La rhinoplastie secondaire (R2) est un véritable challenge, c’est un secret pour personne. Aussi on ne peut que conseiller au candidat éventuel, et à son chirurgien, d’y réfléchir à deux fois avant d’envisager une rhinoplastie secondaire (et a fortiori une tertiaire…). Bien sur, je ne parle pas des simples retouches, qui sont monnaie courante en rhinoplastie. Il est vrai qu’en rhinoplastie, on recherche, si non l’impossible perfection, au moins une relative adéquation du résultat. Le nez étant un organe, dont on ne rappellera pas, qu’il est au milieu du visage.
Ainsi, après avoir mûrement réfléchit à la ré-intervention et au choix du chirurgien – celui-ci est en règle général, et on peut le comprendre, différent du premier et plutôt « spécialisé », il importe d’évoquer les quelques principes chirurgicaux et les grandes lignes de la R2, que le candidat doit savoir. Ceci, afin de poser les questions adéquates aux chirurgiens, et d’en comprendre les explications.
Voici donc les éléments à connaître, sans entrer dans les détails techniques qui sont infinis et variables selon les opérateurs. Le projet de R2 doit être très précis et élaboré de concertation entre patient et chirurgien.
Pour moi, il faut 3 consultations, dont une très proche du jour de l’intervention. Encore plus qu’en R1, il doit y avoir une compréhension et une adéquation parfaite entre, si j’ose dire, « les deux parties » ou mieux : les partenaires. Il faut que l’opérateur saisisse exactement la demande, qui n’est pas toujours évidente ; et le défaut dont parle le patient n’est pas forcément celui qui saute aux yeux du chirurgien (principaux défauts en R2).
Il faut également que le patient comprenne ce qu’il est possible, mais surtout impossible ou périlleux de réaliser. Il vaut mieux un projet de R2 réaliste et sans risque, qu’un projet idéal qui ne sera jamais réalisable, source de déception et de conflits.
Le morphing photo est ici, à mon sens incontournable. Il devra être, non pas idéal, mais réaliste pour donner ne pas donner de faux espoirs au patient.
Le délai pour une R2 est sujet à discussion. Personnellement je pense que 6 à 8 mois est un minimum pour une reprise de rhinoplastie primitive faite par voie endo-nasale (cachée). Pour une reprise de voie externe ou une rhino 3, un an est un minimum, et … 10 ans c’est encore mieux.
La voie d’abord en R2 varie selon les opérateurs, mais la voie externe est la plus utilisée. Elle seule permet de faire un « état des lieux » précis, on ouvre et on regarde ce que le prédécesseur a fait (ou défait!) un peu comme un garagiste qui soulève le capot de la voiture pour voir ce qu’il se passe… Mais comme je l’ai déjà écrit en matière de voie d’abord, chacun utilise celle qui lui semble la meilleure et avec laquelle il se sent le plus à l’aise.
Le scanner facial avec reconstruction 3D est très utile, voir indispensable en R2 car il permet de vérifier l’état des os du nez qui ont étés cassé par les précédentes ostéotomies. Il évalue également l’état de la cloison nasale, qui peut être déviée voire perforée. Il permet de découvrir l’existence d’un greffon osseux (les greffons cartilagineux sont invisibles au scanner). On pourrait lui reconnaître un caractère médico-légal, au moins didactique, pour expliquer au patient l’état de son nez.
Les greffons, tout ceux qui s’intéressent à la rhinoplastie en ont entendu parler, et en général trop ! « Allez-vous me faire un greffon de Sheen? ou un spreader graft ? ». Sans parler de ceux qui nous regardent d’un air désabusé, si on ose pas leur parler de greffons. Ce ne sont pas les greffons qui réussissent la R2, mais bon on peut considérer qu’ils sont incontournables. Cela fera l’objet d’un article entier, mais pour résumer, disons qu’il existe des greffons osseux et cartilagineux. L’os se prend le plus souvent au niveau du crâne. Le cartilage sur la cloison, derrière l’oreille, ou plus rarement sur une côte. Chaque greffon a une indication précise, et chaque opérateur ses préférences. Il y a des greffons structurants pour reconstruire ce qui a été enlevé avec parfois… un peu trop d’ardeur ! Et des greffons modelants pour affiner, adoucir, régulariser une structure, par exemple la pointe ou le dorsum. Les greffons synthétiques n’ont pas, en France, la faveur des spécialistes en rhinoplastie.
