Revision rhinoplasty

Between 5% and 15% of rhinoplasties are done again, and the published series say the second operation is a different problem from the first: the cartilage is gone, the skin is scarred and less able to survive, and the airway is usually part of the complaint. The commonest reasons for coming back, too little tip rotation, a hanging columella and fullness above the tip, trace to technique choices made in the primary. The literature is almost entirely single-surgeon and retrospective, and its strongest finding is preventive: which patients will return can be partly predicted before the first operation.

181papers on file 38this page is written from 9journals, 2011–2026 41open access, full text 145with a plain-language summary

Where these 181 papers were published

52Plastic and Reconstructive SurgeryPlast Reconstr Surg
32Aesthetic Plastic SurgeryAesthetic Plast Surg
27Facial Plastic SurgeryFacial Plast Surg
21Aesthetic Surgery JournalAesthet Surg J
17Plastic and Reconstructive Surgery Global OpenPlast Reconstr Surg Glob Open
11Facial Plastic Surgery Clinics of North AmericaFacial Plast Surg Clin North Am
10Facial Plastic Surgery and Aesthetic MedicineFacial Plast Surg Aesthet Med
7JAMA Facial Plastic SurgeryJAMA Facial Plast Surg
4Clinics in Plastic SurgeryClin Plast Surg

22011 102012 112013 122014 32015 132016 82017 122018 52019 72020 172021 162022 132023 132024 122025 272026

27 further papers on this topic came in through the history rather than the archive query: Millard DR 1969, Sheen JH 1975, Farkas LG 1985, Gunter JP 1987 and 23 more. They are counted on the landmark papers, not here.

What repeats

Six findings reported by independent groups in different countries. Each card carries the papers it rests on.

10.8% came back, and the three commonest reasons were the same three

Screening 252 revisions after open rhinoplasty in one practice, the revision rate was 10.8% and the reasons clustered: insufficient tip rotation (37.7%), hanging columella (30.2%) and supratip deformity (28.6%). The regression is the useful part. Using a columellar strut instead of a tongue-in-groove fixation multiplied the risk of inadequate rotation 5.3-fold, of hanging columella 5.9-fold and of supratip deformity 2.2-fold; being over 40 multiplied hanging columella 6.8-fold, and low tip projection before surgery doubled the rotation risk. Most of this list is decided in the first operation, not discovered in the second.

Rests on: Sibar et al., 252 revisions and their risk factors.

The revision patient usually cannot breathe either

Reviewing 46 consecutive revisions whose main complaint was obstruction, 91.3% had airway obstruction from a deviated septum or nasal valve dysfunction; grafts were placed in 89.1%, septoplasty done in 76.1%, lateral wall support in 47.8% and spreader grafts in 39.1%, and the obstruction score improved from the first month. Purely cosmetic revision is the minority presentation in the published series. The same pattern holds in cleft patients: secondary cleft rhinoplasty improved obstruction scores, with lateral crural strut grafting associated with the improvement and alar revision associated with the opposite.

Rests on: Goudakos et al., 46 revisions with obstruction · Carlson et al., airway after secondary cleft rhinoplasty.

The second operation runs out of cartilage, and rib is the answer

Septal cartilage is usually gone by the revision, so the question is where the framework comes from. Fresh frozen homologous rib in 226 revisions over nine years gave a 2.7% infection rate, most managed with antibiotics alone; a separate 123-case series reported 2.4% infection and 0.8% resorption with improvement across every patient-reported measure; non-irradiated homologous rib in 26 patients gave a 3.6% graft complication rate with no warping. Autologous rib warps, and one series found the external cause: an incompletely removed hump underneath, bending the graft in the sagittal plane. Layered constructions built to defeat warping (perichondrium, rib lamina and fascia in one sandwich) are now reported in more than 300 cases by a single surgeon.

Rests on: Rohrich et al., 226 fresh frozen rib revisions · Taylor and Barrera, 123 cases · Rogal et al., non-irradiated homologous rib · Xu et al., why cartilage warps · Robotti et al., the SPLF graft in 300 cases.

The nose contracted around a silicone implant is a category of its own

In East Asian practice the commonest revision is not a reduction gone wrong but an implant that has to come out, leaving a short, hard, contracted nose. Three answers are published. Cross-linked acellular dermal matrix for the dorsum with autologous cartilage at the tip in 56 patients moved outcome scores from 31.7 to 81.4 at a year, with one infection and three excessive resorptions. Molded, glued diced costal cartilage in 28 patients after failed silicone was rated good or excellent in 91.1%. And adipose-derived stromal vascular fraction injected around a severely contracted nose lengthened it more than saline in a controlled comparison of 40 patients.

