Revision rhinoplasty, also referred to as corrective or secondary nose job, deals with deformity of varying degree. In general, mild asymmetries such as small residual hump along the profile are best addressed after 6-18 months postop; the idea is to wait for all the residual swelling to subside.
Waiting is also ideal for patients with a markedly thick skin that makes them susceptible to protracted postop swelling in order to achieve a more favorable outcome, as suggested by leading Beverly Hills plastic surgeon Dr. Tarick Smiley.
Postponing revision rhinoplasty also ensures that the skin has fully shrink-wrapped to the new contour, and the patient becomes more “objective” in assessing the surgery’s results. Simply put, waiting prevents anyone from making hasty decision that could lead to more problems and frustrations.
However, there is no reason to wait when the issue involves gross deformities and abnormalities, especially when there is very little chance that they will improve even after all the swelling has dissipated. This is particularly true for twisted nose, collapsed appearance, and polly beak (the nose resembles a parrot’s beak due to its excessive convexity).
Function-related problems are also best addressed sooner than later to prevent further suffering.
In addition, patients with significant swelling caused by aggressive scar tissue inside the nose are best treated with steroid (Kenalog) injection as soon as possible, provided that the nasal framework is sturdy.
Steroid injection is commonly used in the supratip (right above the tip) to reduce persistent swelling, which is not uncommon in patients with thick nasal skin. However, the treatment should be used sparingly (i.e., highly diluted form and at intervals of 4-6 weeks) to minimize risk of skin depression, skin discoloration, and abnormal blood vessel formation.
In summary, the right or ideal timing for revision rhinoplasty will depend on many factors such as skin thickness, degree and type of abnormality or deformity, amount of postop swelling, stability of the framework, and presence of function-related problems. Simply put, the “usual” guideline of waiting 6-18 months is not always justified.
Corrective liposuction often deals with bumps and dents whose underlying cause may involve fibrosis (hardened fluids during the recovery process or internal scar tissue), under- or over-correction, use of large cannulas, or a combination of these factors, according to the California Surgical Institute website.
It is almost always a prerequisite to use microcannula, or narrow suction tube whose outside diameter is 2.5 mm or less, when doing some type of corrective liposuction surgery. Large cannulas, meanwhile, are best avoided because they offer less precision as they remove fats in bigger chunks.
For additional accuracy, leading Beverly Hills plastic surgeon Dr. Tarick Smiley may recommend power-assisted liposuction (PAL) in which the microcannula releases tiny, accurate vibrations to break up the fat prior to its extraction. For this reason, the technique is also highly ideal for removing fibrous fats, which are typically found in the back, flanks, upper abdomen, and male breasts.
During a corrective liposuction surgery, it becomes more important than ever to preserve a residual layer of fat right beneath the skin, with its blood vessels intact. Not only does it ensure a smooth skin surface, but it also reduces the amount of postop swelling and bruising.
Furthermore, the use of gentler liposuction techniques, which have become possible thanks to microcannulas and probes that release accurate vibrations, can also prevent excessive internal scarring.
Some doctors avoid ultrasound- and laser-assisted liposuction techniques when doing revisions because the thermal energy could increase the amount of surgical trauma and possibly the risk of bumps and dents as well.
While internal scarring typically resolves on its own as the patient moves forward to her recovery, when there is too much of this (usually due to aggressive liposuction techniques) it would be difficult if not impossible to achieve smooth results from surgery.
How long the microcannula stays in the area will also determine the surface of skin. A good rule of thumb is to move it at a relatively quick pace to prevent inadvertent over-removal of fats. When too much fat is removed, the affected area would collapse to the point that the skin would resemble a “Swiss” cheese.
Occasionally, corrective liposuction entails the use of fat transfer, which essentially is a liposuction in reverse. Doctors collect donor fats from one area of the body, remove all the impurities, and re-inject the highly purified fats into the area with skin asymmetries caused by over-correction.
