SECONDARY RHINOPLASTY
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 350 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.

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 rhinoplasty, which comprises two-thirds of my nasal operations, 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.

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 cartilage may come from 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.