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Revision rhinoplasty

A second rhinoplasty is a different operation from the first: the cartilage that would have been used to rebuild is usually gone, the skin is scarred and less able to survive the dissection, and the commonest complaint is that the patient cannot breathe. Between 5% and 15% of rhinoplasties are done again, and the published series agree that most of what brings a patient back was decided in the first operation.

What brings people back

Four findings from the series that examined revision patients directly.

The commonest complaint is the airway

In 100 consecutive secondary patients, all operated on elsewhere, the leading complaint was airway occlusion, 65%, ahead of dorsal asymmetry (33%), nostril asymmetry (18%) and tip asymmetry (14%). The septum was addressed in 71% of the corrections, an alar rim graft used in 67%, a dorsal graft in 63%, osteotomies in 60%. The paper's own conclusion is a warning to primary surgeons: the rate of airway problems in secondary patients is alarming, and the airway needs attention during the first operation.

Rests on: Lee, Zwiebel and Guyuron, 100 consecutive secondary patients · Toriumi, discussion.

The surgeon sees more wrong than the patient does

In the same series the surgeon recorded significantly more deformities than the patients themselves reported: dorsal asymmetry in 65% against 33%, a wide dorsum in 47% against 13%, nostril asymmetry in 41% against 18%, a wide alar base in 38% against 6%. That gap is the substance of the revision consultation. The patient came about one thing; the surgeon is looking at five. Fixing all five without agreement produces a technically better nose the patient did not ask for, which is why the revision literature is as much about expectations as about cartilage.

Rests on: Lee, Zwiebel and Guyuron · and the psychology of rhinoplasty.

The three commonest reasons trace back to one technical choice

Screening 252 revisions after open rhinoplasty, the reasons clustered: insufficient tip rotation (37.7%), hanging columella (30.2%), supratip deformity (28.6%). Using a floating columellar strut instead of fixing the tip to the septum multiplied the risk of inadequate rotation 5.3-fold, of hanging columella 5.9-fold and of supratip deformity 2.2-fold. Age over 40 multiplied hanging columella 6.8-fold. Most of this list is preventable in the first operation.

Rests on: Sibar et al., 252 revisions · and nasal tip.

The second operation runs out of cartilage

Septal cartilage is the preferred material and it has usually been taken already. What remains is the ear (springy, curved, limited), and the rib, from the patient's own chest or from a tissue bank. Rib makes a big reconstruction possible and brings its own problem: it warps. The choice of material is the first decision in a revision plan, and it is made before the operation, not during it.

Rests on: Cochran and Gunter, secondary rhinoplasty with rib · and cartilage grafts.

What is being corrected

The seven deformities a revision is asked to fix. Each has its own page: what causes it, what the correction is, and what the literature does and does not know about it.

Polly-beak: fullness above the tip

The commonest reason a rhinoplasty is done again: present in 62% of 1,160 revision patients in the largest series on file. Four different causes, counted in that series, a dropped tip in 68%, scar in 36%, an over-resected bony dorsum in 28%, a high septal angle in 24%, and each one needs a different operation. Shaving the supratip fixes only the last of them.

Rests on: Hussein et al., 1,160 revision patients · full account on polly-beak deformity.

Inverted-V: a visible step where the bones end

The upper lateral cartilages have collapsed inward after a hump was removed without rebuilding the roof, so a shadow appears across the middle of the nose months later. Corrected with spreader grafts or spreader flaps; prevented by placing them at the first operation, or by not opening the roof at all.

Rests on: Sheen, the spreader graft · Rohrich et al. · full account on inverted-V deformity.

Open roof: a flat, wide bridge

The hump was taken off and the gap between the nasal bones was never closed. Closed with lateral osteotomies, or with bone dust where the vault is too narrow to osteotomise, or avoided in the first place with autospreader flaps.

Rests on: Taş, bone dust in 240 patients · full account on open-roof deformity.

Saddle nose: the bridge has collapsed

The septum's L-strut has failed, from over-resection, trauma, disease or drug use. A reconstruction rather than a revision: the skin envelope is assessed first, because a contracted envelope, not the graft, is what limits how much height can be restored.

Rests on: Battista et al., 60 patients and an algorithm · full account on saddle nose deformity.

Alar retraction: a notched, risen rim

Too much nostril shows from the front and the profile notches between rim and columella, because the lateral crus is gone or was never in the right place. Corrected by carrying support out along the rim toward the soft triangle.

Rests on: Cochran, extended alar contour grafts · full account on alar retraction.

The nose contracted around an implant

Where a silicone implant was placed and the capsule tightened around it, the nose becomes short, hard and retracted. The published sequence is to remove the implant, capsule and scar, then rebuild the dorsum and tip with the patient's own tissue. This one has no page of its own yet.

How a revision is planned

What is different about the second operation, in the order it is decided.

Timing

The convention is to wait about a year, so swelling has resolved and scar has matured before anything is judged or re-cut. No study on file tests that convention against operating earlier. It is practice, not evidence.

Diagnosis before technique

Every account of secondary rhinoplasty makes the same point in different words: success rests on an accurate diagnosis of every deformity, a plan that addresses each one, and agreement with the patient about which of them are actually being corrected.

