Los Angeles - Repairing a botched rhinoplasty - or one that results in an obvious "nose job" - calls for a totally different operation than performing the initial procedure, according to Los Angeles plastic surgeon Richard Ellenbogen, M.D.

Tissue is generally removed from various areas during the primary surgery, whereas it is often added in the secondary procedure.

Secondary rhinoplasty patients are different from primary patients. They are distrustful, skeptical - even bitter - about having the surgery done again. Often, secondary patients' insurance has run out and they are paying for the correction out-of-pocket. "Very frequently, they forget the adage: Don't shoot the messenger. They end up taking a lot of their aggression and hostility from the first surgeon out on you," Dr. Ellenbogen said.

Listening and note-taking skills are among the most important for successful secondary rhinoplasties. The doctor must observe and listen to the patient to determine what it is that the patient does not like. "It's very easy for us to push our ideas on patients and give them something else that they don't want," said Dr. Ellenbogen, a clinical instructor at the University of Southern California and who is a member of the Rhinoplasty Society.

Perhaps what is most challenging about listening to the secondary rhinoplasty patient is that he or she usually cannot pinpoint the problem.

According to Dr. Ellenbogen, if you are not the type of physician who can listen and empathize with somebody who has a problem, it might not be the operation for you.

Patients tend to closely scrutinize the surgery's artistic success. And they do not want to hear that the swelling should go down in six months to a year because that is the erroneous information they got from their previous doctor.

To encourage the patient's trust and confidence, Dr. Ellenbogen keeps and extensive file of his previous secondary rhinoplasties. This allows him to show new patients pictures of others who have had similar defects successfully corrected. He is also careful to be diplomatic when confronted with negative comments about the other doctor's work.

Never state anything negative about the previous surgeon. It will stimulate bad will and possibly legal retribution by the patient.

CERTAIN CORRECTIONS NOT FEASIBLE

Instead, focus on what you are about to do. Communicate that because of scar tissue, you can only do the best that you possibly can. Certain corrections may be impossible to perform.

"Basically, you're saying to the patient, 'If you cannot trust me to do my best, then possibly you shouldn't have this surgery performed,' " Dr. Ellenbogen said.

Back up your verbal statement with a consent that reads something to the effect of: "Although all efforts are taken to achieve the hoped-for result, previous surgery may make this impossible.

On occasion, all facets of correction of the nose cannot be achieved in just one surgery and possibly another operation will be necessary."

Do not be surprised when the secondary rhinoplasty patient comes back to you for a second interview for further reassurance.

Even though this is one of Dr. Ellenbogen's specialties, he finds patients need to be re-consulted regarding the intricacies of the surgery and their concerns.

Dr. Ellenbogen draws the patient's intended correction on Polaroid pictures of the patient's profile.

He prefers drawing on patients' pictures rather than using his imager.

"Rarely can I achieve exactly what I represent on the imager, but on the Polaroid picture - with my own pen and not a cursor - I'm able to better surgically duplicate what I draw, and satisfy the patient."

While Dr. Ellenbogen sees more types of corrections than are listed here, he said that these are the most common.

In addition, physicians should keep in mind that most secondary rhinoplasties also may be needed to repair a breathing problem.

Dr. Ellenbogen advocates using a general anesthesia the second time around. He said that many patients recall surgeons talking - even laughing - during previous procedures and think it might have had something to do with their outcomes.

Common reasons patients are dissatisfied with their rhinoplasteis include:

• The Pinched Tip

  Frequently, the pinched tip is associated with the rim incision technique bringing the lower cartilage out, anterior to the rim, and some removal of the cephallic margin and cross-hatching. This seems to over-contract the tip on occasion and frequently the cartilage is not placed back into the nasal tip symetrically. To correct this, Dr. Ellenbogen makes an inter-cartilaginous incision 5 mm from the rim and removes all cephalic lower lateral cartilage. Frequently, the pinch is held contracted by the cephalic-most portion of the lower-lateral cartilage and the simple removal of more cephalic cartilage will correct the pinched tip. If this is not adequate, the cartilage that is removed can be placed in the rim to correct the pinch.

• The Hanging Columella

  This happens when doctors remove too much maxillary spine or caudal septum. It is repaired using a graft from the septum placed between the medial crus cartilage, which brings the columella down or directly excising the ala-rim higher.

• The Drop (Rounded) Tip

  Dr. Ellenbogen places a tip graft of septal cartilage through a rim incision to support the tip. Frequently, a columella graft has to be added to hold up this tip.

• The Crooked Nose

  Dr. Ellenbogen has been disappointed using spreader grafts between the septum and upper lateral valvular area and prefers using onlay grafts on the depressed upper lateral valvular area to simulate the straight nose. Onlay grafts are usually taken from the upper portion of a lower lateral cartilage or crushed cartilage from the septum.

• The Scooped Nose

  For dorsal augmentation, he uses septal cartilage. Dr. Ellenbogen rarely uses Gore-Tex, silicone or rib. Correcting the scooped nose is one of the most difficult secondary corrections. Cranial bone which was previously frequently used has proven to dissolve with time and there is also the problem of symmetry. A very carefully fashioned layered septal cartilage graft or pinna ear cartilage graft usually suffices.

• High Tip

  This can be corrected through lowering the tip by removing the foot process of the medial crus cartilage and more cephalic lower lateral cartilage or dorsal septum.

• Crooked Nasal Bones

  These require a careful refracture of the frontal process of the maxilla. Dr. Ellenbogen usually fractures the medial osteotomy, then performs the procedures with a 2 mm osteotomy through the skin just above the medial canvas of the eye, or a superior osteotomy. This guarantees that he will not get a combination or rocking chair deformity when he makes his lateral osteotomy.

• The Wide Nose

  For the wide Caucasian nose, a very judicious defatting of the nasal tip in the sebaceous area, combined with a removal of lower level cartilage and a separation of the upper lateral cartilage from the septum will often suffice. Occasionally, a dorsal onlay graft is necessary.