En conclusion et pour résumer dans une R2, on ouvre, on fait un état des lieux ( ce qui a été abimé, ce qui manque, et ce qui reste en trop), on re-casse ce qui a été mal cassé, on enlève ce qui a été laissé en excès, et on rajoute des greffes là où cela manque. Et on essaye d'harmoniser le tout. OUF !
j’ai eu une rhino de la pointe globuleuse il y a maintenant 10 mois par voie interne.
Mon chirurgien a juste enlevé un peu des cartilages alaires et basta.
Mais voila, je n’aime pas la démarcation que cela a créé entre le septum et les cartilages alaires.
Et j’ai compris en regardant mes photos pré op,
et en me renseignant un peu, que j’avais déjà une faiblesse au niveau des cartilages triangulaires, du tiers moyen. Ce n’était pas génant avant, et enlever juste du cartilage alaire a rendu cette démarcation plus visible…
Bref ma question est la suivante:
est ce que les greffes de cartilage à cet endroit se révèlent être souvent visibles?
Comment savoir si on a la peau fine ou normale?
Dr Alain BOUAZIZ
Les greffes sont le plus souvent invisible mais parfois effectivement elles peuvent se voir. Soit parce que la peau est fine, soit la greffe trop épaisse ou mal placée. Mais je n ai très bien compris la zone qui pose problème .
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j’ai subi une intervention pour un nez avec une petite bosse un peu large. Je souhaitais enlever la bosse et affiner légèrement le nez. Le chirurgien n’a rien compris et il a réduit drastiquement mon nez (1cm de longueur en moins + pointe très relevée + pincée). Je souhaite retrouver un nez quasiment comme avant l’opération (même longueur, pointe à reconstruire et à baisser) une fois qu’il aura complètement cicatrisé. Est-il possible de rallonger un nez d’1 cm ? Est-ce des interventions que vous pratiquez?
Merci à vous Docteur.
Dr Alain BOUAZIZ
Oui je pratique …
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Merci Docteur je vous envoie ça par mail. Merci de votre attention.
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Bonjour a tous,
Je suis désespéré…
J’ai subi une rhino-septoplastie pour corrigé notamment une déviation de la cloison nasale par un ORL en 2009 ainsi qu’une bosse…
résultat: nez trop creusé et encore trop long,il n’a pas touché a ma pointe dévié elle aussi…
Ce meme ORL m’a réopérer d’une rhinoplastie secondaire en 2010… Mon nez fut racourcis (trop) pas défini et je me retrouve avec deux creux au niveau de la base du nez (j’ai l’impression que cela est du au platre…, une pointe globuleuse…
Lors de la consultation de l’enlevement des plaques dans le nez (une seconde fois en plus!) ainsi que le retrait du platre… Mon nez était encore pire qu’avant… Je n’ai rien, simplement pleurer et m’a dit qu’il ne m’opererait plus.
1 ans plus tard donc en Juillet 2011, je décide de consulté un autre ORL sous l’avis d’un médecin généraliste. Cet ORL m’a examiné… M’a opéré en décembre 2011 suite a 2 visites… Uniquement par voie externe et n’a pas du tout touché l’os ou le haut de mon nez car ma priorité était de rectifié cette pointe dévié… (qui le reste toujours)…(chirurgie de la pointe) J’ai deux profil distincts un coté ou la pointe remonte et l’autre ou la pointe et très pointu… Je n’ai subi aucune greffe lors de cette intervention contrairement a ce qu’il m’avait dit (peu etre un point positif)… J’ai conscience que le nez parfait n’existe pas mais je souhaitais simplement un nez collant a ma personnalité…
J’ai l’impression que cela n’a rien changé, notamment l’avis de mes proches…. Dépensais de l’argent pour avoir deux petit trous au niveau de la base du nez, deux profil encore distincts…
Aujourd’hui en 2013… J’ai laissé mon nez évolué avec le temps pour « voir… », mais cela devient insupportable, une véritable souffrance pour moi… J’ai la chance d’avoir le soutien de ma famille!