While revisions often produce good results, it is important to wait for at least six months or until all the swelling has resolved, the internal scar tissue has “soften,” and the skin has shrink-wrapped around the new contour.
Medical literature suggests the revision otoplasty rate has a wide variance, from 0.6 percent to 11 percent. Nevertheless, most patients who need it only require minor corrections involving asymmetry (i.e., “noticeable” difference in the projection between the two sides), under-correction, and scarring.
However, there are various ways to achieve long-lasting and more predictable results from otoplasty and thus minimize the revision otoplasty rate.
Leading Los Angeles plastic surgeon Dr. Tarick Smiley has explained his techniques that help him achieve high patient satisfaction.
- Remove the “offending” cartilage
Some surgeons simply excise some skin and rely heavily on internal sutures to pin back the ears. Dr. Smiley says this “approach” may not provide long-lasting results because the cartilage—a firm but flexible tissue that holds and determines the ear shape—has a rather “strong memory.”
To achieve results that can persist long term, Dr. Smiley highlights the importance of removing and/or “weakening” a small amount of cartilage, in addition to the use of correct suturing techniques.
- Wait until ear growth is near complete
While otoplasty can be performed as early as two years of age, waiting until the patient reaches five offers some unique advantages since during this period ear growth is near complete (about 90 percent). This makes it easier for surgeons to assess the ideal projection of the ear, and deliver results that will most likely last a lifetime.
- Importance of scar placement and wound closure
The incision must lie precisely at the ear-scalp junction for optimal scar concealment. Furthermore, it should be closed in several layers so the skin surface will receive no or very little tension, leading to more “favorable” scarring.
Medical literature suggests that a good number of patients seeking revision otoplasty want to hide or at least improve the appearance of their scars.
Poor scarring from otoplasty is sometimes linked to infection, which can be avoided by taking antibiotics, performing proper wound care, avoiding tobacco products and aspirin (and other blood thinners), and reaching one’s optimal health prior to surgery.
Revision BBL, which is an acronym for Brazilian butt lift, poses unique challenges although with proper patient selection, correct timing, meticulous surgical execution, and 100 percent patient participation (e.g., avoiding direct sitting at least three weeks postop), good results can be achieved.
Renowned Los Angeles plastic surgeon Dr. Tarick Smiley has recently posted a Snapchat video to demonstrate the challenges of revision BBL and the corresponding ways to “counteract” them, ultimately delivering an improved “backside” in terms of shape and size.
The female patient shown in the video not just complained about the minimal improvement of the buttocks from the two previous BBLs, but also the indentations around the abdomen, which was previously used as a donor site.
In BBL, the donor sites refer to areas treated by liposuction to collect the “unwanted” fats, which are later purified and re-injected into the patient’s backside.
Dr. Smiley said the visible indentations in the abdomen were caused by a combination of under- and over-liposuction.
In the video, the celebrity plastic surgeon was shown using a microcannula, a stainless steel tube with an outside diameter less than 2.5 mm, allowing him to remove smaller bits of fats. Large cannulas, meanwhile, were not ideal for revision liposuction because they give little control as they suction out fats in larger chunks, he explained.
Aside from using microcannulas, Dr. Smiley was also seen injecting a small amount of fat to further smooth out the indentations in the patient’s abdomen.
Dr. Smiley said it is of critical importance to maintain enough fats beneath the skin during liposuction to preserve a smooth surface and avoid “surgical stigmata” usually in the form of dents, bumps, and sagging appearance.
After removing the excess fats through microcannula liposuction, and making sure that all the abdominal indentations from the previous surgeries were eliminated, Dr. Smiley then proceeded with the revision BBL.
With proper purification and re-injection of the “best and healthiest” fats, Dr. Smiley said that up to 70 percent of injected volume is expected to survive long term in the buttocks.
