Secondary/Revision Rhinoplasty in New Hampshire, near Boston, Massachusetts

In my practice, I specialize in the correction of problems that have developed or worsened as a result of previous nasal surgery. I perform secondary rhinoplasty, also commonly called revision rhinoplasty, at my New Hampshire practice, near Boston, Massachusetts, to help patients who have already been through surgery one or more times and are now suffering from reduced airway function or serious cosmetic problems.

The Importance of Airway Function

Patients who have already undergone one or more disappointing operations have figured out that nasal surgery isn't as simple as it sounds. Ironically, the most common reason for malpractice suits after nasal surgery is a worsening of the ability to breathe through the nose. In my opinion, this should never occur; patients should breathe as well or better than they did before surgery. We have performed airflow measurements in more than 600 consecutive patients over the last eight years (the largest study of this type in the world), some who have never undergone surgery and many who have had multiple prior procedures. All of the patients had nasal airway obstruction before surgery, and 93 percent were able to achieve a normal airway in one operation. The remaining patients had such complicated problems (because of prior injury or surgery) that more than one operation was required.

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Secondary Rhinoplasty: Principle and Practice

The principles of "secondary rhinoplasty," or nasal surgery on a nose that has already been operated on, are very much the same as those in the primary rhinoplasty situation. It is important to consider nasal balance, function, deformities of cartilage and bone, areas that need additional support or reshaping, and to devise a safe plan that satisfies, to the greatest degree possible, the patient's aesthetic goals.

In practice, secondary (or revision) rhinoplasty, which comprises two-thirds of the nasal operations at my New Hampshire practice, near Boston, Massachusetts, is much more difficult. The nasal septum, which is the prime building material for nasal surgery, has often been partially or completely removed. The cartilage and bone that create nasal shape have already been altered and are scarred or deformed; and the skin has become thicker and less pliable. The airway is often significantly impaired.

Most importantly, the patient has already gone through one or more prior disappointing experiences, has spent money for operations that didn't achieve what he or she wanted (or has made them worse); and now needs to "start all over again." In this setting it is critical that patient and surgeon understand each other. I need to diagnose the problem and explain it to the patient, and then devise and explain a surgical plan that is most likely to achieve what the patient wishes.

Often there are several possible surgical solutions, each with a different outcome, some of which will be more complicated than others. Only by discussing each plan with the patient can he or she decide what will be most satisfactory.

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Using the Right Materials

Because the nasal septum is often missing, I often must find building materials elsewhere, always from the patient's own body. There is no substitute for the patient's own cartilage and bone. Artificial materials, like silicone, are always a bad idea in the nose, particularly the nose that has previously undergone surgery. They rarely provide a lifetime solution, and although they seem like an easier plan at first, in the overwhelming majority of cases they are ultimately doomed to fail. The patient's nasal graft may come from the cartilage of the ear, from the rib, or from the outer layer of the skull. Which donor sites are best depends upon the problem, the age of the patient, the patient's wishes, and many other factors.

Secondary rhinoplasty can be just as successful as the primary rhinoplasty, although because the initial problem is worse, there is a higher chance that second operations or minor touchups may be needed to produce the best result. In my practice, the revision rate for patients who undergo secondary rhinoplasty is about 15 percent. This is a higher number than for other surgeons, but it reflects both the expectations of my patient population and my own desire to produce the best possible result.

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Fees

The consultation fee for Secondary Rhinoplasty is $250.00. Dr. Constantian’s surgical fee for Secondary Rhinoplasty ranges from $7,800.00 to $8,500.00. The surgical fee can be $9,500.00 - $10,500.00 if rib cartilage is needed.

For patients with no insurance (cosmetic/self-pay patients), the Hospital and Anesthesia fees are approximately $3,520.00.

Because Dr. Constantian operates in a hospital setting, the hospital and anesthesia fees are not within his control and may change from time to time. If you would like more information, please call our New Hampshire office

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Common Questions about Revision Rhinoplasty

The following are some of the most common questions about secondary and revision rhinoplasty that patients ask at our New Hampshire practice, near Boston, Massachusetts. Dr. Mark Constantian has provided answers in his own words.

"Why can’t all rhinoplasties be accomplished in one operation? Why is there ever a need for a revision?"

