One of the hardest class of patients that we see are patients who have undergone not just rhinoplasty but at least one two or three previous revisions and are now at a state where they are wondering if it is safe for them to undergo the procedure. There is a constant fear of the Michael Jackson effect where they are scared that they are going to lose their nose and they want to know if it even safe for them to receive the procedure. These are patients who are very often at the end of the road. They feel like they have lost hope and trust. They don’t know who to listen to anymore in terms of what’s possible and we feel an even greater responsibility on our shoulder to be honest with them from the get go in terms of exactly what they can accomplish. We never over promise but for many of those patients if they’re now in the hands of revision rhinoplasty experts who have a lot of experience dealing in these things there can still be significant benefits to be had. What we will tell most of these patients is that probably the most important factor to look at is the skin quality itself. If you don’t have any give to the skin, then often there’s only so much you can do. Second if there is a lot of scar tissues you’ve got to be willing to understand that were going to go in and take out all that scar and it’s going to look great. A year or two years later it’s going to look great and better than it does but you’re going to have to buy into the idea that in 10-15% of those people you’re going to have to remove that rind again. It’s also important that the surgeon isn’t just wedeling away and they’re not constantly going back and removing more structure. It’s important that if you’re going to go back and do something its most and foremost to stabilize make sure the nose is able to hold up and has new supported strength. And that’s where building back structure makes all the difference. For many patients they’ve had reductive rhinoplasty where they had too much cartilage removed and maybe another surgeon would try to take even more cartilage away and that’s where even more problem can happen. These include collapse, breathing issues, twisting and loss of support and these tends of issues tend to get worst overtime. Were very big fundamentalist in terms of building back structure and support to the nose so that this is the last rhinoplasty that you’ll have to have and that sets you up for the rest of your life to really be able to breathe comfortably and have a shape that stays that way as you age, and it ages better than if you’ve never had anything done. It’s important that increasing support and strength does not equate to bigger nose. There is a big difference between these two things. You can remove scar you can do things to make the nose smaller if your building support so that the skin has somewhere to contract. Sometimes it does equate to a bigger nose for people a lot of patients have been over shortened or have been scooped out and looks really unnatural one of the hardest things to do in revision rhinoplasty is to be able to restore length to take a tip that been over shortened and bring it back to a normal natural length we found that using rip grafting over hundreds of patients over many years wave been able to get to a place where we can honestly tell patients we can get a very nice change. The one caveat is to discuss is the skin quality. If the skin has been previously injured, we sometimes must have a discussion on the limitations of surgery. But even then, in many cases we can do very well. So, what we’re saying is that if you’re asking if you’ve done too much and if you should go further, you should see someone who has a lot of experience in revision. This is not the sort of things where you see a surgeon who does a handful a year these have to be people who are doing 50-150 cases a year.