Rests on: Cochran and Gunter · Lee, Zwiebel and Guyuron.

The approach

The external approach was introduced for secondary cases first, in 1987, because the deformity has to be seen to be diagnosed. The closed counterpart goes back to Sheen's 1975 paper and is still practised: 700 revision patients were reconstructed with costal cartilage through a closed approach in a single cohort, with an overall revision rate of 14.2%. The argument is on open versus closed and its history on Jack Gunter and Jack Sheen.

Rests on: Gunter and Rohrich, 1987 · Sheen, 1975 · Gode and Berber, 700 closed rib revisions.

The material

Septum if any remains; ear for rim, contour and composite grafts; rib for structure. Donated rib avoids a chest incision and saves about an hour, and how it was processed changes its behaviour, irradiation is associated with resorption, alcohol preservation with less warping.

Rests on: Cochran and Gunter · and cartilage grafts.

The skin

The limiting tissue. A review that collected every reported case of skin loss after rhinoplasty found 18 patients across eight studies, smoking in 23.5% of them, and named the revision setting itself as a risk factor. The prior operation leaves a scarred envelope with less blood supply, which is why the second operation is planned around the skin as much as around the framework. A revision plan that ignores the envelope is a plan for a nose that cannot heal over it.

Rests on: Ferzli et al., cutaneous compromise after rhinoplasty · Deot and Nassif, salvaging the compromised envelope · and recovery.

Frequently asked questions

The questions people search, answered from the published series.

How long do I have to wait before a revision?

The convention is about a year, so that swelling has resolved and scar has matured before anything is judged or re-cut. No study on file tests that convention against operating earlier. It is practice rather than evidence, and a surgeon who tells you a year should be able to say that it is a convention.

Rests on: the timing section and its absence of a comparative trial.

How often is a rhinoplasty done again?

Between 5% and 15% of rhinoplasties are done a second time. That is a one-in-seven chance at the top of the range, which is why the cost of a first operation is not the cost of the result.

Rests on: Rhinoplasty in StatPearls · what rhinoplasty costs.

Why do revisions happen?

The three commonest reasons trace to one technical choice each: too little tip rotation, a hanging columella, and fullness above the tip. The published series are almost entirely single-surgeon and retrospective, and their strongest finding is preventive: most of what brings a patient back was decided in the first operation.

Rests on: the revision literature.

What do people actually come back for?

Breathing, more often than shape. The commonest complaint in revision practice is that the patient cannot breathe, and the airway is usually part of the complaint even when the patient came in talking about the profile.

Rests on: airway obstruction.

Is a revision harder than the first operation?

It is a different operation. The cartilage that would have been used to rebuild is usually gone, so it has to come from the ear or the rib, and the skin is scarred and less able to survive the dissection.

Rests on: the material section.

Will my surgeon see the same problem I see?

Often not. Reviewing 100 consecutive revision consultations, the surgeon recorded significantly more deformities than the patients themselves could see. Two people look at one nose and describe different objects, which is why the consultation is where a revision is decided.

Rests on: Picavet et al. · the psychology of the request.

The terms, defined

The words a revision consultation uses.

  • Secondary, revision, tertiary: the second operation on a nose, and everything after it. Surgeons say secondary; patients say revision. [20206752]
  • Under-resection and over-resection: too little taken, leaving the original complaint; or too much taken, leaving collapse. The two ways a first operation fails. [20206752]
  • Pollybeak: fullness above the tip that convexes the profile, from an under-reduced cartilaginous dorsum, scar, or a dropped tip. [34550928]
  • Inverted-V deformity: the visible shadow where the nasal bones end and unsupported upper lateral cartilages have collapsed inward. [15457053]
  • Open-roof deformity: the flat, wide bridge left when a hump is removed and the bones are not brought back together. [15457053]
  • Saddle nose: collapse of the dorsum after the septal L-strut has failed.
  • Bossae: knuckle-like points in a thin-skinned tip where over-resected cartilage has buckled.
  • Alar retraction: the nostril rim pulled up, showing too much nostril, from over-resection or scar contracture.
  • 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. [34550928]
  • Contracted nose: a short, hard nose after capsular contracture around an implant, common in East Asian revision practice.
  • Skin–soft tissue envelope: the skin, fat and muscle over the framework, and the tissue that limits what a revision can safely do.

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. It sets what a surgeon should assess and record before a first operation, which is where most revisions are decided.

Rests on: the clinical practice guideline · the plain language summary.

What is not settled

  • The revision rate itself. Reviews quote 5% to 15%; one open-rhinoplasty series measured 10.8%; any single practice's figure excludes the patients who went elsewhere. [34550928]
  • When to operate. A year is convention; nothing on file measures waiting against operating sooner.
  • Whether the first surgeon should charge for their own revision is a policy, not a finding, and few practices publish theirs. See what rhinoplasty costs.
  • Which patients will be satisfied by a revision is predicted better by what they bring to the consultation than by the anatomy, and the predictors are correlations in retrospective cohorts, not a rule. See the psychology of rhinoplasty.
  • Almost every series here is one surgeon's own patients, reported retrospectively. The direction repeats; the percentages belong to the practices that published them.

Written by rhinoplasty.cc from the papers linked above, 2026-09-09. Not medical advice; it does not replace a consultation.