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How to choose your revision rhinoplasty surgeon?
When it comes to secondary nose surgery, patients should choose a board certified facial plastic surgeon that understands the complexity of the procedure and has the skills and expertise to improve the results of previous surgery, prevent additional complications from developing, and restore the functional airways so patients can breathe optimally after surgery.
When Top New York City Facial Plastic Surgeon Dr. Samieh Rizk performs a rhinoplasty, he creates a fully customized look for each individual patient. He does not do a standard cookie cutter procedure. Rather, he works with each patient to maximize the effects of a rhinoplasty procedure. Every operation is individualized based on the patient's goals, desires, and anatomical considerations, such as thickness of the skin, nasal bones, and internal structures. It is important to articulate your main concerns so that we can work together to construct an ideal nasal result to avoid disappointment or miscommunication. NYC Facial Plastic Surgeon Dr. Sam Rizk has performed literally thousands of successful rhinoplasty procedures.
Your nose is the most prominent feature on your face. By making even a small change to your nose, this will affect your whole appearance. New York based Facial Plastic Surgeon Dr. Sam Rizk aims to preserve the general characteristics of your nose, and to only make small alterations to straighten or refine the shape and tip projection. A natural looking profile and tip are what patients desire most of all. The characteristic overdone, over-operated and pinched look that was popularized in the last 25 years is no longer preferable. The nose is considered to be one of the most complex anatomical structures on the face. The internal structure of the nose is supported by a delicate framework of small bones and resilient cartilage.
Dr. Rizk's goal is to create the most natural looking nose possible, based on the structure of the cartilage, the overlying skin, and the surgeon’s aesthetic judgment. A natural nose should be in harmony with your other facial features, including the upper lip, chin and cheeks. The most important factor in achieving a natural result is to create a nose with good structural support so it will stand the test of time. Everyone has seen rhinoplasties that are too pinched at the tip or have a sloping bridge or pulled up nostrils. Dr. Sam Rizk's patients have the most natural and unoperated look possible. He is considered an international expert on rhinoplasty.
Dr. Rizk has a large percentage of revision rhinoplasty in his facial plastic surgery practice in New York City-approximately 50% of cosmetic procedures he performs are revision rhinoplasty. Technical mistakes or poor healing can both result in failures in cosmetic surgery. Also, a nose may be technically well corrected but does not match with other facial features and with the individual's overall appearance. Dr. Rizk creates a nose that is not only naturally attractive and functional but also a nose that fits and is in harmony with other facial features. Technical faults vary in extent and can lead to deformities of the components of the nasal pyramid, affecting not only the aesthetics but also the function of the nose.
However, in cases in which the planned rhinoplasty was successfully completed, the surgeon was satisfied with the immediate result-that is, no apparent technical error occurred-minor defects can be observed in 5%-20% of patients. Sometimes these defects are exaggerated by a patient's unreasonable expectations and minute scrutiny of the nose. A frequent example is the discrete deviations that are seldom noted before the operation but are always seen by the patient postoperatively. These may not be due to surgical error but rather variations in skin thickness in different parts of the nose that may occur after surgery due to scar tissue. Dr. Rizk only operates on patients he deems to have reasonable expectations who understand the reasonable margin of error that occurs despite a perfectly executed nose surgery.
Major defects, on the other hand, may result from excessive or irregular resections of cartilage and bone. Most frequently, defects are observed in noses that look unnatural and "operated-on" because of certain regularly encountered features. Dr. Rizk, a New York plastic specialist, points to these frequently encountered defects such as a nasofrontal angle that has not been adequately deepened, an overly shortened nose, a dorsum which has been overly reduced or scooped (saddle nose deformity), an underlying supratip deformity (pollybeak deformity), an overly resected tip or pinched tip, or a round nasal tip with no definition.
In thick-skinned patients, Dr. Sam Rizk states that certain defects can be masked by the thickness of the covering skin. The most one can expect in such instances is only moderate improvement, justifying limited resection, particularly when a dorsal graft and a tip graft are planned.