Que puis – je faire ? Qui consulter? Je suis sur la région PACA.
Je n’ai plus confiance en moi… Prendre une photo de face est insurmontable… Cela gache ma vie. J’ai peur de reconsulter de peur que l’on me dise « Mademoiselle, on ne peut plus rien faire… »
J’aimerais parfois, dire a toute les personnes qui vont se faire opérer de réfléchir a 10 fois et surtout de voir plusieurs praticiens…
Mon email est: Mglamour83@gmail.com
(si vous pouvez me répondre concernant des praticiens… Si vous voulez parlez de votre vécu si vous, vous reconnaissez à travers mon message!)
Bonjour j’ai vu que vous avez posté un témoignage semblable sur un autre blog de rhino , je vous ai envoyé un mail et j’ai toujours pas de réponse ! J’espérais avoir un peu plus d’informations sur votre expérience notamment avec des photos si ça vous dérange pas
J’ai 33 ans et suite à une mauvaise chute je me suis fracturée le nez en août 2015. J’ai subi une septorhinoplastie au mois d’octobre afin d’aussi corriger l’aspect de mon nez qui avait déjà été fracturée à l’âge de 2 ans.
2 semaines après l’opération j’ai développé un hématome septal dans la narine gauche ainsi qu’une infection qui a nécessité plusieurs traitements antibiotiques ainsi que des perfusions quotidiennes pendant 7 jours. J’ai du aussi porter une attelle pendant plus de 2 mois ainsi que des mèches dans les narines.
Aujourd’hui ma narine gauche est complètement bouchée, mon nez est toujours dévié et asymétrique. J’ai aussi développé une » boule » dans la narine gauche que l’ORL a essayé de faire disparaitre avec des injections de steroids mais sans succès. Aujourd’hui la « boule » est toujours présente et une plus petite est apparue au mois de mars.
Je me surprends souvent à tirer ma joue gauche afin de pouvoir littéralement ouvrir ma narine. Je dors mal et je suis souvent très fatiguée.
D’un point de vue esthétique je suis aussi très déçue.
J’ai essayé d’être positive et de garder espoir mais l’ORL qui me suit m’a récemment fait comprendre qu’il ne pouvait plus rien faire.
Mes attentes sont à la fois fonctionnelle et esthétique et j’aimerais savoir si vous pouviez m’aider ou me conseiller un spécialiste à Paris.
Serait-il possible de vous contacter directement afin de vous envoyer des photos.
Dr Alain BOUAZIZ
Bien sûr vous pouvez m’adresser des photos à mon mail ainsi que des images scanner si vous en avez . Votre cas à l’air difficile mais on peut toujours faire quelque chose.
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J’ai 33 ans et suite à une mauvaise chute je me suis fracturée le nez en août 2015. J’ai subi une septorhinoplastie au mois d’octobre afin d’aussi corriger l’aspect de mon nez qui avait déjà été fracturée à l’âge de 2 ans.
2 semaines après l’opération j’ai développé un hématome septal dans la narine gauche ainsi qu’une infection qui a nécessité plusieurs traitements antibiotiques ainsi que des perfusions quotidiennes pendant 7 jours. J’ai du aussi porter une attelle pendant plus de 2 mois ainsi que des mèches dans les narines.
Aujourd’hui ma narine gauche est complètement bouchée, mon nez est toujours dévié et asymétrique. J’ai aussi développé une » boule » dans la narine gauche que l’ORL a essayé de faire disparaitre avec des injections de steroids mais sans succès. Aujourd’hui la « boule » est toujours présente et une plus petite est apparue au mois de mars.
Je me surprends souvent à tirer ma joue gauche afin de pouvoir littéralement ouvrir ma narine. Je dors mal et je suis souvent très fatiguée.
D’un point de vue esthétique je suis aussi très déçue.
J’ai essayé d’être positive et de garder espoir mais l’ORL qui me suit m’a récemment fait comprendre qu’il ne pouvait plus rien faire.
