Secondary rhinoplasty (also referred to as revision rhinoplasty) is the operation performed on a patient who has undergone one or more rhinoplasties prior to the current procedure. Although it involves many of same considerations and techniques as primary rhinoplasty, it is in many ways very different than primary rhinoplasty. Secondary rhinoplasty is usually a more involved, lengthy operation that requires the surgeon to be able to react to a variety of unknowns, depending on what is encountered during surgery.
This procedure frequently involves a very tedious dissection through scar tissue in order to elevate the skin and mucous membranes from the underlying cartilage and bone. It also frequently requires the use of additional structural material in order to rebuild the support system of the nose and create the necessary contour changes. In a primary rhinoplasty this structural material will usually be obtained by borrowing cartilage and / or bone from the septum.
However, in most secondary rhinoplasties, adequate septal cartilage and / or bone is rarely available. Alternative choices for structural material are the patient’s own ear cartilage, rib cartilage, or cranial bone; as well as cadaver rib cartilage or various artificial implant materials (i.e. silicone, gortex, Porex).
Most of these choices have significant drawbacks and do not meet the criteria of a desirable implant material for secondary rhinoplasty. A desirable implant material must be at low risk for infection or extrusion. It must be in abundant supply. It must be strong enough to maintain the necessary support and withstand the forces of scar contracture without changing shape or position. And it must possess the ability to be contoured in order to recreate the natural elements of the nose.
Even when ear cartilage is taken from both ears, this only yields a small amount of cartilage. In addition, ear cartilage is curved, thin, and soft. It works well for minimal cosmetic grafting, but never works well for grafting large areas or grafting that is required to maintain structural support. Cranial bone, on the other hand, offers more material to work with and is strong enough to maintain structural stability.
However, it is difficult to contour, difficult to secure in various positions, and cannot mimic the natural feel and texture of nasal cartilage. Cadaver rib cartilage is also in abundant supply and is easier to secure in position. It is also a closer match to natural nasal cartilage than cranial bone. However, it is often obtained from very elderly people who have partially calcified rib cartilage, making it difficult to reliably contour and maintain its shape. It also has more of a tendency to warp or change over time.
All artificial implant materials are always a bad idea for nasal surgery. Over time, they have a high rate of infection and extrusion and often need to be removed.
Therefore, the only material which meets all of the criteria explained above is the patient’s own rib cartilage. I have found that when removed in a safe, reliable manner and contoured using the correct technique, rib cartilage is unparalleled. It allows for incredible transformations that many patients have thought or have been told are not possible.