Rhinoplasty 2021. Break in dorsal aesthetic lines and uneven nostrils - can this be improved? (Photos)

Question

I had my rhinoplasty completed in 2021 In Philadelphia. I am no longer in the same area as my surgeon, but I am not 100% happy with my results. The break in my dorsal aesthetic lines is only very noticable in certain lighting, but I am not happy with the appearance. I also now have uneven nostrils and did not have that before. Am I being unrealistic about my expectations for my results?

Eric M. Joseph, MD · Answer

Based on your photos, you appear to have thin nasal skin, and after surgery, I agree that you have excessive nostril show which is asymmetrical, and the curve of your bridge on profile is a bit steep. Microdroplet Silikon-1000 nasal injections may be considered for nostril lowering, and for improving your bridge appearance, depending upon your examination. I hope this helps. Sincerely, Dr Joseph

Alejandro Nogueira, MD · Answer

You had a preoperative "tension nose" tipe of nasal deformity, it is a very peculiar type of nose in which the pyramid or static upper 60% of the nose is overdeveloped to a higher or lesser extent, and the lower 40% (tip, annexes, alae, soft and mobile parts) is tight and constrained by skin hood deficit, making it underdeveloped. The overal philosophy in these types are reduction the enlarged part and augmenting the diminished part, making them meet together at the ideal poing, a very difficult management in all the cases and needind very talented surgeons. However, there is more to this.

A typical mistake happens when the surgeon fails to detect this type of tension noses or ignores its challenges, and believes the pyramidal excess is actual all of it and intends to reduce it to match the lower part (tip and annexes); catastrophic misjudgement, given the actual excess at the upper 60% is magnified by the small size of the lower part, it is never that much in excess, the reduction has to be careful. This was the error in your case, you have a over resected pyramid, scooped dorsum and a saddle nose deformity, making the overal size of your nose massively in disproportion due to lacking the suitable size.

The correct approach is doing a judicious reduction of the dorsum and pyramid to meet what is supposed to be the newly built and augmented tip and alae; reduction is not so difficult, augmenting the hypoplastic lower 40% is really challenging for the surgen, however it is a routing among those practicing high-end structure rhinoplasty cases, like yours and all tension noses.

On top of that, as you well mention, the unsightly lines are an inverted V deformity and an open roof deformity, because no infracturing was made (probably because there was little left to break).

Now you need a very complex revision rhinoplasty using rib cartilage, so better seek the advice and hands of a surgeon with solid experience and talent in complex revision cases, close to a reconstruction given a major part of your nose is missing, the lower part due to congenital issues and the upper part after iatrogenic actions.

Gianfranco Frojo, MD · Answer

Can you please clarify which images are what? Before/after/simulation? It is not clear from the photos presented with your case.

Philip S. Schoenfeld, MD, FACS · Answer

The rhinoplasty result you have is very acceptable.  It is not the nose that I typically create as it is a bit too sloped and rotated for me but like I said, very acceptable.  If you would like to see what some mild changes to the dorsum would look like without undergoing another surgery you may want to explore non surgical rhinoplasty with an experienced rhinoplasty surgeon who also can perform injections to your nose.  I think you would like the result and then can decide how you would like to proceed.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. Based on your photographs, you may benefit from a revision rhinoplasty. This can be designed to improve the symmetry of your dorsal aesthetic lines as well as improve nostril symmetry. With good surgical technique, you could have an outstanding result. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Sean Fisher, MD · Answer

The irregularity of your dorsal aesthetic lines can often be caused by a prior surgery where the upper cartilage structures of the nose are not positioned or supported appropriately. Nostril asymmetry can be due to a number of causes, with the specific treatment being determined based on the specific issue at hand. The only way to confirm exactly what is causing your issue is with physical examination by a surgeon with advanced training in rhinoplasty surgery. I frequently caution patients that perfect symmetry between the left and right side is unrealistic, as almost every patient has some asymmetry at baseline. That being said, you appear to have asymmetries and concerns that are easily identifiable which generally means that with the right techniques-there are improvements that can be made. 
Sean M Fisher, MD Aesthetic Plastic SurgeonSeattle, WA 
To be due to some collapse of your mid-vault where the upper cartilages of the nose meet the nasal bones. This can happen for a variety of reasons, but is typically treated by repositioning the cartilages of the upper nose and may also require cartilage graft to support their position.

William Portuese, MD · Answer

Your photographs demonstrate several different issues that occurred after your surgery, including an inverted V. deformity, an overly rotated nose, and a hanging columella. Revision rhinoplasty is more difficult than a primary rhinoplasty, so choose your second surgeon very wisely based on extensive experience. It would also be important to know how much cartilage is left over on the inside of your nose for grafting purposes, so a copy of the operative report would be helpful.

Rhinoplasty 2021. Break in dorsal aesthetic lines and uneven nostrils - can this be improved? (Photos)

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