor chnages are being contemplated since the wound healing process may correct these changes making a revision surgery unecessary.Moeover, one does not want to chase after a moving target since significant soft tissuse chnages can ocur after rhinoplasty even after a year, especially in thick skin noses.

 

Dr. Boahene was the opening speaker at this international conference of Plastic surgeons in Lima , Peru. Theconference attracted partipants from Europe, Latin America and North America. Dr.Boahene's presentation was titled" Tip rhinoplasty: creating shadows and highligths"He emphasized techniques that created a natural looking rhinoplastyresults by reshaping native cartilage.This approach minimizes the need for major revision rhinoplasty

 

Contact Dr. Boahene for a revision rhinoplasty consultation

 

   410. 502. 2145

info.drboahene@gmail.com

 

                            









  
 Case examples showing  revision rhinoplasty and major nasal reconstruction 

 Before AfterBefore   After
    
 Revision rhinoplasty after previous rhinoplasty with implant placed for dorsal projection left the nose looking harsh and operated.After the implant was removed, dorsal definition was achieved with contoured rib cartilage graft. The tip was refined and nostrils reshped. The dorsal profile now starts higher but looks natural and soft.

 Before After 
  

 Revision rhinoplasty  to correct over rotated  tip.Notice

lengthening of the short nose and derotation of the tip

into a more balance position.

 

      

 

       

 

 

African American female who presented interested in  revision rhinoplasty. The nasal tip is bulbous and without definition after 2 previous rhinoplasties perfomed by another surgeon.

 

 

Abnormally shaped nasal tip cartilages found during revision rhinoplasty. Too much cartilage had been removed and the remaining cartilage was also misshapen. Removal of excess cartillage in an attempt to make a thin nose leaves the nasal tip with inadquate strenght and shape to allow sculpting of the thick nasal skin as seen in this patient. This is a classic error made in african American rhinoplasty

 

 

Excessive scar encountered during the revision rhinoplasty. We debulked the nasal tip extensively

 

 

Through a 1.5 incision hidden in the breast crease, a small piece of rib cartilage was harvested and used in the revision rhinoplasty. We prefer to use cartilage from within the nose (septal cartilage) for our rhinoplasty cases. In revision cases where septal cartilage is absent, we prefer to use rib cartilage grafts. We occasionally use ear cartilage grafts.

 

 

We have rebuilt the tip cartilages replacing the missing parts with carved rib cartilage. We recreated the septum adding more strength and support . Now the thick nasal skin can adapt to the cartilages. In this case, to refine the nasal tip, we created a new pocket for the tip cartilages, rotating  them inferiorly ( caudal rotation of cephalic malpositioned cartilages).

 

Reconstructed tip cartilages now placed in a more natural position, restoring strenght to the amorphous tip. Compare this shape to that of the picture above.We measured the patients skin thickness as 1.5mm. We established that the desire nasal tip width that will look natural based on her facial features will be 8mm. Based on this the tip cartilages are placed 5mm apart. 5 mm with 1.5 mm thick skin on both sides will yeild a 8mm wide tip with slight variation based on swelling and scarring.Revision rhinoplasty requires careful analysis and planning.

BeforeBeforeComposite Rib graft After  
    

 Complex nasal reconstrustion of  a severe saddle nose deformity resulting from Wegeners.With the entire nasal septum lost to

this inflammatory disease, the nose losses  its major support. In this patient, one could push the nose flap against the face. She also had a bulbous nasal tip unrelated to the wegeners. A complex reconstructive rhinoplasty was perfomed with a composite rib-bone graft carved to fit onto the nasal bones and the weak dorsal cartilages. Tip rhinoplaasty performed at the same time refined the tip. The procedure was done with the close-open technique i.e exposure similar to the external rhinoplasty approach but no transcolumellar incision was made  thus avoiding any external scars.  See the improved profile and delicate nasal tip. results show at the end of the case.

 

 A                  BeforeAfter
  

Complex nasal reconstrustion of  a severe saddle nose

deformity resulting from Wegeners. Early

result showing correction and nasal ski contraction,

 improved profile, and correction of notched alar

Nasal reconstruction 

 Complete nasal fracture with

extreme aesthetic distortion

100s of nose to choose from intraoperative finding in rhinoplasty dictates the complete structural reconstruction additinal delicate cartilage reshaping for enhanced aesthetic result 
    
    

The ultimate nose job. She scored the goal yet her team lost but not before the opposing players took her nose out.

Sports injury to the nose is not uncommon and can leave its mark long after the game is over. In this young lady, the injury was extreme. A crunched up nose that needed delicate reconstruction.It always help when friends are supportive , cheering you on to pick a sassy nose...and they have their opinion..100 different noses to choose from..but those were all on back order. But for this young lady, a nose designed to fit her face was what was needed and what she got. Reconstruction of the nose following sport injury should take into consideration changes in function and appearance that will occur many years into the future.