Mes attentes sont à la fois fonctionnelle et esthétique et j’aimerais savoir si vous pouviez m’aider ou me conseiller un spécialiste à Paris.
Serait-il possible de vous contacter directement afin de vous envoyer des photos.
Dr Alain BOUAZIZ
votre cas est complexe et vous l ‘avez bien décrit. Sur le plan fonctionnel vous avez un problème de valve qui vous oblige à écarter la paroi latérale . Sur le plan esthétique j ‘attends vos photos sur mon mail .
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Bonsoir à tous,
Je me suis fait opéré par le Docteur Bouaziz le 17 janvier dernier pour une rhinoplastie tertiaire. Le résultat est remarquable.
Je vous fais un récapitulatif de mon expérience douloureuse en rhinoplastie. En 2008, je subis ma première rhinoplastie ratée après laquelle le chirurgien a fait une série de retouche pour rattraper son travail baclé mais en vain. J’avais la pointe déviée, les cartilages asymétriques et atrophiés, le dorsum irrégulier et creux.
En 2011, je rencontre le Dr G*****lt à Vincennes qui reconstruit mon nez par une greffe. Le résultat était très convenable par rapport à l’opération précédente mais ne me convenait pas car il persistait des imperfections qu’il a jugé minimes, raison pour laquelle il n’a pas voulu réintervenir.
Je me suis donc remis à la recherche d’un chirurgien pour combler mes attentes. Et dieu sait que j’étais exigeant : je voulais une greffe de cartilage sur la pente de l’arete droite afin de la rentre aussi large que l’arête gauche, enlever le creux à l’arrière de la narine, symétriser la pointe elle-meme et qu’elle soit en accord avec l’arete.
Beaucoup de chirurgiens ont refusé d’intervenir pour divers motifs: trop complexe, pas assez rentable, projet trop ambitieux. Mais ils n’ont pas tenu compte du fait que je fasse de la photographie et que cest détails, peut-être minimes à leurs yeux, étaient importants pour moi. L’unique chirurgien qui a compris l’importance d’une nouvelle opération a été le Docteur Bouaziz avec lequel je me suis longuement entretenu en rendez-vous afin de bien expliquer mes attentes, en long, en large et en travers. D’ailleurs, il a également découvert que je souffrais d’une synéchie, à l’origine de mon renifflement permanent depuis très longtemps.
Aujourd’hui, plus d’un mois après l’opération, même si la pointe reste toujours un peu gonflée, on voit plus ou moins le résultat et c’est une délivrance pour moi car tout est comme je l’espérais.
Un énorme merci au vous Docteur Bouaziz pour votre travail.
Lecteurs, si vous voulez me contacter pour parler plus en détails de mon expérience, voici mon adresse email : firstname.lastname@example.org
Un témoignage édifiant qui montre l’importance du choix de son chirurgien en matière de rhinoplastie.
j’ai je suis femme désespérée après mes trois accouchements, j’ai vu que mon nez à changer.j’étais très gênée de regarder les gens en face, je me cachaisuis. j’ai dévidé de faire operer de de mon nez en juin 2014.le résultat était catrophique, le pâtre était déjà de travers bref dévier du côté droit donc raté. depuis plus de 3ans je vis avec un nez dévié.ce sont des moque ries et des railleries au quotidien au travail ou en ville je ne sors plus et suis mis en arrêt de travail.j’ai consulté presque tous les chirurgiens de la région mais j’ai peur que ma situation s’empire. vous me conseille quoi? urgent SVP rhino ethnique secondaire.merci
Dr Alain BOUAZIZ
Vous semblez désespérée . Il ne faut pas car les cas impossibles à améliorer sont exceptionnels et vous n’avez été opérée qu une fois . Envoyez moi des photos et je vous dirais rapidement ce que j’en pense . Mon mail est sur le blog . A bientot
je me suis fais opéré d’une rhinoseptoplastie il y a deux mois , et apres constatation d »un creux au niveau de l’arrete gauche et d »une bosse a la meme hauteur sur l’arrete droite j’ai decidé de lui en faire part directement lors de ma visite aujourd’hui a j+2 mois. le chirurgien a tres vite reconnu un deviation a nouveau de la cloison nasal qui explique le creux et la bosse.
