Revision Rhinoplasty FAQs
THE FOLLOWING ARE THE MOST COMMON ISSUES BROUGHT UP BY REVISION RHINOPLASTY PATIENTS TO DR. SAM RIZK, WHO SPECIALIZES IN REVISION RHINOPLASTY. DR. RIZK DOES NOT PERFORM BODY PLASTIC SURGERY AND HIS PRACTICE FOCUSES ON THE NOSE AND FACE ONLY.
1. HOW DO I CHOOSE A SURGEON FOR REVISION RHINOPLASTY?
First, it is important to realize that revision rhinoplasty is a small specialty with very few surgeons who specialize in it. The surgeon should do at least a minimum of 4 revision rhinoplasty surgeries per week and should have a lot of pictures showing revision rhinoplasty patients. He must specialize in facial plastic surgery and be board-certified by the American Board Of Facial Plastic and Reconstructive Surgery. (www.abfprs.org). Although Board Certification does not guarantee a good outcome alone. A patient must evaluate the surgeon's experience by speaking to them and seeing their pictures. A surgeon who is a general plastic surgeon who also does body and breast surgery probably does not specialize enough in revision rhinoplasty. Additionally, very often, patients have a functional breathing problem after their initial rhinoplasties and the best surgeon to handle these issues is one who is double board certified in Otolaryngology (ENT) and Facial Plastic Surgery. Dr. Sam Rizk is a New York Facial Plastic surgeon who is double board certified in Facial Plastic Surgery and Otolaryngology. Dr. Rizk's practice focuses on the nose as he does not perform body plastic surgery.
2. MY NOSE LOOKS UNNATURAL AND TOO SMALL.
This can be corrected. This is Dr. Rizk's most common complaint that he sees in patients requesting revision rhinoplasty. It usually results from over-resection of cartilage or overreduction of the bony part of the nose, often resulting in a scooped, upturned, or pointy nose. Dr. Rizk has extensive experience with revision rhinoplasty and can rebuild lost or collapsed areas with grafting techniques. Please see the photo gallery below for examples of these common deformities which Dr. Rizk corrects.
3. MY NOSE LOOKS TOO POINTY and TWISTED
If the tip of your nose looks pointy, this is probably related to removing too much cartilage in previous surgeries and over time the tip can become weak and start to twist. This is a correctable problem and can be significantly improved with Dr. Rizk's revision rhinoplasty techniques. You may require cartilage grafts to support the tip of the nose and Dr. Rizk's diamond-powered method for sculpting and smoothing out sharp cartilage edges. Dr. Rizk's sculpting methods for cartilage grafts is a major breakthrough in revision rhinoplasty to avoid the pointy, unnatural tip. Please see the photo gallery below for examples of pointy and twisted noses.
4. WHAT IS THE LIMIT AS TO HOW MANY RHINOPLASTIES CAN BE DONE?
In Dr. Rizk's practice, he has repaired noses that were done previously 6 or 7 times. It is possible to improve noses that were done many times before. However, it is always better to have fewer surgeries. Dr. Rizk will only choose to operate if he sees obvious deformed areas or if the patient cannot breathe. He will not operate for minor deformities or requests.
Occasionally, Dr. Rizk will not be able to perform a revision rhinoplasty if he feels the nose is beyond repair. It is important for patients to understand that revision rhinoplasty requires specialized training and expertise and finding a skilled surgeon who specializes in revision rhinoplasty is necessary to maximize your chances for a favorable outcome.
5. Does Dr. Rizk formulate and discuss a plan for rhinoplasty during consultation?
If Dr. Rizk determines you are a good candidate for rhinoplasty, he will formulate a plan which will include whether he will use open or closed approaches, whether he will use cartilage for grafts or implants, and if cartilage will be used he will also discuss possible sources such as septum, ear, or banked rib cartilage.
6. Will Dr. Rizk perform computer imaging during my consultation?
Not always. Computer imaging may give you an idea from profile in some noses but is somewhat inaccurate in revision rhinoplasty, especially from the front view.
7. I HAVE BREATHING DIFFICULTY AFTER MY RHINOPLASTY
This can happen from many reasons. Sometimes too much cartilage was removed and the skin does not have enough support and may collapse, sometimes the patient's own cartilages are too weak and after a reduction rhinoplasty became weaker, sometimes the skin is too thick and collapses with inspiration, and sometimes an underlying deviated septum becomes more symptomatic after the nose is made smaller in a rhinoplasty. Whatever the cause is, this is a very fixable problem and may require adding more cartilage to the nose or repairing the nasal septum. This is a very common complaint and may not be the surgeon's fault. Fortunately, it is correctable. Please see the photo album below which will show patients with this problem who were successfully treated.