Rests on: Kook et al., acellular dermal matrix in 56 · Fung et al., glued diced cartilage after silicone · Ahn et al., stromal vascular fraction for contracture.

The skin is the tissue that limits the operation

Of 384 open rhinoplasties by one surgeon, 27 (7%) developed skin compromise needing unplanned treatment, and 25 of those 27 were revisions. Age, smoking and the number of previous operations all predicted it, and the revision rate in that group was 22.2%. Two other findings point the same way: bacterial biofilms and persister cells were found in nasal soft tissue in revision patients with no implant present, and Semmes-Weinstein testing showed revision patients still had reduced sensation at the tip, infratip and columellar base at twelve months, where primary patients had recovered.

Rests on: Irvine et al., skin compromise in 384 rhinoplasties · Kao et al., biofilms in revision tissue · Akyigit et al., sensation at twelve months.

Who will come back is partly visible before the first operation

One question on a validated survey, decreased mood and self-esteem because of my nose, separated a 16.7% to 18.8% revision rate from a 0% revision rate in 148 cosmetic patients. Patients carrying a psychiatric diagnosis went on to a further operation at 18% against 12% in a 961-patient institutional cohort. And aesthetic satisfaction sits below aesthetic expectation at every interval past a year, while functional satisfaction exceeds it. A revision request is often an expectation that was never matched, which is why the staging systems proposed for revision include a category for the patient's expectations alongside the anatomy.

Rests on: Okland et al., nasal self-esteem predicts revision · Tie et al., psychiatric diagnoses and revision · Kandathil et al., expectation against satisfaction · Rodman and Kridel, a staging system · and the psychology of rhinoplasty.

By problem

Revision is not one operation. What the papers on file report for each presenting problem.

Rotation, projection and the hanging columella

The three commonest aesthetic reasons for a second operation, and the ones most clearly traceable to the first. Fixing the tip to the septum, the tongue-in-groove, carried lower risk than a floating strut across all three in the 252-case analysis. Where the tip has to be rebuilt rather than repositioned, a Y-shaped auricular strut raised the nasolabial angle in 37 primary and revision patients with no negative outcomes in the revision group.

Key papers: Sibar et al. · Martino et al., Y-columellar strut.

The dorsum: irregularity, warping and the saddle nose

Rebuilding a dorsum that has been over-resected or has warped is the technical centre of revision. Solid rib warps and diced cartilage in fascia loses definition, which is the argument for layered constructions; an embed-in graft is described specifically to rescue cartilage that has already warped. For the collapsed dorsum, a 60-patient algorithm sorts saddle deformity into four types by severity, notes septal perforation in 10% and lining condition as decisive, and reports the first use of hyaluronic acid filler to expand contracted skin before reconstructing under it.

Key papers: Robotti et al. · Robotti et al., refinements · Xu et al. · Battista et al., saddle nose algorithm.

The contracted nose after an implant

Silicone augmentation with tip work is the commonest primary operation in parts of Asia, and its failures (capsular contracture, a short hard nose, notching, pinching, alar retraction, external valve collapse) are the commonest revision there. The published sequence is remove the implant, the capsule and the scar, then rebuild the dorsum with autologous or biological material and the tip with cartilage.

Key papers: Kook et al., acellular dermal matrix · Fung et al. · Ahn et al. · Kook et al., lateral crural strut in 37 secondary cases.

Tip deformities after previous tip surgery

Notching, pinching, retraction, deviation, cephalic malposition. Lateral crural strut grafts corrected all of these subgroups in 37 Asian secondary cases, with the largest gain in lateral crural deformities and the smallest in tip deviation. Repositioning and reconstructing the lateral crus in 42 revisions improved obstruction and cosmesis scores at three and eleven months and improved measured sidewall collapse.

Key papers: Kook et al. · Abdelhamid et al., repositioning in 42 revisions.

Alar retraction, the nostril and the columella

Alar retraction is prevented and treated with a lining graft (42 patients, no extrusion or collapse at a year or more), and a wide or asymmetric base is reduced in two sequential steps in 423 primary and secondary patients. For an actual columellar defect after trauma or surgery, a philtral flap with rib reconstruction in 14 patients improved both breathing and appearance scores.

Key papers: Pozzi et al., alar base lining graft · Pozzi et al., sequential alar base resection · Bastaninejad et al., philtral flap.