Il me parle de me reopérer gratuitement dans quatre mois avec un spreader graft pour redresser cette cloison. Je n’ai malheureusement plus confiance en mon chirurgien car tout d’abord il n’a pas su me donner une explication a cette deviation et il me propose cette operation sous quatres mois ce qui me parait peu de temps . Ce meme chirurgien ne ma pas fait part avant ma premiere rhinoplastie des risques encourut pas la chirurgie et n’a effectué aucune estimation ou projet du nez a atteindre . Je trouve sa maniere de travailler peu profesionnel.
Pouvez vous en tant que medecin me dire si cette attitude et courante chez un orl , si cela est inquietant, et si je dois me conseiller pour la r2 aupres d »un autre chirurgien ou non.
Pouvez vous me parler des risque des spreader graft pour redresser la cloison, et quels sont les echecs possible. es-ce une rhino secondaire generalement reussi ou complexe a realiser.
Dr Alain BOUAZIZ
Tout d abord il ne m’appartient pas de juger un confrère , ce n est pas déontologique .
Il y a de nombreuses questions dans votre post. Une déviation de cloison persistante cela peut arriver , la cloison étant élastique , elle n a qu’une envie , c est de repartir. Les spreader graft qui servent avant tout à élargir la valve nasale , peuvent aussi maintenir le septum en rectitude . Le délai est variable, et je dis toujours que ce qui compte est l examen local de la peau , surtout si vous avez été opérée par voie traditionnelle endonasale. Car là je pense qu’il faudra une voie externe , surtout pour mettre des spreader graft . Donc si vous faites confiance au chirurgien , vous ferez confiance au délai qu’il juge bon. Quand au projet initial, je suis d’accord avec vous , pour moi un projet morphing est indispensable dans tout les cas . Et même si on n arrive pas toujours au résultat, on s’accorde sur la tendance.
Je pense donc que pour vous il faut reprendre tout à zéro ou presque . Scanner 3D , morphing , .. Si vous le désirez vous pouvez m’envoyer des photos, je vous donnerez un avis plus précis .
A bientôt .
Bonjour j ai rendez-vous avec vous la semaine prochaine mais j ai oublié de vous notifier que j ai une peau épaisse, j ai peur en lisant tout les commentaires sur internet qu’une operation n ait aucun résultats et que mon nez ne puisse être affiné et mon remonter. Merci beaucoup
J’aimerais beaucoup avoir votre avis sur mon cas.
Le 22 mai dernier je me suis faite opérer au CHU de Nancy d’une septo rhinoplastie pour redresser ma cloison nasale et râper une grosse bosse sur mon nez par une chirurgienne ORL. Au niveau de la cloison rien à dire je respire mieux seulement le résultat de profil était pire qu’avant (une bosse encore plus grosse et plus longue du au cartilage qui serait remonté) bref la chirurgienne me propose de me reoperer car je ne pouvais plus me regarder dans une glace.
Je me suis donc faite reoperer le 2 octobre il y a un mois (toujours remboursé). Opération très difficile (4h) elle a admit avoir réopéré trop tôt. Résultat plus de bosse de profil nez même presque trop creusé mais ça me va. (Du moins le profil commence lui aussi a etre de moins en moins joli « en v inversé) Mais de face… catastrophe et au bout d’un mois ça ne s’arrange pas vraiment. Nez très très large surtout d’un côté avec un os qui n’a rien à faire la un côté de la pointe plus gonflé que l’autre. Je ne ressemble plus à rien et je ne la revois que dans 15 jours. J’ai été opéré sans même savoir ce qu’elle allait faire exactement. Serait il possible de vous envoyer des photos afin d’avoir votre avis ? Si cela peu s’arranger avec le temps où non ? Et enfin connaître vos tarifs dans ce type de cas.
Dr Alain BOUAZIZ
Bien sur qu’il faut m’envoyer des photos sur mon mail. Et ne désespérer pas on peut toujours améliorer les choses
Merci beaucoup je vous ai envoyé un mail. Ce qui me désespère c’est de rester comme ça minimum une année et de trouver je ne sais comment les fonds nécessaires..