In very adherent tissues, soft tissues can be quite scarred and adherent to the cartilage and bony skeleton, a condition that is often the result of aggressive surgery. The cutaneous layers can also be adherent to the mucosal lining when the cartilaginous resections have been excessive. The lack of suppleness of the nostril orifices increases the difficulty of exposure.
The problems are therefore variable and can exist at the level of the covering tissues, mucosa, and the ossteocartilaginous skeleton. The objective, according to Dr. Sam Rizk, a prominent NYC surgeon, is to restore nasal anatomy and function, and to achieve this in the least invasive method. Graft or implant placement is often required in revision rhinoplasty.
The surgical approach in revision or secondary nose surgery depends on the difficulties that are foreseen or encountered. Both endonasal and open techniques may be used for revision or secondary rhinoplasty. Dr. Sam Rizk uses both approaches, depending on the location and extent of deformities present. With either the external or open approach or endonasal or closed approach, the dissection should be large enough to permit the surgeon to work comfortably. The risks to the skin are minimal if adequate skin cover is maintained and if the undermined flap is handled with care and the incisions closed without tension.
Minor defects most often involve a cartilaginous or bony projection, a slight asymmetry or deviation, or a minor depression. They can appear after several months when edema has completely disappeared. Correction may be simple and rapid and can be carried out in most cases with the patient under local anesthesia. A bony or septal prominence can be trimmed or rasped using a narrow 3 or 4 mm tapered rasp, which, after an endonasal puncture incision, permits direct access to the projecting deformity. A small depression can be corrected by filling in the area with a crushed cartilage graft harvested from the septum or concha: this can be introduced after minimal tunneling. Discrete deviations are more difficult to correct; they often correspond to a residual cartilage deviation or to asymmetric resections. They are not easy to correct, and it is often preferable and easier to correct them by limited procedures rather than carry out wide undermining and more extensive surgery which can lead to more scar tissue and more asymmetries. Dr. Rizk, an expert New York revision or secondary nose surgeon states that a camouflage graft is very useful in these situations and can be placed with a very small endonasal or internal nasal incision with very limited dissection. The camouflage graft is often placed on the opposite side to the deviation and an osteotomy may be required on the same side as the deviation.
A saddle nose deformity (scooped nose) is often a sequela of a traumatic impact to the nose or it can result from overresection of the nasal hump, particularly on the septal cartilage. When the saddle deformity is the result of a postsurgical tissue loss, such as from excessive resection, correction calls for an augmentation procedure with a graft or implant. Saddle nose deformity may involve the entire nasal dorsum to include both cartilage and bony parts. A post-traumatic effect may include a broadened nasal width at the cartilage area in the middle and lower parts of the nose, with a more pronounced appearance in the upper bony part of the nose. Supratip saddling may also be the consequence of overresection of the lower dorsum and is easily correctable with cartilage grafting.
Flat noses often result from surgery in which the lower lateral cartilages have been weakened. On examination, the interalar base distance appears wide in respect to the length of the columella; the nasal tip is easily depressed with poor columellar support and weak and soft lower lateral cartilages on palpation. The goal of secondary or revision rhinoplasty in this situation according to Dr. Sam Rizk is not only to correct a dorsal deformity but also to reinforce the columella and tip support with a solid columellar strut that is long enough to provide adequate projection. In the case of a markedly flat nasal tip, a long, bony or cartilaginous strut will act like a tent-pole; it will reduce the interalar base distance and modifies the shape of the nostrils whose horizontal axis can be made more vertical. The tip cartilages can then be advanced over the strut to create more tip definition and further support. Only tip cartilage grafts can then be used and attached to the columellar strut and advanced tip cartilages to create further projection and definition. Dr. Sam Rizk, a NYC specialist, emphasizes that these tip cartilage grafts have to be smooth and properly sculpted in order not to be palpable or visualized. Dr. Sam Rizk has developed a technique in order to achieve proper cartilage sculpting using specialized burring or smoothing rotating probes (see media section of this site for articles on these sculpting techniques).