The need for revision rhinoplasty can have several causes: inadequate diagnosis, unexpected healing, poor technique. The more experienced a surgeon is, the less commonly any of those situations occurs. After so many years performing nasal surgery, I almost always can make the diagnosis and can form a surgical plan that I have confidence will work. What I cannot control, however, is the quality of the building materials or the patient’s healing. Septal cartilage, even if present, may vary in amount or thickness. Some nasal septa are bony or distorted, or the cartilage can be too thick or too flimsy. Similarly, ear cartilage can be perfect or can be too rubbery or too small and cupped. Rib cartilage can be perfect and smooth, or can be elastic and distort easily. None of these factors can be assessed until the time of surgery. A surgeon can adjust for most variations in building materials, and often produce a very good result even with suboptimal cartilage and bone. However, surgeons are not gods, and neither control the quality of the building materials nor the way in which the patient’s nose heals. It is those factors that create a variation in the beauty, smoothness, and function of the final result.

I can estimate prior to surgery how difficult reconstruction will be based on the examination of my patient’s current nose, the prior procedures that have been performed on it, and what building materials are available and will be needed. The chance for revision is never zero, but it may vary from 5% to 25% or more depending upon the difficulty of the problem; and there are certain particularly difficult circumstances (for example, the collapsed nose produced by cocaine abuse) that almost always require more than one procedure to produce the best possible result. Whether the patient undergoes a second operation is always the patient’s choice. My goal, however, is to achieve the best result that I possibly can, and that sometimes requires more than one procedure.

"Do you use the closed approach for both primary and secondary rhinoplasty?"

Yes. If there is any perfect place to use the endonasal approach, it is in secondary rhinoplasty. While the closed approach is my preferred method for primary rhinoplasty, it has even more advantages in revision rhinoplasty, where the tissues are scarred, circulation is not normal, and the anatomy has been disrupted by the prior operation.  The closed rhinoplasty approach allows the surgeon to limit the dissection, restore function and appearance with less recovery for the patient, preserve the most circulation, and make maximal use of graft donor sites that may have already been used by the primary surgeon.  The more operations a patient has had, the more important it is to limit further damage to the circulation, limit the dissection, and have the best chance of improving the airway and appearance with limited building materials.

I completely disagree with surgeons who say that “easy” cases can be corrected by either method, the harder the case, the more important it is to use the open approach.  They have it exactly backward.  There is no biological or surgical rational for that viewpoint.  In fact, good surgical principles lead to exactly the opposite conclusion, which is why I perform the closed approach when I do.

"My nose is too long and droopy, but my surgeons have told me that I 'make too much scar tissue'. Can anything be done for me?"

As I have said elsewhere, nasal skin is more or less limited. Depending on its thickness and volume, each patient’s skin can shrink to varying degrees, but not infinitely. The patient whose nose is too long before any surgery, or whose nose becomes longer after the rhinoplasty, is similar to the person who is wearing pants or a skirt that is too long and who then loses weight (analogous to having the nasal skeleton reduced). The pants hang lower. If there is less support inside the nose, the skin also hangs. The way to lift the nose is to increase the support underneath. Paradoxically, this “enlargement” of the underlying skeleton during secondary rhinoplasty often makes the nose look smaller and better proportioned, and frequently makes significant improvements in the airway.

"My nose is too short and the nostrils are too visible; what can be done?"

The short nose is one of the most difficult rhinoplasty problems. How much the nose can be lengthened (in other words, how much the tip can be rotated downward and how much nostril visibility can be diminished) depends on the general shape of the nose, the available building materials, and, most importantly, the pliability of the nasal skin. Every time a nose is reduced, the nasal skin shrinks and becomes stiffer. Even if I could magically replace everything that has ever been removed from a nose in prior operations, the nose would not return to its original size and shape, because the skin has undergone irreversible changes in texture and volume.

Nonetheless, short noses can often be lengthened by raising the bridge (if it is too low), changing tip contour (to provide the illusion of greater length), and adding “composite grafts” (cartilage and skin grafts taken from the ear) to the inside of the nose to lower the nostril rims and decrease nostril visibility.

"I had a rhinoplasty 15 years ago. Now the tip is too sharp, the nose is much too turned up, and the nostrils are too visible from the front. Can you do a facelift at the same time?"

The problems of a bridge that is too low, a tip that is too turned up, and nostrils that are too visible are common following rhinoplasty, and are actually connected: As the surgeon reduces the height of the bridge, the nose naturally turns up at the tip; this can be worsened if the surgeon reduces the tip or shortens the nose in an attempt to make it "smaller" and more delicate.

The secondary rhinoplasty procedure can be simpler or more complex depending upon what else has been done. Because these kinds of corrections usually require building up areas that are too low or reducing nostril visibility by adding cartilage and skin to the inside of the nose, I cannot develop a surgical plan without knowing whether your septum has been removed, how big the depressed areas are, how much additional length you want, and so on. The procedure has to be customized to your individual problem and your own request, and so an examination is mandatory for a worthwhile opinion. At the time of your appointment, I will show you photographs of patients with similar problems that I have corrected by the method that I would propose.