The cleft nose, where secondary surgery is the plan

A cleft nose is operated on in childhood and again at skeletal maturity, so "revision" here is a stage rather than a failure. A systematic review of 25 studies found primary rhinoplasty at the time of cleft lip repair did not restrict nasal growth in eight of nine studies that looked, and between 43% and 100% of those patients avoided a later revision. At maturity, a septal extension graft with a reverse-U incision moved 194 unilateral and 92 bilateral cleft noses measurably toward matched normal controls, with a 4% complication rate in the bilateral series. A 276-patient classification of nasal sill shape gives the base-view deformity a common language.

Key papers: Zelko et al., primary cleft rhinoplasty reviewed · Saito et al., 194 unilateral cases · Saito et al., 92 bilateral cases · Liu et al., the Tajima technique at five years · Xia et al., nasal sill classification.

The revision that is not surgery

Filler, used deliberately as a structural correction of a postsurgical nose rather than as a cosmetic top-up: 1,122 post-rhinoplasty patients over twenty years, 2.8% complications, all minor and transient, 92% satisfaction. It is the largest secondary series on file by patient count, from a single practice, and it treats contour rather than structure or airway.

Key paper: Valente and Zanella, secondary liquid rhinoplasty in 1,122 patients.

The terms, defined

Every term the papers above use to mean something specific, in plain language.

Revision, secondary, tertiary: the second operation on a nose and everything after it. "Secondary" is the surgeon's word, "revision" the patient's; in cleft care a secondary rhinoplasty is a planned stage rather than a failure. [34550928, 37797231]
PGS staging: a proposed system that grades a revision by problem, number of grafts required and number of previous operations, with a separate category for the patient's expectations, so two surgeons can describe the same difficulty. [27149684]
Tongue-in-groove: fixing the medial crura onto the caudal septum rather than propping them on a floating strut. Lower risk of under-rotation, hanging columella and supratip fullness in the 252-case analysis. [34550928]
Hanging columella: the columella hanging below the alar rims on profile, one of the three commonest reasons for revision. [34550928]
Supratip deformity (pollybeak): fullness above the tip, from scar or from an under-corrected cartilaginous dorsum. [34550928]
Homologous costal cartilage: cadaveric rib, supplied fresh frozen, irradiated or minimally irradiated. It avoids a chest incision; the series on file report infection rates of 2.4% to 2.7%. [35511072, 40674713, 32522045]
Warping: the tendency of a carved rib graft to bend after implantation. One cause identified from outside the graft: a hump left in place beneath it. [36656674]
Diced cartilage in fascia (DCF): cartilage cut small and wrapped, used to build a dorsum that shows no edges; criticised for losing definition, which is the argument for layered alternatives. [40826294, 37289986]
SPLF graft: a sandwich of perichondrium, a rib lamina and rectus fascia placed as one unit on the dorsum; reported in over 300 revision cases by its originator. [40826294, 42012848]
Acellular dermal matrix (ADM): processed donor dermis used as a dorsal filler in place of an implant, particularly after silicone removal. [36728206]
Stromal vascular fraction (SVF): the cell fraction separated from the patient's own fat, injected to soften and lengthen a scarred, contracted nose. [33620926]
Capsular contracture and the contracted nose: the scar capsule around a silicone implant tightening, shortening and hardening the nose; the commonest revision problem in East Asian series. [36728206, 40920505]
Saddle nose: collapse of the dorsum from lost septal support, graded here in four types, with the mucosal lining and skin condition deciding what can be rebuilt. [42324394]
Biofilm and persister cells: bacteria living in a matrix on tissue, tolerant of antibiotics; found in revision patients' soft tissue with no implant present. [35724255]
Skin compromise: impaired blood supply to the nasal skin during or after surgery. 7% of one 384-case series, and 25 of those 27 patients were revisions. [33054380]
Lateral wall insufficiency (LWI): graded collapse of the sidewall on inspiration, scored by zone before and after repositioning. [37115534]
Tajima reverse-U incision: the standard incision for the secondary cleft nose, most effective in children aged 4 to 13 with mild to moderate deformity at five years. [38967637]
Nasal stenting: a splint kept in the nostril after cleft rhinoplasty; associated with less reported trouble breathing afterwards. [36696324]
Digital osteotomy: refracturing along a previous osteotomy line with finger pressure rather than an osteotome, to avoid creating dead space in a revision. [36877619]

The papers this rests on

The 38 papers everything above was written from. Every one links to its abstract, its authors and its DOI.

APS
Reconstructive Approach to Saddle Nose Deformity: A Diagnostic-Therapeutic Algorithm and the Preoperative Use of Hyaluronic Acid Filler for Skin Expansion in Rhinoplasty
Battista RA, Ferraro M, Nobile A et al.

