Edwin Kwon, MD, FACS

I'm sorry you've been dealing with this for so long. Some tenderness after fat grafting to the brow is common for the first few weeks, but deep, recurring pain more than a year later isn't typical and deserves a proper evaluation. The mid-to-inner brow is where the supraorbital and supratrochlear nerves exit the bone to supply sensation to the forehead, and a hot or burning twinge is a classic sign that a nerve is irritated. One possibility is that a nerve was irritated by the cannula during grafting, or that fat or scar tissue now sits tightly around it where it exits. Fat that doesn't survive can also form small oil cysts or areas of fat necrosis, which can cause inflammation and pain even when you can't feel a distinct lump. Pain that worsens with swelling fits with pressure in a tight space. Less often, the cause is unrelated to the grafting, such as the frontal sinus or a migraine or tension-type headache, so those should be ruled out as well. An ultrasound performed by someone experienced with facial soft tissue is a good first step and can show cysts, fat collections, or firm scar near the nerve. An MRI gives more detail if the ultrasound is unclear. A small numbing injection near the nerve can also help confirm the source, since temporary relief points to the nerve being involved. Depending on the findings, treatment may include a steroid injection, medication for nerve pain, or careful removal of fat or release of scar that is pressing on the nerve. Not having pre-op photos makes comparison harder, but an exam and imaging will tell you more. I'd encourage you to schedule a consultation with a board-certified plastic surgeon experienced in facial fat grafting who can examine your brow in person and help pinpoint the cause.

Although it is apparent in the photo that you attached, I am curious to see how your face looks when it is in repose and not smiling. If the indentation is present when you are not smiling, it is likely a contour deficit, while if it only appears when you are smiling, it may have more to do with your facial muscles. The location of the indentation may indicate that it is a festoon line, which cannot always be resolved with more volume augmentation. A way to determine this is to utilize either fillers or even saline to see if injection into this area can make the dent go away, even temporarily. If it does go away, repeat fat injection to this area may solve your issue. If, however, it does not go away or becomes even deeper, it may indicate that the festoon line is not going to be improved with further fat transfer. I'd encourage you to schedule a consultation with a board-certified plastic surgeon experienced in facial fat grafting and revision eyelid surgery so the fat, the hollow, and your skin can be evaluated in person.

Extra nostril show in profile along with a small triangular notch at the top of the nostril is a common pattern of alar rim retraction. It usually comes from the rim being pulled upward rather than from too little tissue at the edge. However, in your case, you have very minimal retraction, and the amount of nostril show appears to be within normal variation. Alar rim contour grafts are thin strips of cartilage placed along the edge of the nostril. They work well to support a rim and smooth out mild notching, but on their own they often lower the rim only minimally. When the retraction is more noticeable, the lining inside the nostril often needs to be released, and a small composite graft of skin and cartilage from the ear is added to lengthen the lining so the rim can actually come down. Although there are minor changes or improvements that you can seek, there does not appear to be anything about your nose that attracts unwanted attention, and thus, even if you undergo revision surgery, you may only see small changes. If the amount of nostril show is really bothering you, I'd encourage you to schedule a consultation with a board-certified plastic surgeon experienced in Asian and revision Rhinoplasty so your rims, lining, and tip support can be examined in person.

Some settling of the tip after Asian Rhinoplasty is common, and it usually has more to do with tip support than with the implant itself. An S-shaped implant mainly builds the bridge, while the tip is held up by your own lower cartilages and the ear cartilage that was added. Ear cartilage is soft and naturally curved, so under the steady pull of the skin and healing scar tissue it can bend or flatten a little over the first year or two, and the tip can rotate slightly downward as a result. Keep in mind that cartilage doesn't show up well on an X-ray, so the images mainly tell you whether the implant has shifted, not what the tip cartilage is doing. Braces can also change the position of the upper lip and teeth, which can make the tip look different in profile even if the nose hasn't moved much. Comparing photos taken at the same angle and lighting every few months is a more reliable way to tell whether the change is ongoing. Most of this settling happens early, so at 1.5 years any further change is usually slow. If the droop is mild and stable, many patients choose to leave it alone. If it bothers you, a revision would focus on stronger tip support, often with a firmer cartilage graft such as septal or rib cartilage, and some patients prefer to replace the implant entirely with diced cartilage wrapped in fascia at the same time. I'd encourage you to schedule a consultation with a board-certified plastic surgeon experienced in Asian and revision Rhinoplasty, ideally after your orthodontic treatment is finished, so your tip support can be examined in person.

A lump that shows up months after Rhinoplasty and slowly becomes more noticeable is a fairly common late change, and it usually isn't new tissue growing. As the swelling fully settles over the first year or two, the skin over the tip shrinks down onto the cartilage framework underneath. When the tip skin is thin, an edge or corner of cartilage, a slightly uneven graft, or even a suture knot can start to show through. A lighter or whitish color often means the skin is stretched tightly over that point, which is why it can look more obvious with time rather than less. The right fix depends on what the lump actually is, and that needs an in-person exam to feel how firm it is and whether it moves. A small, isolated irregularity can often be trimmed or smoothed through a limited approach, and a thin layer of soft tissue such as fascia or even ADM can be laid over the tip to add padding and keep edges from showing again. If the cartilage has shifted or the tip support is uneven, a more complete tip revision may give a more lasting result. Filler is sometimes used to hide small irregularities, but in the tip of a nose that has already had surgery, where the skin is thin and the blood supply is more delicate, it should be approached with caution. At 15 months, your nose is close to settled, so this is a reasonable time to start planning. I'd encourage you to schedule a consultation with a board-certified surgeon experienced in revision Rhinoplasty so the tip can be examined in person and the right approach can be chosen for you.

