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Every surgeon, in every specialty, understands that a secondary or " revision" surgery is always more difficult than the original or "primary" surgery. So indeed it is for nasal cosmetic plastic surgery. There are several reasons for this including the fact that there is always scar tissue and some loss of normal anatomical landmarks. That is why sometimes the wisest decision that must be made before "signing up" for revision rhinoplasty is perhaps not to do the surgery; Therefore, wisdom suggests it may be wise to accept a minor imperfection rather than risk the possibility of worsening the appearance.
Since the American Academy of Facial Plastic and Reconstructive Surgery has reported that approximately 25% of patients are unhappy with their nasal cosmetic surgery, we are facing an epidemic of unsatisfactory results. To those of us involved in teaching, we are concerned that perhaps the residency programs in the two specialties that generate cosmetic nasal surgeons - plastic surgery and head and neck surgery - are not doing a good enough job.
Surgeons with inadequate training, less experience, and a lack of what we call "aesthetic sense" are more likely to generate an inadequate result and an unhappy patient. On the other hand, those surgeons who are highly focused in cosmetic nasal surgery, who have had the intense and long training and a high volume of rhinoplasty experience, have relatively few problems.
Further complicating the issue is that many patients need to have corrective nasal surgery to improve the airway. This often consists of correcting a deviated nasal septum or trimming enlarged turbinates. Patients with previously broken noses or nasal allergies or a history of sinus problems due to a nasal blockage wish to have all of these things corrected at the same time that the cosmetic procedure is done. This adds to the complexity of the case and, in less talented hands, yields a higher percentage of poor results.
Many times, dissatisfaction with rhinoplasty is such because there is a small depression that resulted in the postoperative healing phase. While some of these are known only by feel, many, of course, are visible, particularly in certain camera views or from certain angles. If such a depression could be "cured" by an office injection rather than surgery, wouldn't that make sense? Likewise, often there is a rise or thickening or slight convexity anywhere on the nose, and that too is amenable to non-operating room improvement. For those situations, the appropriate medication is a steroid or cortisone injection done very easily after the surface of the skin is anesthetized with a cream. Therefore, there are medications that flatten bumps and other medications that raise depressions. Since this is a more practical, less expensive and "no down time" procedure, there is great value here.
In the case of a depression, dip, divot or mogul, as these may be known, it is nice to get a sense of what the result would be before consenting to the injection since, in fact, the injection is permanent. One might consider a demonstration injection of saline or sterile salt water which would immediately create the desired effect so that you can see what the ultimate outcome would be. There is no downside to this because the injection will disappear within one hour to an hour and a half with no traces of having been done. It is always nice to be able to see what you are going to have without literally "paying any price." I am always fond of recommending such a trial dosage before one makes the final decision.
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