2026PMID 42324394Summary
APS
The Evolution of the SPF-SPLF Graft in Rebuilding the Dorsum in Revision Rhinoplasty-an Update in an Over 300 Case Series
Robotti E, Clauss A, De Bernardis R et al.

2026PMID 40826294Summary
APS
A Novel Classification of Nasal Sill Morphology Provides Strategies for Secondary Cleft Rhinoplasty
Xia Y, Yuan J, Wang Z et al.

2025PMID 39572464Summary
APS
Preoperative Desmopressin for Bleeding Reduction During Rhinoplasty: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
Gutierrez RWH, Gobbo HR, Fujimura Júnior AY et al.

2025PMID 40456991Summary
PRS
Primary Cleft Rhinoplasty: A Systematic Review of Results, Growth Restriction, and Avoiding Secondary Rhinoplasty
Zelko I, Zielinski E, Santiago CN et al.

2023PMID 36409217Summary
PRS
Revision Rhinoplasty after Open Rhinoplasty: Lessons from 252 Cases and Analysis of Risk Factors
Sibar S, Findikcioglu K, Pasinlioglu B

2021PMID 34550928Summary
PRS
Evaluation of Preoperative and Postoperative Patient Satisfaction and Quality of Life in Patients Undergoing Rhinoplasty: A Systematic Review and Meta-Analysis
Yang F, Liu Y, Xiao H et al.

2018PMID 29135891Summary
FPS
Revision Rhinoplasty: Retrospective Chart Review Analysis of Deformities and Surgical Maneuvers in Patients with Nasal Airway Obstruction-Five Years of Experience
Goudakos JK, Daskalakis D, Patel K

2017PMID 28571072Summary
FPS
Evolution of Preoperative Rhinoplasty Consult by Computer Imaging
Lekakis G, Claes P, Hamilton GS 3rd et al.

2016PMID 26862968Summary
FPS
Three-Dimensional Surface Imaging and the Continuous Evolution of Preoperative and Postoperative Assessment in Rhinoplasty
Lekakis G, Claes P, Hamilton GS 3rd et al.

2016PMID 26862969Summary
JAMA FPS
A Staging System for Revision Rhinoplasty: A Review
Rodman R, Kridel R

2016PMID 27149684Summary
ASJ
Preoperative Serotonin Antidepressants Are Associated With Increased Postoperative Complications Following Rhinoplasty: A Propensity Score-Matched Analysis
Zontag N, Skorochod R, Wolf Y

2026PMID 41672725Summary
ASJ
Secondary Liquid Rhinoplasty: Challenges, Techniques, and Long-term Outcomes
Valente DS, Zanella RK

2026PMID 41124352Summary
APS
Columella Reconstruction Using the Philtral Flap in Patients with Columellar Deformity in Revision Rhinoplasty
Bastaninejad S, Kanani B, Ferreira MG et al.

2026PMID 41731229Summary
PRS
Surgical and Patient-Reported Outcomes of Fresh Frozen Homologous Costal Cartilage in Primary, Revision, and Functional Rhinoplasty
Taylor CM, Barrera JE

2026PMID 40674713Summary
PRS
Fresh Frozen Rib Cartilage Grafts in Revision Rhinoplasty: A 9-Year Experience
Rohrich RJ, Abraham J, Alleyne B et al.

2022PMID 35511072Summary
FPSAM
Safety and Efficacy of Non- and Minimally Irradiated Homologous Costal Cartilage in Primary and Revision Rhinoplasty
Rogal J, Glasgold A, Glasgold RA

2021PMID 32522045Summary
PRS
Versatile Usability of Lateral Crural Strut Graft for Correction of Various Nasal Tip Deformities in Secondary Rhinoplasty in Asians
Kook WS, Kim K, Suh I et al.

2026PMID 40920505Summary
FPSAM
Patient Outcomes in Lateral Crural Repositioning and Reconstruction in Revision Rhinoplasty
Abdelhamid AS, Kimura KS, El Abany A et al.

2024PMID 37115534Summary
PRS
Refining the SPLF Graft: Innovations in Revision Rhinoplasty
Robotti E, De Bernardis R, Clauss A et al.

2026PMID 42012848Summary
PRS
Prevention and Resolution of Silicone Implant-Related Problems in Secondary Rhinoplasty Using a Cross-Linked Human Acellular Dermal Matrix
Kook WS, Ryu DH, Baek W et al.

2023PMID 36728206Summary
ASJ
Revision Rhinoplasty Using Glued Diced Costal Cartilage Shaped With Mold for Management of Complicated Silicone Rhinoplasty
Fung CY, Kim JH, Liao PH et al.