Je me suis fait opéré le 12 décembre 2016
septoplastie des sinus et en même temps j’en n’est profité pour refaire une petit défaut que j’estimais défaut sur la pointe.
Un côté plus convexe donc une légère asymétrie de la la pointe
Le chirurgien m’a dis que c’était très simple à faire et q’uil n’y aura aucun problème
Il m’a parlé de sectionné un tout petit bout de cartilage et m’affaire est joué.
A l’entendre c’était très facile, sauf que aujourd’hui la convexité est toujours là et en option j’ai gagné la narine de ce même côté plus relevée et les narine asymétrique
Pensez vous que cette aile de narine va descendre?
Si vous voulez je peut prendre rdv A votre cabinet
Dr Alain BOUAZIZ
Rien n’est facile au niveau de la pointe . Je ne suis pas certain que la narine va redescendre . Envoyez moi des photos que je me rendre compte mais cela dit vous êtes vraiment encore dans le premier mois post Operatoire et le nez va beaucoup évoluer
J’ai eu une rhinoplastie en 2012, pas vraiment réussie puisque si cela ne se voit pas, la partie haute est pleine d’irrégularités (comme des petits creux), et le greffon au niveau de la pointe à bougé.
Il n’est également pas parfait au niveau des côtés.
Les irrégularités finiront-elles par se voir/peuvent-elles évoluer?
Un retrait du greffon serait-il judicieux?
Dr Alain BOUAZIZ
L’opération datant de 2012 , il ne fait plus espérer d amélioration . Tout au plus les défauts peuvent se voir plus ou moins quand on maigrit . Il n’est pas rare de devoir repositionner un greffon de Sheen au niveau de la pointe car ceux ont tendance à se déplacer . Parfois il est trop dur ou trop gros et il faut le réduire ou l’assouplir . Parfois on le retire . Envoyez moi des photos . A bientot et meilleurs vœux.
Est il dangereux de mettre un implant de medpor pour une rhinoplastie secondaire?et de l’utilisé aussi pour rallonger un nez trop court et une pointe peu projetee?
Dr Alain BOUAZIZ
Personnellement je n utilise aucun implant en rhinoplastie. Je n’ai recours qu’à des greffons autologues ( pris sur la personne elle même ), cartilagineux ou osseux . Pour plusieurs raisons: c’est comme cela qu on m’a appris. Le nez est un organe microbien qui supporte mal les corps étrangers. Le risque d’infection est nul avec une greffe, mais non négligeable en cas un implant synthétique , avec pour conséquence un rejet de l’implant. De plus les implants sont peu modelable et utilisés pour les grandes pertes de substances. Alors que l’on peut mettre de tout petits greffons là oú c’est nécessaire . La peau est déjà fragile en rhino. secondaire et supporte mal les corps etrangers. Au fil des années , on voit apparaître différent matériaux d’implants, mais qui finissent souvent par être abandonnés, os de bœuf, gortex, proplast…qui finissent par passez aux oubliettes, quand ce n ‘est pas à la poubelle …De plus ces implants sont souvent chers et majorent le prix de l’intervention . Leurs seul intérêt est la simplicité et le gain de temps opératoire.
Pour résumer , les implants sont surtout utilisés pour les rhinoplastie ethniques des asiatiques qui tolèrent plutôt bien le silicone. Il s’en pose des milliers en Chine et sans problème . En France c’est rare , et a mon avis peu indiqué en rhinoplastie secondaire.
Suite à une R1 ratée, la pointe de mon nez est très remontée et trop projetée (hauteur du nez disproportionnée par rapport à la longueur). Y-a-t’il un espoir ?
Dr Alain BOUAZIZ
Bonsoir il y a toujours de espoir, surtout à l’aube d’une nouvelle année . Déjà il faut savoir si votre intervention est récente , dans ce cas le nez redescendra toujours un peu. Si par contre l intervention est déjà ancienne , alors oui on peut améliorer les choses . L allonger et le reculer un peu . Vous pouvez m envoyer des photos sur le mail .
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