Middle vault (middle part of nasal bridge) deformities may result from an excessive resection of the upper lateral cartilages or an aggressive rasping that can cause a disinsertion of the upper lateral cartilages from the nasal bones or from excessive dorsal resections. The appearance and extent of the deformity is related to the conditions of the skin cover: thin skin and destruction of the subcutaneous layers during previous rhinoplasty will make the deformities more pronounced and visible, but a thick skin often masks deformities of the underlying framework. Surgical correction is carried out by using cartilage grafts, often called spreader grafts, which play a role of both camouflage and reinforcement of the skeletal structures. Grafts to the dorsum may also be needed in addition to lateral or spreader grafts.
Secondary deformities of the nasal base are often caused by excessive and asymmetric resection of the tip cartilages (alar cartilages) or caudal nasal septum. Dr. Sam Rizk, a New York surgeon, states that, depending on the skin condition, overresection can cause various types of defects but thick skin provides some support to the tip or alar cartilages and can mask a projection or a cartilaginous defect. The most common defects are the following:
- Undercorrection, leaving an excess of tip projection, a wide tip, or a falling tip.
- A loss of projection, which may occur after excessive resection but can also be caused by other factors, such as extensive undermining or a lack of adding cartilage grafts to support the tip in the initial rhinoplasty.
- Asymmetry and deformities of the nasal tip.
- A collapse and depression of the nasal alae or nostrils associated with an overresection of the tip cartilages in the region of the external or internal nasal valve. This causes not only a cosmetic but also a functional breathing problem. This may be also caused by preexisting floppy cartilages and would require a secondary rhinoplasty with cartilage graft or implant to correct.
The above described problems may be aggravated by nostrils that are narrow or a lack of suppleness or poor-quality skin cover, such as scarred skin. The surgical correction of the deformities of the nasal base should be corrected, taking into account the remaining parts of the nose so that the whole nose is harmonious with its differing sections. The procedures for reconstructing the nasal tip are numerous and frequently require cartilaginous grafts from the nasal septum, concha (ear), or using banked rib cartilage or nasal implants. According to Dr. Sam Rizk, types of grafts used may include customized unnamed grafts Dr. Rizk creates as well as the typical shield grafts, columellar strut grafts, onlay grafts or rim grafts (see section of this website on nasal grafts for a detailed description of the grafts). In all cases of graft use, Dr. Sam Rizk emphasizes the importance of his cartilage sculpting smoothing techniques (see media section of this website for articles on Dr. Rizk's innovations in cartilage sculpting -published in Plastic Surgery Practice Journal).
A short nose (or more commonly described by lay person as a pig nose), is defined as one with a short distance from the root of the nose in between the eyes to the domes. Correction of a short nose is always the most difficult type of secondary rhinoplasty, particularly when the covering tissues are scarred and adherent. Most short noses are the result of a previous rhinoplasty, but some noses can be congenitally short. A nose which has been over-shortened in a previous rhinoplasty is often the consequence of excessive resection of the caudal septum and mucosa or overresection of the tip cartilages (alar cartilages). Dr. Sam Rizk, a NYC rhinoplasty surgeon who has a large number of revision rhinoplasty in his practice, states that the correction of the short nose entails reconstructing and lengthening of the nasal tip using various types of cartilage grafts as well as undermining to allow the soft tissue and skin to accommodate the new length. Adaptation of the soft tissues (skin and mucosa) to the lengthened skeleton depends on the tissue condition and extent of scarring. Both the external (or open) and the endonasal (or closed) rhinoplasty approaches may be used, or the short nose, depending on the extent of deformity and amount and size of the cartilage grafts needed.