2023PMID 37289986Summary
ASJ
Analysis of the Cause of Cartilage Warping in the Rhinoplasty of Costal Cartilage and Application of Embed-In Graft in Revisional Surgery
Xu Y, Zhang X, You J et al.

2023PMID 36656674Summary
PRS
Use of Autologous Adipose-Derived Stromal Vascular Fractions in Revision Rhinoplasty for Severe Contractures in Asian Patients
Ahn TH, Lee W, Kim HM et al.

2021PMID 33620926Summary
PRS
Y-Columellar Strut Graft: A Method for Reconstructing the Nasal Tip in Primary and Revision Rhinoplasty
Martino C, Salzano FA, Martino D et al.

2023PMID 36729933Summary
PRS
Alar Base Lining Graft: A New Technique to Prevent and Correct Alar Retraction in Primary and Secondary Rhinoplasty
Pozzi M, Susini P, Murante A et al.

2024PMID 38346139Summary
PRS
Sequential Alar Base Resection in Primary and Secondary Rhinoplasty
Pozzi M, Susini P, Losco L et al.

2026PMID 42554673Summary
PRS
Revision Rhinoplasty Finesse with Digital Osteotomies
Lisiecki JL, Chiodo MV, Rohrich RJ

2024PMID 36877619Summary
FPSAM
Association Between Psychiatric Diagnoses and Revision Cosmetic Rhinoplasty
Tie K, Montañez-Azcarate V, Lin SJ

2025PMID 40139802Summary
ASJ
Using Nasal Self-Esteem to Predict Revision in Cosmetic Rhinoplasty
Okland TS, Patel P, Liu GS et al.

2021PMID 32856710Summary
FPSAM
Examining Preoperative Expectations and Postoperative Satisfaction in Rhinoplasty Patients: A Single-Center Study
Kandathil CK, Patel PN, Spataro EA et al.

2021PMID 33337943Summary
FPSAM
Outcomes of a Treatment Protocol for Compromised Nasal Skin in Primary and Revision Open Rhinoplasty
Irvine LE, Azizzadeh B, Kerulos JL et al.

2021PMID 33054380Summary
FPSAM
Evidence of Biofilm and Persister Cell Formation in Revision Rhinoplasty
Kao WK, Faddis B, Chole RA et al.

2022PMID 35724255Summary
ASJ
Comparison of Changes in Nasal Skin Sensation After Primary and Revision Rhinoplasty Procedures Using Semmes-Weinstein Monofilament Testing
Akyigit A, Keleş E, Yıldırım YSS et al.

2021PMID 33738466Summary
PRS
Septal Extension Graft in Cleft Rhinoplasty: Patients with Secondary Unilateral Cleft Lip Nasal Deformity
Saito T, Lonic D, Lo CC et al.

2024PMID 37797231Summary
ASJ
Secondary Bilateral Cleft Rhinoplasty: Achieving an Aesthetic Result
Saito T, Lo CC, Tu JC et al.

2024PMID 38314894Summary
PRS
Long-Term Outcome of Secondary Cleft Rhinoplasty in Patients with Secondary Nasal Deformity: Optimal Indications for Tajima Technique
Liu Y, Zhang C, Yao M et al.

2025PMID 38967637Summary
PRS
A Longitudinal Study of Improvement in Nasal Airway Obstruction after Secondary Cleft Rhinoplasty
Carlson AR, Kosyk MS, Zapatero ZD et al.

2023PMID 36696324Summary

What is still contested

The revision rate itself. Reviews quote 5% to 15%, one open-rhinoplasty series measured 10.8%, and a single practice's figure depends entirely on who is counted, including the patients who go somewhere else. [27149684, 34550928]
Homologous rib against autologous rib is settled by nobody. The homologous series report 2.4% to 3.6% complications with no control arm; the case for autologous rests on it being the patient's own tissue. [35511072, 40674713, 32522045]
The layered dorsal constructions and the tissue-based rescues (acellular matrix, stromal vascular fraction) are all single-surgeon series at Level IV or V. Direction is consistent; none has been compared against anything. [40826294, 42012848, 36728206, 33620926]
Nothing on file tests when a revision should be done. The convention is to wait about a year; no paper here measures the outcome of waiting against operating earlier.
The predictors of returning (a self-esteem item, a psychiatric diagnosis, an expectation gap) are correlations in retrospective cohorts, not a validated rule for declining an operation. [32856710, 40139802, 33337943]
Biofilm was found in three of fourteen revision samples. Whether it explains the higher infection rate in revision surgery, or is incidental, is untested. [35724255]
Nearly every series here is one surgeon's own patients. The direction repeats across practices and countries; the percentages belong to the practices that published them.