Among the aesthetic reasons that drive patients to return to the surgeon or seek a specialist in secondary rhinoplasty is the classic "nose job" or "surgical nose" appearance. Revisions characterized by a lack/insufficiency of structural support on the bridge and/or tip are particularly complex. This problem arises especially when the initial rhinoplasty was performed incautiously, with excessive resection of supporting structures such as the septum, bridge, and tip. It is the rhinoplasty surgeon's duty to clarify to the patient, from the first meeting, that the simple "nose job" requested by the patient may involve complex reconstructive aspects.

Especially in the last decade, minimally invasive techniques have been developed that have reduced the frequency and complexity of revision rhinoplasty. Specifically, these minimally invasive techniques significantly reduce the use of structural grafts in primary rhinoplasty. Each rhinoplasty for men and women is unique and requires careful preoperative analysis and a surgical plan tailored to the individual patient.

The surgeon, especially if experienced and farsighted, cannot ignore the possibility of having to operate a second time on the same patient. In experienced hands, this is a rare occurrence, but possible. Therefore, the surgeon will adopt a cautious and conservative approach starting with the primary rhinoplasty, so as to be in the best position should a minor "touch-up" or a full-blown revision rhinoplasty be necessary.

Revision rhinoplasty: from simple adjustments to more complex cases.

While there are no "routine revision" rhinoplasties/septorhinoplasties, we can distinguish between technically more complex and simpler cases. We cannot equate an extreme revision with a nose job, which can also be performed under local anesthesia. However, both situations require the full attention and experience of the specialist, who must be prepared to evaluate and address the specific complexities of each individual female or male rhinoplasty.

Among the most complex problems that the specialist surgeon must face during revision rhinoplasty, we recall:

• saddle nose, or loss of height of the nasal bridge, caused by excessive removal of bone and/or cartilage;
• the formation of steps on the back and/or lateral walls due to insufficient or inadequate osteotomies;
• the “inverted V deformity”, a severe complication linked to overly aggressive demolition maneuvers on the back which cause a more or less extensive disarticulation between the bony back and the cartilaginous back;
• “collapse of the middle third of the nose”, caused by inconsiderate resections of the triangular cartilages;
• “wing collapse”, or a loss of support of the wing walls with respiratory obstruction especially during inspiration and an unpleasant “pinching” of the nasal wings which gives an “operated” and unnatural appearance to the tip of the nose
• “severe ”asymmetries” of the nose, localized in different areas (bridge, tip, lateral walls).
• severe respiratory defects.
• “perforation of the nasal septum.