Some nasal tips look as if they have been amputated and are often too "rounded". This can be caused by a previous rhinoplasty when the nose was overresected at the location of the tip cartilages. It sometimes results in loss of tip projection with lack of definition and sometimes a flat rounded tip. Dr. Sam Rizk states that the most effective treatment consists of reconstructing the deficient cartilaginous structures by using a combination of cartilage grafts and suture-cartilage-reshaping techniques to increase tip projection. Cartilage grafts commonly used in this area include onlay grafts, columellar strut grafts as well as shield grafts. Dr. Sam Rizk has designed a custom onlay graft that is more rounded and redefines as well as projects the tip of the nose in a natural way. This graft has a dual function of projection and definition while creating a naturally defined rounded, rather than pinched tip. Endonasal and open rhinoplasty techniques can both be used for tip deformities and that depends on the individual extent of deformity. Either septal, conchal, or rib cartilage may be used for these deformities.
A pollybeak deformity may result from various factors and is usually secondary to a previous rhinoplasty. It can either be the result of excessive cartilage in the area above the tip, a tip drop which gives a relative fullness in the area above the tip, or from inability of the skin to contract to the new skeleton in the area above the tip. This can be an obvious unnatural give away of a previous failed rhinoplasty. Dr. Sam Rizk will examine your nose to determine the cause of this deformity and points to the fact that the skin factor is often misunderstood or neglected during rhinoplasty. It is important to apply pressure in the area above the tip with tape and sometimes a cortisone injection or multiple injections are necessary to thin the skin in this region. According to Dr. Sam Rizk, the surgical correction of a pollybeak deformity if there is excessive cartilage or thick skin can be done with the endonasal approach by resecting the appropriate cartilage or thinning the skin in this area surgically. If the pollybeak is due to a post-rhinoplasty tip drop, then it is necessary to use cartilage grafts and suture techniques to raise the position of the tip enough to eliminate the fullness above the nasal tip.
A pinched tip and alar collapse usually results from overresection of the tip cartilages and weakening the tip support from a previous rhinoplasty. The degree of this deformity depends not only on the amount and site of resections, but also on the quality of the skin and the strength and configuration of the tip cartilages. Alar or tip collapse is more noticeable when the skin is thin, but thick skin can mask alar collapse and a pinched tip look. This pinched tip look gives a very unnatural appearance to the nose. Besides alar or tip collapse on inspiration and the appearance of a pinched tip, overresection can lead to alar or tip retraction in an area missing cartilage. According to Dr. Sam Rizk, reconstruction involves correction of the alar depression and pinching with grafts. The revision rhinoplasty or secondary rhinoplasty can properly restore the natural tip shape which is harmonious and is matched by a satisfactory projection of the nasal tip. In some cases, when the tip cartilages are slightly weak and there is only moderate or mild inspiratory collapse, a small batten graft can correct this problem from a small incision inside the nose. In more extensive cases, the nasal alae or tip cartilages may need multiple cartilage grafts. These grafts can be harvested from either the nasal septum or the concha or ear. In severe cases of alar retraction and collapse, the missing cartilage must be reconstructed, but it is sometimes necessary to correct the defect in vestibular skin with the use of a composite graft harvested in the superior pole of the concha (ear).
A good candidate for revision rhinoplasty or secondary rhinoplasty is one who is looking for improvement and not perfection. There are many factors that affect final result in revision rhinoplasty even with a technically excellent rhinoplasty such as scar tissue, skin thickness, skin pliability and elasticity.
For more information, please see: REVISION RHINOPLASTY FREQUENTLY ASKED QUESTIONS
- "Correcting the Drooping Tip and Hanging Columella in Revision Rhinoplasty" Chapter in Rhinoplasty Medical Textbook
45 year old female who had a previous rhinoplasty and presented for secondary rhinoplasty. Patient wanted a straighter nose and to make her nose longer. Preoperative profile photos show a very short nose and hanging columella. Preoperative front views shows a deviated nose and a collapse of the right upper lateral cartilage and a bone on the right that is not in properly. Patient underwent revision rhinoplasty (endonasal) with osteotomy on right bone and spreader graft on right cartilage collapse and multiple tip grafts to elongate the nose. Patient is shown 6 years after secondary rhinoplasty.
