News & Features


Revision Rhinoplasty

Rhinoplasty Revision: The 'Do-Over'


CosmeticSurgery.com Staff Report
Medically Reviewed by Jason Diamond, M.D.

Consumer brief: The rhinoplasty, or " nose job", is an incredibly complex plastic surgery procedure. That's because the human nose is a three-dimensional structure that requires years to understand and master. But even more mastery and skill are required when a nose job is botched and the patient needs a revision.

When Laurie Manoli crashed nose first into two other skaters during a medal competition, her nose had already been broken, repaired and fixed yet again by a plastic surgeon. The skating accident was the equivalent of two fists hitting her already delicate nose. Laurie, now 34, was very displeased with her nose and set out to have it fixed once and for all.

Breathing Troubles

"Although I've been skating since I was five, I was a half second off on a maneuver at Lake Placid and ploughed into two other skaters' joined hands," Laurie told CosmeticSurgery.com.

The collision also brought on breathing troubles.

Mirrored Noses

While Laurie's nose did not precisely fit her face, it was worse in her mind. In many of the events in which she competed -- figure skating, ice dance, synchronized skating and others -- the aesthetic beauty of the participant influenced the final score.

Encouraged by her husband George, and the start of their new travel business, Laurie started researching revision rhinoplasty specialists on the Internet.

Although the couple lives in Florida, she eventually settled on Paul Nassif, M.D., a Beverly Hills board-certified plastic surgeon who specializes in revision rhinoplasties.

Before and After Rhinoplasty Photos

"I spent months on the Internet researching nasal surgery revision specialists and looking at before and after pictures that were profound and, frankly, moving," Laurie says.

The couple traveled to California in September, 2006, where Laurie underwent a six hour surgery to repair the inner and outer damage to her nose.

While the leading plastic surgery organizations -- American Society of Plastic Surgeons (ASPS), American Academy of Facial and Reconstructive Plastic Surgery (AAFRPS), and the American Society for Aesthetic Plastic Surgery (ASAPS) -- don't compile statistics on the number of rhinoplasties that must be revised, experts surmise that five to 12 percent of rhinoplasty patients must undergo a major or minor nose job revision. Other knowledgeable sources say one in five rhinoplasty procedures is botched.

"I spent months on the Internet researching nasal surgery revision…"

"The learning curve for a surgeon being comfortable doing a rhinoplasty is about 150 cases over two or three years," says Richard Fleming, M.D, a board certified plastic surgeon at the Beverly Hills Institute. "To really understand the nose, a surgeon must follow his rhinoplasty cases over about ten years to get an idea how time changes the nose."

Nose Jobs Botched

Dr. Nassif says his facial plastic and reconstructive surgery fellowship director once said a rhinoplasty surgeon hasn't learned anything until he or she has performed at least a thousand nasal surgeries and followed them for many years.

Rubber Nose

Many patients assume that undertrained surgeons are responsible for nose jobs that are botched. But that's not always the case.

"Sixty-six percent of the surgeries we do are revision rhinoplasties to provide a natural looking nose for the patient," says Sharon Clawson, administrator at the Beverly Hills Institute. "The patients who come to us with a request for a nose job re-do can afford the best the first time around. Nonetheless, we see many who are unhappy with a rhinoplasty that has been done by a top practitioner right here in Beverly Hills."

Because knowledge about rhinoplasty is ever increasing, some techniques performed until only several years ago have been found to lead to collapsing noses.

"Medicine is so specialized now that results which were okay ten or 15 years ago are no longer acceptable," says Andrew A. Jacano, M.D. a board certified plastic surgeon in New York.

Scar Tissue

Every time a surgeon repairs a nose, some scar tissue forms; that process hinders succeeding surgeries. Most surgeons consider three or four surgeries to be the outside limit of what can be tolerated. (Nonetheless, Michael Jackson, the poster child of the over-operated nose, is estimated to have had anywhere from six to 11 nose surgeries, depending on whom you ask.) After the third or fourth nose operation, the surgeon must start taking donor cartilage from other sections of the patient's body to brace the nose.

