Los Angeles - Repairing a botched rhinoplasty - or one
that results in an obvious "nose job" - calls for a totally
different operation and surgeon than are performing the initial procedure,
according to Los Angeles plastic surgeon Richard Ellenbogen, M.D. Tissue
is generally removed from various areas during the primary surgery,
whereas it is often added in the secondary procedure.
Secondary rhinoplasty patients are different from primary patients.
They are distrustful, skeptical - even bitter about having the surgery
done again. Often, secondary patients' insurance has run out and they
are paying for the correction out-of-pocket. "Very frequently,
they forget the adage: Don't shoot the messenger. They may end up taking
a lot of their aggression and hostility from the first surgeon out on
you," Dr. Ellenbogen said.
Listening and note-taking skills are among the most important for
successful secondary rhinoplasties. The doctor must observe and listen
to the patient to determine what it is that the patient does not like.
"It's very easy for us to push our ideas on patients and give them
something else that they don't want," said Dr. Ellenbogen, a clinical
instructor at the University of Southern California and who is a member
of the Rhinoplasty Society.
Perhaps what is most challenging about listening to the secondary
rhinoplasty patient is that he or she usually cannot pinpoint the problem.
According to Dr. Ellenbogen, if you are not the type of physician
who can listen and empathize with somebody who has a problem, it might
not be the operation for you. Patients tend to closely scrutinize the
surgery's artistic success. And they do not want to hear that the swelling
should go down in six months to a year because that is the erroneous
information they got from their previous doctor.
To encourage the patient's trust and confidence, Dr. Ellenbogen keeps
and extensive file of his previous secondary rhinoplasties. This allows
him to show new patients pictures of others who have had similar defects
successfully corrected. He is also careful to be diplomatic when confronted
with negative comments about the other doctor's work. Never state anything
negative about the previous surgeon. It will stimulate bad will and
possibly legal retribution by the patient.
CERTAIN CORRECTIONS NOT FEASIBLE
Instead, focus on what you are about to do. Communicate that because
of scar tissue, you can only do the best that you possibly can. Certain
corrections may be impossible to perform.
"Basically, you're saying to the patient, 'If you cannot trust
me to do my best, then possibly you shouldn't have this surgery performed,'
" Dr. Ellenbogen said.
“In some rare cases, all facets of correction of a very scarred
secondary nose cannot be achieved in one surgery and possibly another
operation of much less magnitude will be necessary."
Do not be surprised when the secondary rhinoplasty patient comes back
to you for a second interview for further reassurance. Even though this
is one of Dr. Ellenbogen's specialties, he finds patients need to be
re-consulted regarding the intricacies of the surgery and their concerns.
Dr. Ellenbogen draws the patient's intended correction on Polaroid
pictures of the patient's profile. He prefers drawing on patients' pictures
rather than using his imager.
"Rarely can I achieve exactly what I represent on the [computer]
imager, but on the Polaroid picture - with my own pen and not a cursor
- I'm able to better surgically duplicate what I draw, and satisfy
the patient."
While Dr. Ellenbogen sees more types of corrections than are listed
here, he said that these are the most common. In addition, physicians
should keep in mind that most secondary rhinoplasties also may be needed
to repair a breathing problem.
Dr. Ellenbogen advocates using a general anesthesia the second time
around. He said that many patients recall surgeons talking - even laughing
- during previous procedures and think it might have had something to
do with their outcomes.
Common reasons patients are dissatisfied with their rhinoplasties
include:
The Pinched Tip
Frequently, the pinched tip is associated with the rim incision technique
bringing the lower cartilage out, anterior to the rim, and some removal
of the cephallic margin and cross-hatching. This seems to over-contract
the tip on occasion and frequently the cartilage is not placed back
into the nasal tip symetrically. To correct this, Dr. Ellenbogen makes
an inter-cartilaginous incision 5 mm from the rim and removes all cephalic
lower lateral cartilage. Frequently, the pinch is held contracted by
the cephalic-most portion of the lower-lateral cartilage and the simple
removal of more cephalic cartilage will correct the pinched tip. If
this is not adequate, the cartilage that is removed can be placed in
the rim to correct the pinch.
The Hidden Columella
This happens when doctors removes too much maxillary spine or caudal
septum. It is repaired using a graft from the septum placed between
the medial crus cartilage, which brings the columella down or directly
excising the ala-rim higher.
The Hanging Columella
This can be corrected by trimming the ala-rim to a higher placement.
The Drop (Rounded) Tip
Dr. Ellenbogen places a tip graft of septal cartilage through a rim
incision to support the tip. Frequently, a columella graft has to be
added to hold up this tip.
The Crooked Nose
Dr. Ellenbogen has been disappointed using spreader grafts between
the septum and upper lateral valvular area and prefers using onlay grafts
on the depressed upper lateral valvular area to simulate the straight
nose. Onlay grafts are usually taken from the upper portion of a lower
lateral cartilage or crushed cartilage from the septum.
The Scooped Nose
For dorsal augmentation, he uses septal cartilage. Dr. Ellenbogen
rarely uses Gore-Tex, silicone or rib. Correcting the scooped
nose is one of the most difficult secondary corrections. Cranial bone
which was previously frequently used has proven to dissolve with time
and there is also the problem of symmetry. A very carefully fashioned
layered septal cartilage graft or pinna ear cartilage graft usually
suffices.
High Tip
This can be corrected through lowering the tip by removing the foot
process of the medial crus cartilage and more cephalic lower lateral
cartilage or dorsal septum.
Crooked Nasal Bones
These require a careful refracture of the frontal process of the maxilla.
Dr. Ellenbogen usually fractures the medial osteotomy, then performs
the procedures with a 2 mm osteotomy through the skin just above the
medial canvas of the eye, or a superior osteotomy. This guarantees that
he will not get a combination or rocking chair deformity when he makes
his lateral osteotomy.
The Wide Nose
For the wide Caucasian nose, a very judicious defatting of the nasal
tip in the sebaceous area, combined with a removal of lower level cartilage
and a separation of the upper lateral cartilage from the septum will
often suffice. Occasionally, a dorsal onlay graft is necessary.
