Mark K. Markarian, MD, MSPH, FACS

Hello and thank you for your question. Although photographs and an exam in person is ideal, from your story alone, I will tell you that yes, it is a possible to augment the radix for a permanent solution not achieved with fillers. With that said, oftentimes filler may not dissolve completely and remnants can remain permanently. My surgical solution to augment the radix involves the careful placement of mastoid fascia and diced cartilage along your dorsum instead of a rigid cartilage graft (or implant) that may be palpable, prominent, and potentially "unnatural" in appearance. Would this be an open rhinoplasty? I only perform open rhinoplasties -- this offers me the best exposure to your "osseo-cartilaginous framework" i.e. the bones and cartilages of your nose. Would this be the same recovery as prior rhinoplasties? Every rhinoplasty (or surgical intervention) increases scarring and can therefore potentially add to the recovery time. However, if bones are not broken to narrow the nose, this can reduce the recovery time. Furthermore, I perform steroid injections frequently during your recovery period which not only speeds up the resolution of your swelling, but also reduces the scarring under your skin -- both factors help your recovery overall. Is the surgery risky? Every additional rhinoplasty adds risk due to the potential disruption of blood supply to the skin. However, if your nasal skin is not too thin, you're a healthy non-smoker, and at least a year has passed since your last surgery, the overall surgery risk is significantly reduced. Is excision of scar tissue easy to do? In my opinion, rhinoplasty is the most difficult surgery in aesthetic plastic surgery. However, scar excision, especially from the nasal tip, is something I do routinely in my practice and carries minimal risk in my experience. Due to your prior rhinoplasties, the cartilage in your septum was likely harvested and so you will likely require MTF (Musculoskeletal Transplant Foundation) aka cadaver cartilage to perform this revision rhinoplasty. Also note that if your septum is deviated and you have breathing difficulty, a revision septoplasty may benefit you as well, which can be covered by health insurance. The next step for you is to pursue the right aesthetic plastic surgeon for your revision rhinoplasty. In your rhinoplasty consultation, be sure your surgeon addresses all your aesthetic goals and concerns specifically, and discusses the surgery details including the position and size of the incisions used (with actual photographs and not just digital animations), the risks and benefits of the procedure, recovery time, and post-operative course. Also, be sure to see plenty of before-and-after pictures in women who have a similar nose appearance to yours, and preferably at different time frames (3 weeks out, 3 months out, etc) to more accurately predict your own surgical outcome. After seeking out a board-certified plastic surgeon who specializes in aesthetic plastic surgery, I think the most important component of the consultation is to establish a good connection with your plastic surgeon. It’s the connection that allows you to clearly define your desired nose outcome goals, the first step of this whole process. If you don’t feel you have a good connection with your plastic surgeon after your consultation, he/she may not be the best surgeon for you. For more information on rhinoplasty, please refer to my link below. Good luck. Mark K Markarian, MD, MSPH, FACS Harvard-trained Board Certified Aesthetic Plastic Surgeon

Hello and thank you for your question and photographs. First off, it's important to recognize that complications happen to ALL surgeons, and any surgeon that does not have complications or any suboptimal results is either not operating enough or lying. With that said, although an exam in person is ideal, from your photographs alone, I agree that your nose is slightly crooked with an asymmetric tip and nostril collapse. I would recommend the following: (1) Straighten the nose: excision/revision of any cartilage grafts already present in your nose with extended spreader grafts -- this can improve any crookedness, and add further stability to the tip by connecting to the tip complex. Moreover, by placing "sleek" grafts, this can also slightly narrow the nose overall. If the top (bony) third of your nose is also slightly asymmetric (or crooked), the surgery may also involve osteotomies (bone breaks) to narrow the bony portion of your nose. (2) Stabilize the nasal tip: revision of the nasal tip with cartilage grafts to improve stability, symmetry, and reduce the risk of nostril collapse. Deprojection of the nasal tip can also add tension (and further sturdiness) to help with the overall integrity and stability of the nose. The surgery I perform to achieve this also involves excision of any soft tissue scarring, placement of a columellar strut graft connected to the extended spreader grafts (mentioned earlier) and placement of new extended alar contour grafts to stabilize the nostrils and minimize the risk of nostril collapse. I would also place a mastoid fascia tip graft (with additional soft cartilage) between the reconstructed tip complex and your skin to (a) reduce cartilage prominence (tenting up of the nasal tip skin by cartilage) and (b) to also create a feminine tip-defining point (subtle natural upturn). To cut the long story short -- I would suggest a revision rhinoplasty and I am confident you can get the result you wanted -- improved tip symmetry without nostril collapse and improvement of any crookedness in the nose. Due to your prior rhinoplasty, the cartilage in your septum was likely harvested and so you will likely require MTF (Musculoskeletal Transplant Foundation) aka cadaver cartilage to perform this revision rhinoplasty. Also note that if your septum is deviated and you have breathing difficulty, a revision septoplasty may benefit you as well, which can be covered by health insurance. If you are at least 1 year out from your rhinoplasty, the skin has likely healed and is healthy enough to undergo a surgical intervention. The next step for you is to pursue the right aesthetic plastic surgeon for your revision rhinoplasty. In your rhinoplasty consultation, be sure your surgeon addresses all your aesthetic goals and concerns specifically, in person, and discusses the surgery details including the position and size of the incisions used (with actual photographs and not just digital animations), the risks and benefits of the procedure, recovery time, and post-operative course. I also think a key component of your consultation is to establish a good connection with your plastic surgeon. It’s the connection that allows you to clearly define your desired nose outcome goals, the first step of this whole process. If you don’t feel you have a good connection with your plastic surgeon after your consultation, he/she may not be the best surgeon for you. For more information on rhinoplasty, please refer to my link below. Good luck. Mark K Markarian, MD, MSPH, FACS Harvard-trained Board Certified Plastic Surgeon

