Why is a Revision Rhinoplasty So Much More Difficult that a Primary Rhinoplasty?

In my practice, I see many patients who are interested in a surgical rhinoplasty procedure.  About half of them have had surgery elsewhere and are unsatisfied with the results so they come in for a consultation for revision rhinoplasty.  Rhinoplasty alone is the most difficult plastic surgery procedure to perform for numerous reasons.  The main reason is that there is very little wiggle room for error when it comes to rhinoplasty.  Every millimeter counts and I take this into account when I perform my rhinoplasties.  When it comes to revision rhinoplasty, this difficult procedure becomes even more difficult.  The skin is usually scarred down, so it takes more time to elevate the skin to see exactly what is going on.  Some surgeons do not respect surgical planes, so there is extensive scarring underneath the skin as well as inside the nose that can cause breathing problems.  This all needs to be addressed at the same time as the rhinoplasty.  When it comes to shaving down bumps or shaping the cartilage, this can also be more difficult because of scar tissue.  The bones can be weakened from the previous surgery, so the revision rhinoplasty surgeon must be careful when refracturing these bones to improve the shape.  When it comes to the tip cartilages, they can be scarred in such a way that you cannot shape them exactly the way that you want, and so it takes very clever and intellectual grafting to produce a very nice, artistic result that looks natural.  In addition, in some revision rhinoplasty patients their septal cartilage has been removed.  Septal cartilage is thin and strong and is therefore ideal for grafting in rhinoplasty.  We typically use cartilage grafts to support the tip and to create shape to the tip.  If a person does not have any leftover septal cartilage, then we have to use alternative sources such as the ear or rib cartilage.  In my practice, I usually use cadaveric rib cartilage, which is ordered in the mail.  The rib cartilage is from someone who has usually donated their body to science and that person has been tested for any communicable diseases such as HIV and hepatitis.  All donors are deemed to be clean of any of these diseases.  The extra cartilage can be used to place inside the nose to achieve the goals that we want.  In some cases, we use ear cartilage, although ear cartilage is softer and thicker and so it is not ideal for supporting the nose, like the tip.