8. WHO IS A CANDIDATE?
First you must be realistic about your goals. If you do not like the way your nose looks or cannot breathe well and you are in good health, you might be a good candidate. You have to meet with your skilled revision rhinoplasty surgeon and discuss your concerns. In Dr. Rizk's consultation, Dr. Rizk will talk to you and examine your nose in detail, both the external nose and the inside of the nose to determine if you are a good candidate and if your goals and expectations are reasonable and can be met. Sometimes the patient's expectations are unrealistic and Dr. Rizk may choose not to operate even though there are deformities and even though the patient is in good health.
9. THE ROLE OF COMPUTER IMAGING
Sometimes it is useful to show a nose from the profile. However, it is very inaccurate from the front view and should not be relied upon because it can be misleading. In revision rhinoplasty, there are many surgical factors which determine the final shape of the nose which cannot be shown by Dr. Rizk's preoperative computer imaging. Its usefulness is in a profile view. Dr. Rizk will sometimes do it to show the possible change in a revision rhinoplasty.
It is a normal emotion to be afraid of a revision rhinoplasty, especially since a patient has already had an unpleasant experience. Dr. Rizk's confidence and experience in his results with revision rhinoplasty makes the patient immediately feel at ease. His staff will help you through the process and will be a large part of your more pleasant experience both before and after your surgery. Dr. Rizk will answer any of your questions and may put you in touch with some of his patients who have had a revision rhinoplasty to ease your fears.
11. EXPERIENCE WITH ETHNIC NOSES
Ethnic noses such as Mediteranean/Middle Eastern, Hispanic/Latino, Asians, and African american rhinoplasty surgery require different techniques to obtain a natural and beautiful nose. Dr. Sam Rizk has specific techniques he developed and has extensive experience with these noses. He sees a large number of these noses in revision rhinoplasty with loss of tip support and postoperative tip drop which he corrects. These patients have thick skin which gets even thicker with scar tissue from previous rhinoplasty. Dr. Rizk has specialized defatting techniques to remove scar tissue and cartilage sculpting techniques which form smooth grafts without sharp, pointy edges. Please see various sections on this website on these specific ethnicities for more information.
12. TECHNIQUES FOR REVISION RHINOPLASTY
There are 2 approaches to revision rhinoplasty, so called endonasal (closed) or open rhinoplasty (external). The endonasal technique is done with small incisions inside the nose and the external or open rhinoplasty is done with a small incision in the middle of the columella (center bottom part of the nose). Dr. Rizk performs revision rhinoplasty with both the endonasal endoscopic technique as well as the open technique, depending on the nose and what is needed. If an open is performed, the incision on the columella heals excellent and is almost invisible. In Dr. Rizk's experience the endonasal technique is more suitable for lateral (on the side of the nose) collapses and the open technique is more suitable for central collapses in the tip. Once Dr. Rizk examines your nose, he will make a determination regarding the best technique for you.
13. OUT OF TOWN PATIENTS
Dr. Rizk has a large number of patients in his practice that travel to his Park Avenue Center to undergo revision rhinoplasty from different states or countries. Patients stay in various hotels and need to remain in New York City for 1 week after the surgery. Usually these patients have decided to have surgery with Dr. Rizk after emailing their pictures and having a phone consultation with Dr. Rizk regarding their revision rhinoplasty. The revision rhinoplasty is done outpatient in Dr. Rizk's center and patients return to their hotel that day. Follow-up is done in 6-7 days for removal of splint.
14. THE RECOVERY
Pain is usually minimal. Some discomfort is expected after revision rhinoplasty, but usually resolves with Tylenol. Dr. Rizk also provides patients with a rapid recovery packet of medicines which he feels promote a quicker recovery. Icing is recommended in the first 2 days after the surgery. Patients usually return to work 1 week following their revision rhinoplasty surgery, but swelling continues to diminish for up to a year after the surgery. Aspirin and products that cause bleeding such as vitamin E, ginko biloba, or fish oil should be discontinued 2 weeks before surgery and 2 weeks after the revision rhinoplasty. Please review Dr. Rizk's before/after instructions on this website for more information.