45 year old male with previous rhinoplasty who presents for revision or secondary rhinoplasty. Patient has inverted v deformity, pollybeak deformity, a drooping nasal tip and a deviated septum to the right side. Patient is shown 6 months after revision rhinoplasty with septal cartilage grafts to correct the tip and middle vault of the nose.
24 yo female who underwent revision rhinoplasty with Dr. Sam Rizk using banked rib cartilage and temporalis fascia to correct an overshortened, scooped nose with multiple areas of collapse secondary to previous rhinoplasties. Patient is shown 1 year following revision rhinoplasty with Dr. Rizk. The short nose is one of the most difficult deformities to correct.
54 yo female with history of severe nasal trauma to nasal bridge/nasal reconstruction. Patient has a severe saddle nose, overprojected nasal tip, deviated nasal septum, and multiple collapsed areas in external nasal valve region. Patient underwent rhinoplasty, septoplasty, as well as medpor implant placement on nasal bridge. Patient had septal cartilage grafts to external nasal valve and nasal tip as well. Patient shown 4 weeks postoperatively. Patient was given options of rib versus medpor for the nasal bridge and chose the medpor instead after the advantages and disadvantages of each were given.
26 yo female who underwent previous rhinoplasty who wanted further improvement in shape of her nose. She was unhappy with the boxy tip which was also overprojected as well has her bony bump (slight). She underwent secondary rhinoplasty with correction of the boxy tip as well as deprojection of the nasal tip (bringing it closer to her face) and reduction of the bony bump. Patient is shown 1 year after surgery.
29 yo female ethnic rhinoplasty patient with thick skin who had previous rhinoplasty who requests improvement in symmetry, breathing and definition. Patient underwent revision rhinoplasty with multiple cartilage grafts into tip and middle nasal vault to correct her breathing and cosmetic appearance. Patient is shown one year after revision rhinoplasty.
25 yo with history of previous rhinoplasty and is unhappy with scooped, short nose, with nostrils showing too much and a rotated up tip. Patient underwent revision rhinoplasty with Dr. Rizk using banked irradiated rib cartilage for grafts and Alloderm to soften the edges of the grafts. Dr. Rizk does not like to use the patient’s own rib due to scarring, risks to lung and danger to patient. Banked rib cartilage works excellent and has been used for many years in patients who are collapsed and need significant nose support. Patient is shown postoperatively at 1 year.
30 year old female who underwent previous rhinoplasty who presented to Dr. Rizk for secondary septoplasty and rhinoplasty with an inverted v deformity, collapse of her external nasal valves, a nasal hump, and a hanging columella, and pinched nasal tip. Patient had trouble breathing as well. Patient is shown 1 year after revision rhinoplasty and septoplasty with grafts to correct the collapsed middle nasal vault and external nasal valves.
30 yo female with history of chemical dependency who was concerned cosmetically with her open roof deformity, saddle nose deformity (cartilaginous saddle nose) and also her wide nasal bridge. Patient underwent revision rhinoplasty but since she had not septal cartilage available, banked rib cartilage and temporalis fascia was used as a graft to correct the saddle nose. By raising her nasal bridge and narrowing her nasal bones the brow-tip aesthetics have improved. Patient is shown 3 years after surgery.
55 year old female who underwent endonasal revision rhinoplasty for bump reduction to soften her features and improvement in her skin with laser resurfacing. Also note the nasal tip was subtly lifted to improve a slight droop.
Female patient who previously had rhinoplasty wanted to change her asymmetrical nasal tip and difficult breathing. The patient had a combined procedure septorhinoplasty performed with cartilage grafts and fascia to balance out its appearance. The photos are 1 year after the revision rhinoplasty.
NOTE: ALL THE IMAGES USED ON THIS PAGE ARE ACTUAL PATIENTS THAT DR. RIZK PERFORMED RHINOPLASTY ON WITH APPROVED CONSENT.