Revision rhinoplasty and ethics

I saw two patients today, both requesting secondary Rhinoplasty, having had surgery elsewhere some time ago.

Both patients were clear as to what they didn’t like about their nose and such specifics are good.  In both cases as is often the way too much tissue had previously been removed either from the  bridge or the tip or both resulting in a lack of nasal harmony and balance.  Skin over the bridge tends to shrink more than skin over the tip and this can leave the nose looking big in the lower third.  Unfortunately there is a limit to how much nasal skin on the outside and lining on the inside can shrink.  Patients usually hope that the tip of the nose can be made smaller by taking out more cartilage to match the small size of the bridge.  Unfortunately this isn’t the case.  One of the toughest things to accept as a patient and surgeon is that if the skin doesn’t shrink on the outside anything we do on the inside however sophisticated to change cartilage size will not produce the desired result on the outside.

In such circumstances when a patient doesn’t want a better balanced nose because this means a bigger nose then we all have to accept that surgery cannot achieve what is hoped for and therefore it is always the right thing to do to advise against surgery.