The term “revision rhinoplasty” refers to secondary surgery, often performed on unsatisfied patients who do not like the results of their primary surgery. Dr. Samieh Rizk, a New York double board certified facial plastic surgeon with extensive experience and skills in both rhinoplasty and revision rhinoplasty surgery, performs these procedures on a daily basis. He explains that revision rhinoplasty surgery is a more challenging procedure than a rhinoplasty since the nasal structure may have lost some of its original anatomical characteristics and patients tend to have scar tissue which makes it more difficult to improve both functional and cosmetic results.
Patients have sometimes had up to 6 or 7 previous rhinoplasties and were unhappy with the results. Dr. Rizk operates only if the patient is realistic about their expectations and if they are in good physical and mental health and are unhappy about either their cosmetic appearance or their breathing. This procedure is considered one of the most difficult in plastic surgery and it is therefore essential that the patient select a qualified and experienced surgeon who shares the same aesthetic plan as the patient. Sometimes Dr. Rizk will choose the open rhinoplasty technique and sometimes he will choose the closed (endonasal rhinoplasty) technique depending on the deformity. Many times cartilage grafts need to be added to correct various areas of collapses or to smoothe sharp-edged grafts. Dr. Rizk has innovated a special technology with with micro-sanding rotating tips that smoothes and sculpts cartilage edges to eliminate the sharp-edges of rhinoplasties performed with older techniques.
Sometimes revisions are necessary even if surgery was performed by adequately trained surgeons and patient had poor healing. But a surgeon needs to understand the internal support mechanisms of the nose and be trained with a background in ENT and facial plastic surgery to not violate these support structures of the nose. Many revisions Dr. Rizk does have areas of collapses from over-aggressive resections of cartilage done previously with scooped ski-slope noses and pointy or upturned tips. Many of these patients can't breathe because of these multiple areas of collapses and require a highly trained facial plastic surgeon that does many revisions. Dr. Rizk is one of only a few double board facial plastic surgeons worldwide who has a large practice and experience with revision rhinoplasty.
Many revision rhinoplasty surgeries require cartilage grafting so support collapsed areas. Dr. Rizk prefers the cartilage from the septum or ears or rib cartilage if needed. Medpor is an artificial implant that has holes in it and integrates into the nose with ingrowth of tissue to stabilize it and is sometimes used by Dr. Rizk in selected cases, but Dr. Rizk does not use silicone and usually has to take it out from previous rhinoplasties. Dr. Rizk custom sculpts the medpor implant to fit your nose during your procedure, It is not a one size fit all implant.
Patients who underwent primary rhinoplasty years ago exhibit defects in the structural support of the nose. Sometimes the nose scoops out or is overly pointy. In other cases, patients reported having difficulty with breathing. Many patients had a previous nose job done using silicone implants which were not integrated with their bodies, changing their location within the nose months after surgery. The body naturally creates a space between the nose's tissue and the alien silicone object. This can result in infections that complicate recovery and hamper results. Dr. Rizk usually removes the silicone implants and uses patient’s own cartilage, preferably from the nasal septum, the back of the ears or synthetic medpor in case there is not enough cartilage.
Besides the higher technical challenge, there are also additional complications such as the need to improve an airway blockage by correcting a deviated septum and reducing an enlarged turbinate. Additional complexity occurs in patients who have broken noses, allergies and a previous history of sinus problems which contribute to nasal blockage. These patients need to be in good hands of an extensively trained and a highly experiences facial plastic surgeon since these problems need to be fixed properly from both functional and cosmetic perspectives.
Revision rhinoplasty surgery is one of the most challenging operations in plastic surgery. Dr. Rizk has pioneered technology to help perfect this operation. Operating on a 3D structure in the middle of one's face such as the nose is much more accurate when using 3D technology to better visualize the intranasal structures. Additionally, as Dr. Rizk sees many patients who have revision noses with multiple areas of collapse and pointy edges, he has innovated new technology and tools to micro-sculpt sharp edged cartilages which far surpasses older technology using a regular knife to reshape cartilages. This innovation comes from Dr. Rizk's background as a sculptor and the powered tools he used in his artistic hobby. Today's revision rhinoplasty also involves rebuilding structures that have been damaged or removed by older more aggressive rhinoplasty operations. This rebuilding process involves the use of cartilage grafts which also need to be accurately smoothed with Dr. Rizk's technology to create smooth edges, thus creating more naturally defined lines without jagged or sharp irregular edges.
