Q: Dr. Eppley, a month ago I underwent jaw advancement surgery as well as open rhinoplasty. My surgeon harvested bone from my skull and used it for both the nose and the jaw. Immediately after the surgery I realized that I had a hump, which I never had. I had a droopy nose and flared nostrils, but I had a really nice bridge, no hump. As the inflammation subsided, it became more and more apparent that the bone implant was very visible and crooked. I consulted my surgeon and he said it was just swelling. I saw several other surgeons and they all said it was not swelling, that it will not resolve, and that the bone was poorly shaped and implanted. I now must find a doctor to correct this deformity and I would like your professional opinion as to how long I should wait for a revision.
A: I don’t know the other details of your open rhinoplasty, other than you clearly have had a cranial bone graft augmentation. While cranial bone would not be my first choice for dorsal nasal augmentation, the logic of using it if bone was being harvested anyway for your mandibular osteotomy is logical. While you are only one month out from surgery and there still is persistent swelling, I would agree that the bone graft is oversized. While cranial bone will undergo some remodeling and even potential loss of volume, there is no assurance that this will happen in an even and regular fashion. Most certainly, you can not count on it remodeling into the desired amount and shape of dorsal augmentation that is desired. So the question is not whether a revision rhinoplasty will be needed but when and what exactly to do at the revision. There are arguments to be made for early vs delayed revision and, in my mind, it depends on what else was done to the nose and what the end goals were. If everything is fine and headed in the right direction with the rest of the nose and only the bone graft is the problem, then an earlier revision at 2 to 3 months could be done. If other aspects of the nose are undesired or unknown yet due to swelling, then it may be better to let the whole nose settle down and delay a revision until six months after the original procedure so any other adjustments can be done at the same time. One also has to factor in how much this new hump bothers you now, as if it is causing some distress, a revision can be done quite soon using a closed approach to remove, reshape and reinsert the bone graft so it has a better profile.
Dr. Barry Eppley