You can get an idea of my work and my philosophy from the journal articles that I have written, listed here in the website bibliography.

If your deformity is as difficult as you describe, the nasal surgery itself will be complicated enough; I would not add a face lift at the same time.

"I have had several nasal surgeries, but my nose now looks very surgical and unnatural. I have a lot of sinus problems and my husband says that I now snore. Can you help even after all of these operations?"

The size of the airway depends upon the straightness of the nasal septum (the wall inside the nose that separates one nasal passage from the other), the turbinates (swellings on the inside of the nose that warm and humidify the air); and two sets of valves called ("internal" and "external") located in the sides of the nose, which may be naturally weak or may become weak after nasal surgery. Often patients do not recognize how bad their breathing is because they have gotten used to it. Frequently sinus problems and snoring are related to a bad airway (although there may be other causes as well). Revision rhinoplasty can not only improve airflow through the nose, but also symptoms such as snoring, sinus problems and the symptoms of seasonal allergies as well.

A "surgical appearance" to the nose can be the result of many factors, but it is important to remember that nasal surgery is very difficult and that healing is unpredictable. By trying to achieve a "smaller nose" and a better shape, the nose may have healed in a way that shows irregularities, sharp edges, looks too short or too long or is too wide or narrow at the tip. Many of these problems can be improved with revision, or secondary, rhinoplasty at our practice, serving the Boston, Massachusetts and New Hampshire region, by removing the distorting parts of the skeleton and adding new support (using the patient's own cartilage and bone as needed) to rebuild a more normal shape.

"I had an operation to make my nose look smaller but now it seems fatter, rounder, and bigger at the end. The doctors say that I have 'scar tissue' under my nasal skin and they can't help me. Can I be helped?"

The traditional idea about nasal surgery has been that the surgeon can reduce the skeleton and that the skin will shrink to that smaller size and better shape. However, the "shrinkability" of the skin depends a great deal on its thickness and is often much less than surgeons recognize. Nevertheless, patients can often obtain much better appearing noses with more contour and balance and a nose that actually looks smaller, even when the skin cannot shrink very much. Well-shaped noses look good because of the shape that the underlying cartilage and bone creates in the skin, not because of the skin shape itself. The answer is to support the skin differently by removing cartilage and bone where it is excessive (reducing the nose), and then adding cartilage to improve the shape and balance.

The nasal airway often becomes worse after surgery because reduction of the skeleton has made the valves weaker. During secondary rhinoplasty, this structure can be replaced by using the patient's own cartilage and the airway can be improved, frequently beyond what it was before surgery.

"I had nose surgery to make my nose look better, but instead my breathing got worse and my nose looks worse. I have had two operations to fix a 'deviated septum' and I still can't breathe. The doctors say it is all in my head. Am I crazy?"

Just as or perhaps even more important to the airway as a deviated septum (and perhaps even more important) is the stability of the sides of the nose. If the sides are naturally weak, or have been weakened by surgery, the airway can be bad even if the septum is straight. When doctors examine the nose, the septum may look straight and the air passages may appear wide open, but often the sides of the nose will collapse when the patient breathes in. The collapse occurs because of weakness in any of four nasal valves; this weakness can be corrected surgically by cartilage grafts. There are two sets of valves; our research has shown that correcting airway obstruction at either one generally doubles airflow. When both sets of valves are not working and reconstruction is done, airflow can increase three or four times over what it was before surgery.

"What if Dr. Constantian can't help me at all?"

There are some patients whose noses are already as good as they can get. This does not mean that they are perfect, but rather that there is no current surgical procedure that will improve them.

There are occasionally patients whose goals simply cannot be achieved: For example, the patient with the perfectly shaped nose that the patient still believes is too large often cannot be helped. Nasal skin size is limited and is an individual characteristic, like height or eye color. No patient has the option of having the best possible nasal shape and airway in several different sizes. There is one size that gives an optimal result; smaller versions are either more poorly shaped, distorted, or have smaller airways. For some patients, the goals that they have in their minds are not surgically possible.

All this having been said, it is rare that I cannot think of some way to help a patient regain an airway or a better nasal shape through revision rhinoplasty. The solutions that I can conceive, however, may not achieve what the patient wants or may involve more stages or a more complex reconstruction than the patient would ideally like. That is why examination and thorough discussion here in the office is so important, not only so that I can understand exactly what the patient wishes, but so that the patient can understand what is possible and what is not, and how much of his or her goals I can realistically achieve.

"I have undergone two prior nasal surgeries. I had an implant put in to give my nose shape, then had the implant taken out because it was too big.  Now most of the support in my nose has disappeared. I have already spent too much money and if I do another surgery, I want it to be successful. Can you advise me on a specialist here in the South, where I live?"

