Edwin Kwon, MD, FACS

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.

What you're describing is often called an A-frame deformity, where the upper eyelid sinks in under the brow bone and the inner corner of the upper lid looks hollow. It can make the brow look heavier and the eyes look tired or older than you are, even at 30. In many cases the brow bone itself isn't too prominent; it just looks that way because the soft tissue below it has thinned out. Fat transfer to the face is a good fit for this concern because it replaces lost volume with your own tissue. Small amounts of nano fat placed carefully along the upper eyelid hollow and just under the brow can soften that shadow, and adding a little to the temples and the upper cheeks often helps the whole upper face look fuller and more youthful. The key for a natural look is restraint, since the eyelid area is very thin and needs tiny amounts placed in fine layers. I centrifuge the fat to disturb it as little as possible, which helps it survive, but some fat is always reabsorbed, so a small touch-up is sometimes needed. When you meet with surgeons, it helps to tell them you feel your upper eyes look sunken and hollow, that you want a soft, natural result rather than an overfilled one, and to ask how they'd balance the temples and cheeks along with the eyes. I'd encourage you to schedule a consultation with a board-certified plastic surgeon so your face can be examined in person and a plan can be tailored to your features.

Changes to your bridge can occur over time but tend to be very subtle. However, in the photos that you provided, the changes appear to be very noticeable and warrant further investigation. It's worth separating a true hump from swelling, though. A hump that is firm, painless, and stays the same from day to day is usually part of the structure of the nose. A bridge that feels soft, tender, warm, or puffier on some days than others, or that comes with congestion, nosebleeds, or trouble breathing, should be checked by a doctor first, because that points to inflammation or another problem rather than a cosmetic shape issue. If it turns out to be a structural hump, Rhinoplasty can lower and smooth the bridge by carefully shaving down the bone and trimming the cartilage, then narrowing the bones if needed so the nose stays straight and balanced with your face. I'd encourage you to schedule a consultation with a board-certified plastic surgeon so your nose can be examined in person and the cause of the change can be confirmed before planning any surgery.

I'm glad the ultrasound came back clear, because it rules out a fluid collection, which is one of the main things we worry about when an older implant becomes painful, swollen, and tight. A two-week cough strong enough to make you choke puts a lot of repeated strain on the chest wall and the muscle sitting over your implants, so inflammation in that area after an episode like this isn't surprising. Since the pain is easing, that pattern fits a strain that is slowly settling. The redness and tightness are worth watching more closely, though. Mild redness that is shrinking and fading usually goes along with that strain, but redness that spreads, warmth, fever, a breast that keeps getting firmer or larger, or a change in its shape should be seen promptly rather than waited out. Anatomical implants are typically silicone gel, and ultrasound can miss a small rupture, so if the tightness or the change in feel persists once the cough-related pain is gone, an MRI is a reasonable next step and is the most reliable way to check the implant shell. In the meantime, finish the medications you were prescribed, avoid heavy chest exercises, and take a photo every few days in the same lighting so you can tell whether the redness is truly improving. I'd encourage you to schedule a consultation with a board-certified plastic surgeon if you can't reach yours soon, so the breast can be examined in person and imaging can be ordered if it's needed.

A bump that was visible the day the splint came off and has stayed the same for two to three years is almost certainly not swelling at this point. Most swelling settles within the first year, so what you're seeing and feeling now is part of the structure of your nose. A one-sided bump usually comes from one of a few things: a nasal bone that healed slightly out of line or was left with a sharp edge or a piece of cartilage along the bridge that sits higher on that side. It is unlikely to be scar tissue if it was present initially. The fix depends on what the bump is made of. A small bony edge can sometimes be smoothed down, while a cartilage step-off may need to be trimmed or repositioned, and in some cases a thin layer of finely diced cartilage wrapped in fascia can be placed to smooth the contour and hide irregularities. Since this would be a revision, it helps to know exactly what was done in your first surgery, so try to obtain your operative report if you can get it. I'd encourage you to schedule a consultation with a surgeon experienced in revision rhinoplasty so the bump can be examined in person and the right approach can be planned for your nose.