A. The septum almost always provides the best building material for the nose because it is generally flat and relatively straight, which is ideal for contouring the bridge or tip and supporting the airways. If there is not adequate septal cartilage to support and shape the nose, a graft of ear cartilage, rib cartilage or bone, or occasionally bone from the outer layer of the skull can be safely used. Synthetic materials, such as silicone, can slip out of place, have a higher risk of causing complications, and do not generally last for the patient’s entire lifetime. The patient’s own bone and cartilage will provide the most effective, long-lasting results.

A. Although the “deviated septum” is what most people think of when they think of a blocked nasal airway, the strength of the sidewalls is also very important. My published research in 600 patients since 1991 indicates that the valves in the sidewalls are more important for good nasal airflow than a straight septum. If the sides are too narrow or the cartilages are so soft that they collapse on inhalation, the airway will be poor even if the septum is straight. On most patients, I will straighten the septum and also support the sides because that gives a far superior result to simply straightening the septum. Some patients have already had a good septoplasty and I just need to stiffen the sides, in which case I can use septal cartilage if it is present or ear cartilage if it is not.

A. The need for revision rhinoplasty can have several causes: inadequate diagnosis, unexpected healing, or poor technique. The more experienced a surgeon is, the less commonly any of those situations occurs. After so many years of performing rhinoplasty, I almost always can make the diagnosis and a surgical plan that I have confidence will work. What I cannot control, however, is the quality of the graft materials or the patient’s healing. A surgeon can adjust for most variations in materials and often produce very good results even with suboptimal cartilage and bone. However, surgeons are not gods and neither control the quality of the cartilage nor the way in which the patient’s nose heals. It is those factors that create a variation in the beauty, smoothness, and function of the final result. If patients want the best result I can provide, additional surgery is occasionally necessary.

A. It is best to wait at least six months, and usually a year or more, before undergoing a revision surgery. Things that may not look good early on often improve over time, and occasionally a problem arises that was not apparent at first. Further, the tissues have to become soft enough for the revision rhinoplasty surgery to be safe and so that the skin will cooperate and permit me to make the types of changes that I would like. It is difficult to be patient when waiting for the nose to heal, but it is much worse to be rushed and fail to achieve what the patient wants because healing was not yet complete.

A. In a recent paper in Plastic and Reconstructive Surgery®, the official journal of the American Society of Plastic Surgeons, I showed research that indicated that about 20% of secondary rhinoplasty patients are unhappy because they have lost their sense of personal, ethnic, or familial identity, and another 70% have either uncorrected or new problems. This means that 90% of secondary rhinoplasty deformities are potentially avoidable by better patient/surgeon communication.