The key to formulating a treatment plan in revision rhinoplasty is a THOROUGH NASAL EXAM AND DIAGNOSES. Dr. Rizk always performs a detailed examination of the internal and external nasal structures and any abnormalities evident on both static and dynamic examinations (ie. with inspiration and smiling). This can detect areas of nasal collapse, inverted v-deformities, external and internal nasal valve collapse, pinched tips, saddle nose deformities, scar tissue, pollybeak deformities, thick skin, weak tip support, drooping nasal tips, as well as functional conditions such as a deviated nasal septum, twisted nose, turbinate enlargement and sinus disease.
Repairing the internal and external nasal structures is done together and the goal is not just an aesthetically pleasing natural outcome but also a functioning nose where the patient is able to breathe.
Dr. Rizk likes to review old operative reports from previous rhinoplasty surgery, pictures of the patient's old nose prior to any alteration, and pictures of the nose after each of the previous rhinoplasty surgeries, if possible. Then Dr. Rizk evaluates and discussed with the patient the areas of concern and their goals. Are the patient's goals realistic or is the patient asking for something which cannot be accomplished? Does the patient have a breathing disorder? Is the patient able to follow instructions? How is the patient's health? Does the patient have any psychological conditions which require evaluation? If the patient has nasal obstruction, where is it and does anything make it better or worse? Is the septum still present or did patient have septoplasty? Was ear cartilage removed for grafting in previous surgery, if so, which ear? Has rib (costal) cartilage been used in the nose. All these facts are important. Very often, Dr. Rizk needs to know these details because some patients may be unhappy with size of the nose if too much rib cartilage was used and was not sculpted properly and can make the nose appear larger and with sharp edges. If ear cartilage is used in the tip, it usually does not provide enough tip support and the tip will re-droop. Has the patient had alloplastic (artificial implants), and if so, which ones. Very often, Dr. Rizk will see patients with infected silicone implants or silicone implants which have moved since the body never integrates silicone so it becomes mobile in a pocket. Silicone implants which are too large can also thin the skin and extrude. Dr. Rizk uses a detailed analysis worksheet in his examination and obtains a detailed history from the patient. The examination involves evaluation of the bony and cartilaginous structures of the nose. The bony dorsum needs to be assessed to see if osteotomies were done and if so were they done too high because Dr. Rizk a large number of revision rhinoplasty patients with an open roof deformity and very wide bony dorsum secondary to inability to bring the bones in correctly. The middle of the nose (middle nasal vault) is then examined for collapsed or indentations from front view and for saddles or bumps from profile view. The tip is finally examined for tip projection, rotation, support, alar and columellar retractions or deformities such as a hanging columella and for asymmetries or deviations. The internal structures of the nose need to be examined for presence or absence of a nasal septum, if it is deviated or has a perforation in it, turbinate hypertrophy, internal valve collapse or scar tissue in the internal nasal valve or between the septum and turbinates. The sinus openings need to be examined with a telescope for blockage or sinusitis or polyps. Dynamic nasal airway needs to be examined for collapses as the patient inspires quickly. Finally, the skin thickness needs to be assessed by pinching the skin of the tip (where skin is usually thickest in the nose) and rolled over from side to side. A trick to assess asymmetries of the tip is also to push on the tip upwards from the columella to see where it bends and becomes full. All these factors become important in a revision rhinoplasty.
55 year old male status post revision rhinoplasty done with endoscopic approach to correct a polybeak deformity and loss of tip support. Multiple grafts were placed in the tip from the septum. Additionally, patient had nasal valve collapse and deviated nasal septum. The nasal valve and septum were corrected at the same time with cartilage grafts in nasal valve
54 year old interior designer who had a lower blepharoplasty, revision rhinoplasty with tip lift procedure, as well as facelift/necklift. Shown 2 years after surgery. Patient had baggy eyelids from fat removed as well as lower eyelid laser resurfacing to tighten the skin.
55 year old female with previous rhinoplasty complains of overrotated nose, pointy tip, saddle nose and inability to breathe. Patient shown 5 years after Revision Rhinoplasty with multiple cartilage grafts from ears and septum to build her tip, elongate her nose and rotate it down. I also improved her breathing by correcting external nasal valve collapse, where the skin of the nose collapses on inspiration due to excessive removal of cartilage.
45 year old female with previous history of rhinoplasty where too much bone was removed and not enough cartilage from area above tip. Additionally, nose is too rotated. Patient had an auricular (ear) cartilage graft to repair bony scooped area. the cartilage bump was reduced and nose was lengthened with a caudal septal cartilage graft. From the front, nostril on right side was reduced to create more symmetry.
