19 Dec Revision Rhinoplasty: The Ultimate Guide Part 2
WHERE DOES THE FIRST RHINOPLASTY GO WRONG?
This is a broad question, but one of the overwhelming contributors to a bad outcome is infection after surgery. It can often go unnoticed both by patient and surgeons as the signs are sometimes mild and can be confused with normal postoperative healing. There are a few important factors here – the first is that a rhinoplasty is not a sterile surgery and so infection afterwards is definitely possible. The inside of the nostrils and nose cannot be sterilized completely and the surgery is classified in medical parlance as a “clean, contaminated” surgical field. The second is that infection has a direct effect on wound healing, and healing of the surgical spaces, leading to powerful contracting forces that can significantly distort the position of the tissues.
This has a lot of implications for the patient. For example this is why the surgeon will administer antibiotic intravenously prior to any incisions being made. It also means that good postoperative follow up is critical. This is one reason why traveling for surgery can sometimes be challenging as it makes follow up more difficult. In my practice I am very aggressive about managing potential infections to preserve the intended outcome.
Another historically important reason why the first rhinoplasty goes wrong is essentially outdated techniques. It used to be that surgeons saw a nose that was large, and concluded the solution was to remove structures, cartilage, bone etc. This resulted in a smaller nose, but over time many problems were likely to arise. The tip especially has a very three-dimensional structure and simple removal of cartilage leads to a pinched configuration and a loss of support, rather than a tip that looks natural but just smaller. Even worse, loss of support not only creates aesthetic deformity, but almost always leads to a loss of the breathing function of the nose. This is a compound problem with miserable results. Thankfully newer ideas such as “preservation” and “structural” concepts in modern rhinoplasty have helped to prevent this kind of problem, where surgeons are now trained rigorously on the important functions of the nose and techniques to preserve or enhance them.