This study measured the prevalence of patients considering undergoing revision rhinoplasty, as well as identified their main cosmetic and functional complaints, their primary reasons for considering the surgery, and possible factors associated with considering revision rhinoplasty. In our study, 44.7% of participants who had undergone a primary rhinoplasty were considering revision rhinoplasty. This rate is much higher than the rates of patients who had actually undergone revision rhinoplasty, which has been reported to be between 7.5 and 23% [8, 11,12,13,14, 32]. However, only 8% of our study population were seriously considering revision rhinoplasty, which is relatively closer to revision rhinoplasty rates that have been previously reported [12, 3].
In the current study, the most frequently presented motivation for considering revision rhinoplasty was the desire for further esthetic improvement in an already acceptable result (50.16%), followed by failure to correct the original cosmetic complaints (29.74%), and the development of new esthetic complaints (24.84%). In contrast, Constantian MB et al. revealed that the most common reasons for undergoing revision rhinoplasty were the development of a nonexistent deformity (41%), failure to correct the primary cosmetic deformity (33%), and the loss of ethnic or personal characteristics (15%), with only 10% wanting further improvement in an already acceptable result [16]. This contrast could be due to the differences between the two study populations. The population in Constantian MB et al’s study was responding retrospectively after they had performed revision rhinoplasty, whereas our participants were still considering the procedure. It is important to note that not all of those considering revision are necessarily going to seek re-operation. In addition, the ability of our participants to select more than one reason for considering revision rhinoplasty in the questionnaire might play a role in this variation. However, the aforementioned findings indicate that the vast majority of our participants were considering revision rhinoplasty due to esthetic concerns. Prior studies demonstrate similar results, where cosmetic complaints were more common than functional complaints among revision rhinoplasty patients [16, 20, 23, 25].
Surgeons should understand the cosmetic and functional concerns that their patients consider most troublesome. The results of the present study show that the most prevalent esthetic complaint concerning the upper and middle portion of the nose is crookedness. Other studies have also found that 36–38% of patients admitted for re-operation are more likely to have crookedness as their primary esthetic complaint [14, 25].
Concerning the tip of the nose, the most common complaints reported subjectively by participants were poorly defined nasal tip (32.35%), followed by asymmetrical nasal tip (31.21%), and wide (bulbous) nasal tip (25.82%). Such complaints have also been reported by secondary rhinoplasty patients in multiple studies [8, 14, 20, 24]. This is perhaps attributable to the technical challenges of tip refinement maneuvers and the failure to address the nasal tip at the time of operation.
The most frequently stated cosmetic concerns of the columella and nostrils were having a long columella (19.77%) and wide nostrils (24.51%). A study conducted by Kathy Yu et al., showed similar findings [24]. These cosmetic concerns shed light on the importance of preoperative deformity analysis of all aspects of the nose.
We found that 37.91% of those considering revision rhinoplasty complained of either moderate or severe nasal obstruction symptoms as assessed subjectively using the NOSE scale. Vian HN et al. also found that 37.2% of patients submitted for revision rhinoplasty have obstructive respiratory concerns [20]. However, Kathy Yu et al. showed an even higher percentage of patients experiencing nasal obstruction complaints (62%) [24]. Differences in the prevalence of obstructive symptoms may be attributed to contrasts in surgeon vigilance, and ultimately paying attention to functional concerns prior to operating on a patient. In our study, the top three nasal function symptoms reported by those considering revision rhinoplasty were nasal obstruction (56.9%), followed by nasal stuffiness (51%), then trouble breathing through the nose (50.2%). Similarly, Kathy Yu et al. demonstrated that the sensation of nasal blockage ranked to be the main functional symptoms among revision rhinoplasty patients [24].
Certain factors can negatively affect the outcomes of primary rhinoplasty leading a patient to consider a revision rhinoplasty. We were able to identify seven independent factors associated with considering this procedure. Receiving inadequate information about the expected results was the most significant predictor of considering revision rhinoplasty among our sample. Unrealistic expectations have been linked to negative outcomes of rhinoplasty [33]. Thus, it is important to acknowledge patients’ expectations carefully and clarify all expected outcomes to ensure delivering a realistic expectation.
The second associated factor for considering revision rhinoplasty was not using computer imaging, or morphing, in predicting the postoperative result before the primary rhinoplasty. Despite the role of computer imaging as a tool to enhance communication between the patient and surgeon, the accuracy of the image is directly related to the imaging skills of the surgeon, limiting its reliability [34,35,36]. Therefore, it is vital to use imaging with caution and educate patients accordingly [34].
The third, fourth, and fifth predictive factors were the surgeon’s lack of understanding the patient’s problems, spending inadequate time with the patient, and patient dissatisfaction with the relationship with the surgeon. This emphasizes the impact of the surgeon’s encounter with the patient, and how that may influence consideration of revision rhinoplasty. Moreover, this highlights the value of establishing a good surgeon-patient relationship, which cannot be fulfilled without good communication skills. Proper communication consequently enhances the ability to address patients’ concerns, as well as increase the quality of the clinical consultation.
Our study did not reveal a significant correlation between almost all sociodemographic factors (gender, marital status, educational level, employment status) and considering a revision rhinoplasty, except for family income. Lower family monthly income (i.e., those with a monthly income of ≤ 15,000 Saudi riyals,) was the sixth significant predictor found to be associated with participants’ consideration of revision rhinoplasty. We hypothesize that a lower budget available for performing a rhinoplasty may encourage patients to choose their surgeons according to the overall cost of the procedure, without taking into account the surgeon’s level of qualification. As a result, patients may not exactly obtain their desired outcome, and may wish for further improvement.
Surprisingly, receiving adequate information about the risks and complications of the procedure was ranked as the seventh predictor associated with considering revision rhinoplasty. This might be attributed to the fact that clear explanation of all potential surgical benefits, risks and complications involved would help in dispelling misconceptions and provide thorough knowledge of the nature of a rhinoplasty. Consequently, the patient may feel under less pressure to proceed with that operation again, especially due to prior self-experience of rhinoplasty and their familiarity with it.
Limitations of this study include that the identified esthetic and functional nasal concerns were subjectively reported by the participants, and were not objectively confirmed by surgeons. However, images were included in the questionnaire in an attempt to clarify nasal anatomy for better reporting of esthetic problems by the participants. Strengths of this study include the sample size, which is larger than in other studies in the literature. Second, our sample was discrete, as we targeted those who were only considering revision rhinoplasty, and not those who had actually undergone revision rhinoplasty. We were able to identify their main cosmetic and functional complaints, their primary reason to consider revision surgery, and the factors associated with considering revision rhinoplasty. Third, multiple surgeon and patient-related factors were assessed to predict their possible association with considering revision rhinoplasty.