35 year old female with history of previous rhinoplasty at age 15 where too much cartilage was removed. Preoperative pictures show a severly pinched tip in addition to a scooped out area on the left side near the rim of the nostril. Also the nose is too short. Postoperative pictures shown at 9 months after revision rhinoplasty with the open approach. Patient required a caudal septal extension graft from her septum to lengthen the nose as well as a left alar rim cartilage graft to correct the scooped out hole on the left and bilateral lower lateral cartilage grafts to correct the pinched tip. All cartilage grafts were obtained from patient's own septum.
53 year old female shown after revision rhinoplasty with the open approach to correct a twisted bulbous tip on front view and a saddle nose on profile view. Multiple cartilage grafts from the ear and septum were used to build her nose and straighten it.
26 year old female status post previous rhinoplasty, complaints of collapse on right side as well as droopy tip. Patient underwent revision rhinoplasty with addition of cartilage for tip support and addition of cartilage to the right side of nose to correct the collapse. Patient is shown 2 months after surgery, healing will continue for one year.
35 yo female South American/Latino patient who underwent revision rhinoplasty to straighten the nose as well as remove the bump (actually we call this a pollybeak because it is mostly cartilage). The bony bump was overresected and the cartilage bump was underresected. Patient is shown at 1.5 years postoperatively.
35 year old doctor who has had previous rhinoplasty with severe difficulty breathing and crusting/dry nose. She also has a mild saddle nose on profile and on frontal view, external nasal valve collapse was worse on the right. Patient is shown after endonasal 3D rhinoplasty with ear cartilage grafts to correct the collapsed areas. Patient is shown 3 weeks after surgery. Patient went back to work 1 week after surgery.
45 year old male who underwent revision rhinoplasty to fix his asymmetric pinched tip as well as saddle nose deformity. Patient had multiple collapsed areas in his nose corrected with cartilage grafts from his septum.
27 year old Asian female who had a previous rhinoplasty with silicone implant which became infected and extruded through her tip and also became crooked. Patient underwent revision rhinoplasty with Dr. Rizk to remove silicone implant and Dr. Rizk used cartilage from inside her nose to lengthen her nose and define her tip.
48 year old female with previous history of rhinoplasty unhappy with her front view irregularities and areas of collapse (worse on right side) and inability to breathe. Patient shown after revision rhinoplasty using septal and auricular cartilage grafts to correct multiple areas of deformities and collapses. Both spreader and alar batton grafts were needed as well as dorsal onlay grafts. Graft edges were smoothed using Dr. Rizk's new graft sculpting technology. Only front pictures are shown as there was mainly front changes only.
31 yo old male Indian doctor who underwent previous rhinoplasty in Beverly Hills who is dissatisfied with his lack of definition and his scooped feminized nose. Patient is shown only 1 week after revision rhinoplasty with multiple sculpted grafts in his tip and bridge to masculinize his nose and successfully define it despite having very thick skin with underlying scar tissue. Additionally, the nostrils were asymmetric and were adjusted. Patient is still swollen as he is shown only 1 week after surgery.
25 year old female who underwent rhinoplasty 8 years ago and was very dissatisfied with her nose. Her preoperative pictures shows the typical stigma associated with an overreduced rhinoplasty. Preoperative pictures shows the following deformities from the profile: Scooped out saddled cartilage bridge and a bony bump, overprojected tip with a hanging columella, pointy tip on the right. Preoperative picture from the front view shows the following deformities: open roof deformity near the bony top part of nose, inverted v deformity in the cartilage part of nose, pointy tip on right, and hanging columella. Postoperative pictures are shown after rhinoplasty with the use of septal cartilage graft. Additionally, patient could not breathe preoperatively secondary to a deviated septum and could breathe after that was fixed at the same time.
25 year old female complains about her tip as too boxy. Patient has separation of her lower tip cartilages and a saddle above her tip. This was corrected with cartilage grafts obtained from patient's septum and suture techniques were used to make tip cartilages narrower.
25yo female with a severe rhinoplasty deformity from a previous rhinoplasty with both a floating bone open roof problem as well as tip bulbosity. Patient actually has attachment of bone into thin skin in dorsum. Patient is shown 5 months after revision rhinoplasty.
NOTE: ALL THE IMAGES USED ON THIS PAGE ARE ACTUAL PATIENTS THAT DR. RIZK PERFORMED RHINOPLASTY ON WITH APPROVED CONSENT.