Facelift revision cost will vary depending on the amount of correction one needs. Also, revisions do not always deal with botched results due to technical errors during surgery; occasionally, issues may arise because of poor healing and continuous aging.
Nonetheless, major revisions are rarely an issue when the surgery is performed by a board-certified facial plastic surgeon who conducts facelift and its ancillary procedures on a regular basis.
Due to differences in healing, some facelift patients may need minor revisions. Oftentimes, surgeons revise their own work for minimal fees, some even waive their professional fees, although they will still charge for the anesthesia and the operating room.
A good number of facelift revisions deal with improving the appearance of scars. It is important to note that the incision lines must curve around the ear’s contours and remain hidden behind the hairline. While scars generally fade and stay hidden, due to unexpected healing a few patients may have their scars slightly revised.
However, major revisions are almost always caused by poor surgical execution. For this reason, a prudent patient should select her plastic surgeon based on experience, training, and other relevant qualifications, as opposed to shopping around to get the cheapest bargain deals.
As of this writing, the average cost of facelift is $6,000-$7,000, although it could be more expensive when combined with other procedures such as fat transfer, eyelid surgery, etc.
When one charges way below the “standard price,” it is almost always a sign that patient safety has been compromised—i.e., the surgery is not performed at an accredited surgical facility, the anesthesia is not administered by a licensed anesthesiologist, etc.
Leading Los Angeles plastic surgery expert Dr. Tarick Smiley warns patients that “non-specialists” offering facelift has high “major” revision rate, while board certified plastic surgeons have very low complication rate, a “trend” which has been shown by several studies.
Facelift revision cost can be more expensive when it deals with major corrections—e.g., pleating along the jawline, overly tight mid face, “flattened” cheeks, and other types of facial distortion.
Occasionally, facelift revision could simply mean non-surgical touch-ups in the form of dermal fillers and Botox.
Standard fillers such as Restylane and Juvederm can address soft tissue shrinkage that causes hollowed eyes, deep tear trough, and gaunt cheeks. They typically cost between $600 and $800, depending on the injection sites.
The average cost of Botox, meanwhile, is $300-$500.
Revision rhinoplasty nose tip, aka, secondary or correction nose surgery involving the tip, is a highly customized procedure to ensure high patient satisfaction, according to California Surgical Institute website.
While rhinoplasty is supposed to provide near permanent results, medical literature has suggested that 10-15 percent of patients will require some type of revision. Contrary to popular belief, technical error is not always the culprit; unexpected changes during healing and other factors that are beyond the surgeon’s control do occur and may warrant a corrective surgery.
Furthermore, not every revision rhinonplasty nose tip is an extensive one. Some patients just require minor correction, which typically entails a shorter downtime.
For patients who require minor corrections, the closed technique is generally favorable; this uses incisions that are placed within the inner lining of the nostrils, thus avoiding the risk of visible scars.
However, patients who have severe deformity or require a great deal of work will generally need the open rhinoplasty technique that offers their surgeons better visibility as it allows them to lift the “roof” of the nose by cutting the strip of tissue between the nostrils.
It is important to note that open rhinoplasty results in more bleeding, surgical trauma, and “disturbance” that it typically entails longer recovery than the closed method.
The specific surgical maneuver during a revision rhinoplasty nose tip will largely depend on the patient’s cosmetic concerns, underlying anatomies, gender, and ethnicity. In this procedure, there might be a need to change the angle of tip rotation, its projection or vertical height, and/or its width.
In female rhinoplasty, it is ideal to create a slightly upturned tip appearance (about 95 to 108 degrees angle of rotation), while in men a straighter profile (or even a minimal droop) is deemed more appropriate.
Aside from gender, one’s ethnicity will also dictate the ideal tip appearance. For instance, patients of African and Asian background should not have their tip significantly narrowed lest the results would appear ethnically inconsistent with their facial features.
Of course, good patient-doctor communications will also play a critical role in achieving results that will satisfy both parties.