Your problem is not uncommon. The most frequent complaint patients have about their prior rhinoplasties is that too much was taken out. Unfortunately, artificial implants are not good solutions because they move, don't create very good contours, and often become infected or have to be removed. Your best solution is rebuilding the nose with your own cartilage or bone.

Many patients are in your position, having spent a great deal of money and now wanting a solution that is really going to be right. It is important that you select a surgeon that will give you a good plan and has experience in this specialty.

I can only recommend the work of surgeons whom I have heard speak or whose writings I have read. Unfortunately, there are not many surgeons who teach and write about secondary rhinoplasty, although there may be many others who do it well but who never publish their ideas. Therefore, I know no one in your specific area, but can recommend others in cities around the country. You should definitely see an experienced surgeon so that you maximize your chances of success in the next operation.

"I have had three previous rhinoplasty operations. I have reservations about undergoing further surgery. I am happy to send photographs or have an initial phone conversation, but after having had phone consultations with other surgeons, I would prefer to meet face to face even though I would be traveling from overseas. Can you send me consultation and hotel information?"

You are very right that satisfying your questions and concerns before surgery (rather than afterward) is extremely important. This can only be done accurately by consultation, initially by corresponding by mail, and then by coming to the office for an appointment.  We often assist patients with airport and airline suggestions, transportation, along with hotel information. To begin the long-distance consultation process, follow the instructions provided on our At-home Consultations page. Hotel and travel information is included on our "Where's Nashua?" page.

"I would be willing to travel for the procedure, but I could not see you for a consultation. Can you consult via email?"

Follow the "At-home Consultation" protocol.  Remember that my advice can only be as good as your photographs!  After receiving my answer, some patients wish to come for a consultation in addition, and some schedule surgery directly.

"I had a rhinoplasty to correct a broken bridge from a previous surgery. Now the tip looks even bigger, fat, and unattractive. The plastic surgeon swears that he reduced it and says that this could be scar tissue. I have heard that steroid shots can be used. Do you have any ideas about what can be done?"

Frequently, surgeons try to make a tip smaller by reducing the cartilage inside it. As the nose heals, the loose nasal skin in the tip shrinks, which makes the tip look rounder, thicker, and "bigger." In fact, there is less cartilage underneath, but because the tip is rounder and has less shape, it looks "bigger." If this is the case, the problem is not that you formed scar tissue or that you need steroid injections. The way to fix your tip is to recreate the shape that you would prefer by replacing cartilage (from your septum, ear, or somewhere else), which will give the tip of the nose a better shape, and often make it look narrower, and usually much more refined.

"Can a nose that has been shortened after a rhinoplasty be lengthened? I think a normal nose should only have a glimpse of nostrils from the front; mine now have more than this and they are now a different size and shape. Can anything be done?"

Yes, the nose can be lengthened after a prior surgery; how much depends upon what has been done, what building materials are available (that is, septum, ear, rib) and how loose the nasal skin is. The more the nose has been reduced, and the more the skin has shrunk, the less length can be regained. However, something can almost always be done, but it is important that the patient understand what realistic goals are and how complex the secondary rhinoplasty surgery will be. I can only give you an honest opinion by examining you and finding out what you would like to achieve.

"If things aren't perfect, how soon can I have a touch-up?"

I like to wait until “the ground stops moving.”  Things that may not look good early on often improve, and occasionally a problem arises that was not apparent early.  Even if I see something in the first few months after surgery that I would like to change, I will still wait because something else may or may not appear, and I would like to fix everything at once.  Further, the tissues have to become soft enough that the revision rhinoplasty surgery can be done safely and so that the skin will cooperate and permit me to make the types of changes that I would like.  It is difficult to be patient when waiting for a nose to heal, but it is much worse to be impatient.

Fees

Consultation fee: $250

Surgical fee: $7,900 to $10,500 ($9,500 to $14,500 or higher if rib cartilage or time-consuming procedures are needed)

Hospital and anesthesia fees (for cosmetic/self-pay patients): Approximately $3,520

Contact Our Practice

If your previous nasal surgery has left you with breathing problems or an unsatisfactory cosmetic appearance and you are considering undergoing secondary (revision) rhinoplasty, please contact our New Hampshire practice, convenient to the Boston, Massachusetts area.

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If you are interested in secondary (revision) rhinoplasty, contact our New Hampshire practice, convenient to the Boston, Massachusetts area, to schedule a consultation with Dr. Constantian.

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Mark B. Constantian, M.D., F.A.C.S.
19 Tyler Street, Suite 302
Memorial Medical Building
Nashua, New Hampshire 03060, USA
Phone: 603.880.7700