Hello and thank you for your question -- a very good question at that ☝️ The short answer is that carefully placed spreader grafts (to stent open your internal nasal valves) when combined with careful osteotomies to narrow the nasal bones will not widen your nose. The long answer is as follows.., Many factors can create difficulty with your nasal breathing: (1) internal nasal valve collapse, (2) external nasal valve collapse, (3) a deviated septum, (4) internal bone obstruction, and others... Each of these etiologies can be individually addressed in surgery and be combined with other surgical maneuvers to prevent widening of your nose. Those 4 factors are discussed below... (1) Internal nasal valve collapse is essentially when the side cartilages are collapsed onto your septum. Cartilage is cut into small segments called "grafts", and are used to "spread" this valve open, hence the name "spreader grafts" -- this is what your doctor was likely referring to when repairing your nasal valve. (2) External nasal valve collapse (aka nostril collapse) can be treated by again stenting your nostrils with carefully placed grafts to stabilize each nostril (also called ala) and are called alar contour grafts or alar strut grafts. I place extended alar contour grafts to stent your nostrils open and add stability to your nostrils routinely in all my rhinoplasties (and septoplasties). (3) A deviated septum can be corrected by straightening the septum or cutting out the portion of your septum that's deviated -- this is called a septoplasty. (4) Inner bony obstructions that disrupt airflow in your nose can be debrided, excised, or shaved down to improve your breathing. Again, all of the above can be done without widening your nose when combined with other careful surgical maneuvers. Moreover, health insurance can cover all this at minimal cost to you☝️ If you have any cosmetic concerns, a rhinoplasty can also be performed to improve your nasal appearance. The next step for you is to pursue the right plastic surgeon for your septoplasty, with or without a rhinoplasty. In your consultation, be sure your surgeon addresses all your functional (and aesthetic) goals and concerns specifically, IN PERSON, and discusses the surgery details including the position and size of the incisions used (with actual photographs and not just digital animations), the risks and benefits of the procedure, recovery time, and post-operative course. I also think a key component of your consultation is to establish a good connection with your plastic surgeon. This is difficulty to do without seeing your surgeon in the office, in person. It’s the connection that allows you to clearly define your desired nose outcome goals, the first step of this whole process. If you don’t feel you have a good connection with your plastic surgeon after your consultation, he/she may not be the best surgeon for you. For more information on septoplasty, please refer to my link below. Good luck. Mark K Markarian, MD, MSPH, FACS Harvard-trained Board Certified Aesthetic Plastic Surgeon

Hello and thank you for your question. Although an exam in person is ideal, from your photograph alone it appears that you have a deviated septum -- the key issue is if this causes a functional deficit i.e. any difficulty with your nasal breathing. You mentioned that you "breathe very deeply." If you mean that you have nasal airway obstruction, you can likely benefit from a septoplasty where the deviated septum is revised, excised, and re-set as necessary; any further breathing difficulty can also be improved with spreader grafting -- health insurance can cover all this at minimal cost to you☝️ If you have any cosmetic concerns, a rhinoplasty can also be performed. The next step for you is to pursue the right plastic surgeon for your septoplasty, with or without a rhinoplasty. In your consultation, be sure your surgeon addresses all your functional (and aesthetic) goals and concerns specifically, IN PERSON, and discusses the surgery details including the position and size of the incisions used (with actual photographs and not just digital animations), the risks and benefits of the procedure, recovery time, and post-operative course. I also think a key component of your consultation is to establish a good connection with your plastic surgeon. This is difficulty to do without seeing your surgeon in the office, in person. It’s the connection that allows you to clearly define your desired nose outcome goals, the first step of this whole process. If you don’t feel you have a good connection with your plastic surgeon after your consultation, he/she may not be the best surgeon for you. For more information on septoplasty, please refer to my link below. Good luck. Mark K Markarian, MD, MSPH, FACS Harvard-trained Board Certified Plastic Surgeon

Hello and thank you for your question. I am unsure from your question if you are 1 or 2 years out from surgery -- the title of your question states 28 months, and the question stem mentions you had your surgery last June... In general, it takes 12-18 months to fully heal from a rhinoplasty or septoplasty, with some patients experiencing improvement in swelling even after that period. Regardless, whether you're 1 or 2 years postop -- overall stiffness, hardness, and scarring should be significantly improved at this point. Steroid injections can help soften the scarring. Sometimes, Accutane can also help with the nasal skin thickness. How is your breathing? If your septoplasty has not improved your breathing, you may need to consider a revision septoplasty where the residual deviated septum is revised, excised, and re-set as necessary; any further breathing difficulty can also be improved with spreader grafting -- health insurance can cover all this at minimal cost to you☝️ Your nose does not appear to be deviated, but if you have any cosmetic concerns, such as nasal droop when smiling as you mentioned, a rhinoplasty can also be performed to revise your nasal tip overall to create a more refined look. Structural support with careful cartilage grafting can also prevent tip droop when smiling. I would recommend discussing your concerns again with your surgeon, and suggesting steroid injections or potentially Accutane. If you don’t feel you have a good connection with your plastic surgeon after your consultation, he/she may not be the best surgeon for you. For more information on septoplasty, please refer to my link below. Good luck. Mark K Markarian, MD, MSPH, FACS Harvard-trained Board Certified Plastic Surgeon