Many of the changes on your list are reasonable to aim for, but a few of them pull in different directions, and that is worth understanding before you settle on a plan. Bringing the nostrils closer together is usually done with an Alar Base Reduction, which removes a small wedge of tissue where the nostril meets the cheek. That tends to make the openings slightly smaller, not larger, so it works against your wish for bigger nostrils. Narrowing the columella by bringing the inner cartilages together at their base can open the nostrils a bit and may partly offset that. The rim is the most delicate item on your list. Taking 1 to 1.5 mm from an edge with so little substance leaves almost no margin for error, and I understand your concern about grafts adding bulk. Keep in mind, though, that making the tip smaller also takes away some of the support the rims rely on, and a rim that is both thinned and unsupported is more likely to buckle or retract as it heals. Heavier skin also softens fine detail, so a refined tip usually depends on a strong, well-supported framework underneath rather than simply removing cartilage. Straightening the nose and creating smoother lines along the bridge from the front are generally achievable through work on the septum and careful reshaping of the nasal bones. With thicker skin, swelling lingers longer, and the final shape can take a year or more to show. I'd encourage you to schedule a consultation with a board-certified plastic surgeon who can examine your skin and cartilage in person and help you decide which of these goals matter most to you.

Editing your own photos is a helpful way to show a surgeon what you're hoping for, and the change you made is a subtle one, which works in your favor. Thinning the rim by about one seventh is a modest goal, and a small refinement like that is often within reach. It's important to keep in mind, though, that the rim is only a few millimeters thick to begin with, so the actual change in tissue is very small, and surgery can't be controlled to the exact fraction the way a photo edit can. The rim has almost no cartilage support, so this is an area where a little goes a long way. Tissue can be carefully thinned from the inside of the nostril, but removing too much can cause notching, a pinched look, or a rim that pulls upward and shows too much of the nostril. That last point matters for you, because a slightly larger opening can look good, but an opening that gets larger because the rim has lifted usually looks unnatural. In some noses, a small cartilage graft along the rim is used to keep the edge smooth and supported after thinning. Skin thickness also plays a big role in how crisp the result looks. Swelling in the nostril rims can take many months to settle, so the final shape is something you judge closer to a year out rather than in the first few weeks. Your morph is a reasonable starting point for that discussion. I'd encourage you to schedule a consultation with a board-certified plastic surgeon so your rims and skin can be examined in person and you can find out how closely your goal can be matched safely.

An L-shaped silicone implant runs down the bridge and bends into the tip, so the end of the implant sits under some of the thinnest, most mobile skin on the nose. Over the years, that constant pressure can thin the tip skin. There isn't a set number of years before a revision is needed, and many implants stay stable for a long time. What matters is how the tip skin looks and feels. Redness that doesn't fade, skin that looks shiny or thin, an edge you can see through the skin, tenderness, or any opening or drainage are warning signs that the implant may be working its way out, and those should be seen promptly. Once the skin breaks down, it's much harder to get a good result. For an L-shaped implant, the most common fix is to take pressure off the tip by removing the implant or replacing it with a shorter bridge-only implant, then supporting the tip with your own cartilage. A lot of patients prefer to replace the silicone entirely with diced cartilage wrapped in fascia, which avoids a foreign implant and risk of future infections in the nose. A closed approach can work for a limited change, but rebuilding the tip and narrowing the nostrils is usually more precise with an open approach. I'd encourage you to schedule a consultation with a board-certified plastic surgeon experienced in implant revision so your tip skin can be examined in person and the safest option can be planned.

Fat grafting and facial implants can both add projection, but they do it in different ways, and which one fits depends on how much change you want and how sharp you want the result to look. Fat adds soft volume. It's very good at filling hollows and rounding out an area, but it doesn't hold a crisp, angular edge the way a solid implant does. For the areas you mentioned, the answer may be different for each one. The under eye and upper cheek region often responds nicely to fat, because the goal there is usually smoothing a hollow and softening a flat look rather than creating a defined edge. The area beside the nostrils can also be supported with fat, though a recessed maxilla is a bone issue, so fat can soften it but won't truly bring the base of the face forward. Widening across the zygomatic arch is where fat tends to have a harder time. In men, width in that area looks best when it's crisp and structural, and adding enough fat to get there can end up looking full or puffy rather than strong. Some patients do best with a combination, using an implant where structure matters most and fat to blend and soften the transitions. Since you already have a chin implant, your overall balance from the front and side views should also be part of the plan. I'd recommend a consultation with a board-certified plastic surgeon so your facial skeleton and soft tissue can be evaluated in person and the right mix of options can be discussed.

Dark circles at a young age are very often a mix of causes rather than just one, and the stretch test you did is a helpful clue. When pulling the skin smooth makes the area look noticeably better, part of the darkness is a shadow from a hollow tear trough. The color that stays behind after stretching usually comes from pigment in the skin itself or from thin skin letting the blood vessels underneath show through. Fat transfer can be a good option for the volume part of the problem. Placing small amounts of your own fat along the tear trough and the upper cheek fills the hollow so light no longer catches it as a shadow, and the added layer of tissue can also soften some of the bluish or purple tone from vessels showing through thin skin. I centrifuge the fat to disturb it as little as possible, which helps more of it survive, but the under eye skin is very thin, so the fat has to be placed in tiny amounts and fine layers to avoid lumps. It's also fair to expect that some fat will be reabsorbed. What fat won't change is true pigment in the skin. That part is better treated with skin care and in-office skin treatments, and many patients do best with both approaches together. I'd encourage you to schedule a consultation with a board-certified plastic surgeon so your under eye area can be examined in good lighting and the right combination of treatments can be planned for you.