"Given eight or ten grafts from the ribs or the ears, a revision rhinoplasty can cost three to five times more than the first nose job," says Dr. Fleming. (Read more about the costs of plastic surgery.)

Healing Process

Sometimes, the skill of the surgeon is undone by the healing process itself.

"There are three partners in any rhinoplasty," says Peter Hilger, M.D., a board certified plastic surgeon and president of the American Academy of Facial and Reconstructive Plastic Surgery.

Nose In Profile with Glasses

"Involved are the patient, the surgeon, and Mother Nature who leads a very complicated healing process and can take as long as a year," Dr. Hilger says. "All three must be synchronized for any nose surgery revision to turn out correctly."

Dr. Hilger, a full professor at the University of Minnesota, adds that tolerances in the nose are very, very slim and that a sliver of bone measuring 1 millimeter (equal to the width of the period at the end of this sentence) can make or break an attractive nose.

"Tiny tolerances also affect the patient's breathing," says Dr. Hilger. "Additionally, healing causes tissues to shrink but the reduction in breathing space happens over a long period of time. Even in the best of surgical hands, Mother Nature can be the cause of a bad nose job."

The result: a nose surgery can continue to heal for many months after the operation while some changes can take place one to two years afterwards.

Given those variables, what would Dr. Hilger look for in a surgeon to repair his own nose?

Find an Expert Surgeon

"I would look for a surgeon certified by the American Board of facial and Reconstructive Surgery, the American Board of Plastic Surgery or the American Board of Otolaryngology (head and neck surgery,)" he says. "I would also want to know if he or she actively participates in local teaching societies because a surgeon is always learning about the process." (Read more about how to choose a qualified plastic surgeon.)

Dr. Jacono says another way to pinpoint a master surgeon is asking how often he or she does a particular procedure.

"I would choose a doctor who performs rhinoplasty two or three times a week," Dr. Jacono says.

Revision Rhinoplasties

"I saw one patient whose nose was done three times by a Park Avenue plastic surgeon who also stars on a television show," says Dr. Jacono. "And still, it was done incorrectly."

"…experts reckon that five to 12 percent of rhinoplasty patients must undergo a major or minor nose job revision."

Adds Dr. Fleming: "The biggest mistake we see when doing revision rhinoplasties is that too much bone or cartilage has been removed. Besides breathing difficulties, sinus infection and chronic headaches can result from an over-operated nose.

"Today's concept in nose surgery is that less is more," Dr. Fleming says. "So much less bone, cartilage and tissue is being removed and repositioned than just several years ago."

Computer-based Photo Morphing

The human nose is so complicated that when Dr. Nassif first sees a patient for a possible rhinoplasty revision, he examines pictures of the patient's original nose, his or her medical records and around 35 various nasal structures. He must then reconcile all those findings with what the patient wants in order to know if it's okay to go ahead with the actual surgery.

Sometimes, what the patient wants to see in a nose is known to cause additional problems after healing. And, some patients have unrealistic expectations for what plastic surgery can do. For instance, some want a very small nose that will cause nasal obstructions and breathing difficulties. Still others come into the office and want a smaller nasal tip when the tip they have is perfect.

Rhinoplasty In 3 Stages
A 36-year-old rhinoplasty revision patient shows his before picture, left, and then
what the computer morphing technology predicted his nose would look like after
healing. On the right, the actual nose is seen. (Photos, courtesy Dr. Nassif.)

"I use computer-based morphing to show patients what the likely outcome of surgery will look like," Dr. Nassif says. "Those photos give good clues about the patient's realistic expectations. If I show on the computer what the likely outcome will be -- and the patient wants more radical changes -- we must rethink the approach we want to use.

"I also use computer morphing as a guideline and goal during surgery," he says.

Laurie Manoli was over the moon about her new nose and said it improved her relationships and even inspired her to lose 10 pounds.

"After my nose healed, I felt like Dorothy when the house lands on the Wicked Witch of the West," Laurie says. Until then, I did not think looks could have such a deep, profound impact on somebody's life."

About our medical reviewer: Jason Diamond, M.D., F.A.C.S., frequently seen on television's Dr. 90210, is a board certified facial and reconstructive plastic surgeon who practices in Beverly Hills.

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