Revision rhinoplasty — not the same operation again, but a harder one for the first time

The rhinoplasty page says this: 'This is an operation people often have more than once. Each time there is less cartilage to use and more difficulty using it.' This page is what comes next.

A revision is not a repeat of the first operation. The inside of the nose is in a different state.

• Scar tissue has filled in. Layers have stuck together, clearing them takes time, and tissue thins further in the process.
• Usable cartilage has run down. The septum may already have been used the first time. Then it is the ear, and after that the rib.
• Blood supply is reduced. Skin that has been lifted once heals more slowly.

So the operation runs longer, the swelling lasts longer, and the result is harder to picture in advance than it was the first time.

There are usually three reasons people come — they dislike the shape; the implant has caused a problem (contracture, showing through, shifting, infection); or breathing has become worse. The third is a functional problem, not a cosmetic one, and it is judged differently.

The convention is to wait at least a year. The tip keeps changing for six to twelve months after a first operation. Judge before then and you mistake swelling for the result; go back in before the tissue has healed and you can make things worse.

Swelling lasts longer than the first time. Thick scar tissue drains poorly. Expect a year to eighteen months for the final shape.

Rib cartilage tends to warp. Revisions often use rib because septal cartilage is gone, and the shape can drift slightly over months. Where the rib was taken is also an operated site.

The skin is thinner. Pushing the tip up through already-thinned skin can let cartilage edges show through and, rarely, damage the skin.

It may not all be fixed in one go. Revisions after revisions are not rare.

If breathing gets worse, if swelling returns on one side, or if pain worsens, report it.

Put into words what the problem is before you go. 'The tip looks droopy in profile' or 'the right nostril is smaller' makes a more accurate plan than 'I don't like it.'

Bring the record of the first operation if you can get it. What was placed, and how much septum was used, changes the next plan.

Check whether breathing is affected too. If congestion appeared after the first operation, a plan that only changes shape is not enough.

Ask in advance about the possibility of using rib cartilage. It changes the scope of recovery and of scarring.

The more modest the aim, the safer. The realistic goal of a revision is not perfection but better than now.

Not smoking matters especially here. This is tissue whose blood supply is already reduced.

Less can be undone than the first time. An implant can come out, but by then the skin and the tissue beneath it have been stretched twice.

Each round makes the next one harder. Cartilage goes down, scarring goes up. It is better to plan as though this were the last one — that keeps the aim from becoming unreasonable.

Waiting is also an option. If it has not yet been a year since the first operation, part of what you are seeing is swelling.

If the problem is breathing rather than shape, this is a different conversation. That is a functional judgement, not a cosmetic one, and delay can cost you.

Whether to have it done is settled with a doctor, and it is better not to settle it on one consultation alone.