14 Months Post Rhinoplasty: Still Swelling or Did I Get a Bad Nose?

Question

After rhinopalsty my nose swelled abnormally, to the extent that I looked almost like a pig. All these months I have been blaming swelling for my below-average results but now I am running out of patience. By looking at these photographs do you think its still the swelling? The tip is puff and sometimes shrinks/expands according to heat level/sweat. The biggest concern, however, is how big and **relatively shapeless** the nose looks on my face, even as I could live with my average profile.

Howard Webster, MBBS (Hons), FRACS · Answer

Hi there.

	Your rhinoplasty has been competently performed without doubt, and I'm not sure your initial swelling was significantly more than average.

	Your preop shows a long, thin, overprojecting nose and you have an above average facial appearance.  It's understandable why you would have sought rhinoplasty surgery.

	On your postops at 14 months there's a lot to like about the result whilst being able to explain your concerns.  You can see from your side and front views that the tip has been deprojected and rotated up as it should be.  Your front view looks fine and the bridge has been nicely done.

	The reason for the appearance you have is that your tip and columella are full, with I suspect medial and intermediate crura which are too long. resulting in a heavy looking bottom half of the tip and a bowed columella.  This creates an impression of a nose that's too long and an upper lip thats too short.

	The solution is a tip revision.  I don't think there is a non surgical option which will help.  The bridge height and shape looks good, and the lateral alae are rotated into a good position.  The tip cartilages are too long however and what's happened when your nose tip was deprojected and upward rotated an apparent down ward rotation of the central tip has occurred  because of the excessive length of the lower lateral cartilage. ( I have caused this problem myself).

	At operation through an open approach, the lateral crura of the lower lateral cartilages need to be shortened or overlapped, and the medial crura need to be shortened ( or the footplates resected which is my preferred way of doing that).

	That's all that needs to be done and I think your rhinoplasty will be excellent.

	As a surgeon, we do not want to shorten the tip supporting cartilages unless we have to, so we will tend to leave them if we are not sure or if we think we have deprojected enough just through the rotation and repositioning.  Its safer to do later if needed, than to overdo at the initial procedure. I stress that I think your rhinoplasty has been well done and that you had a difficult nose initially, it's hard to get that tip short and deprojected enough.  No damage has been done.

	Correcting the problem will take around an hour of operative time, and less of a recovery than the initial rhinoplasty, but not no recovery.

	I hope this makes sense and helps you.

	 

	Good luck.

Eric M. Joseph, MD · Answer

I read your concerns and reviewed your photos:

	You appear to have achieved natural-looking profile-hump reduction and tip rotation. I'm not sure what you mean by the "relative shapeless" appearance of your nose. Your nose does not appear to be too large. In my opinion, your appearance has improved after your Rhinoplasty.

	If you could be more specific as to what is bothering you about your nose, I would be happy to share my thoughts with you.

	I hope this is helpful for you.

	Regards from NJ.

Michael L. Schwartz, MD · Answer

You definitely have some nice changes and shape to your nose. Everyone's aesthetic is diffferent and individual. You need to do some computer imaging to try and better articulate what concerns you and see if you really would like it if further changed. You do have some alar retraction and tip underprojection but whether you would like your nose if these are changed is still unknown.

Joseph Campanelli, MD · Answer

Thanks for the series of photos.  It is clear what your concerns are.  At one year, there is not a great deal of change to occur, so this is your final result.

	When first looking at the pre-operative photos, it appears that you have an over rotated, over projected tip.  This led your surgeon to rotate the tip of your nose up.  This was a mistake.  To understand what I mean, take a look at the preop frontal picture.  The amount of nostril show was near ideal.  From the side, the angle that the nose made with the upper lip was about 90 degrees, again near ideal.  Compare this to the postop photo.  On the frontal picture, you can now see far too much of the nostril (pig nose deformity) and from the side, the tip is over-rotated upwards.

	To be fair, this was a very difficult nose to deal with aesthetically.  Sometimes, you can not create the perfect nose and so it is a matter of determining what you can compromise on and what you can not.  I would have had to think about your nose a great deal prior to your original surgery.  Incidentally, there is where I think photomorphing (changing the photo on the computer to simulate operative results) is most valuable.  It would have demonstrated that rotating the tip was not the way to go.

	The question now is what to do from here?  There is where an in-person consultation is required.  All of the pre-operative aesthetic concerns still exist but now in a post surgery environment.  Make sure you pick a surgeon with a strong background in revision rhinoplasty and make sure you really understand what the goal of the procedure is cosmetically.  Again photomorphing would be a good tool in proceeding forward, so ask for it.

Richard W. Fleming, MD (retired) · Answer

At 14 months after your rhinoplasty, there will only be  subtle changes in the future. If you're not satisfied, talk to your surgeon and/or get a second opinion. After reviewing your pictures it is apparent that you have achieved some improvement but further refinement may be desireable. You do have a hanging columella with some nostril rim retraction. There appears to be a hint of an Inverted V deformity at the lower margin of the nasal bones. Share your concerns with an experienced revision rhinoplasty surgeon. You have been patient.

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