Realistic expectations for a third revision rhinoplasty? Filler a viable alternative? (Photos)

I don't see any reason why we can't improve your results in a meaningful way. There is a twist at the bottom and a cleft between the cartilages. Additionally there is over resection in the supratip area which creates the appearance of a bump.
Using techniques to secure the cartilages well we should get you a great outcome.

Yes, a third (tertiary) rhinoplasty is possible. I would really very carefully research who you would potentially trust to do this procedure. You would need a rib graft. I would go see an American Board of Plastic Surgery certified surgeon with experience in rhinoplasty/revision rhinoplasty. You can look up if your surgeon is American Board of Plastic Surgery certified by Googling "is my plastic surgeon certified?".

Hello and thank you for your question.

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 tip is asymmetric and I'm concerned that camouflaging the imperfections with filler (such as Restylane) does not provide the optimal aesthetic that a surgical correction would. Without the benefit of an in-person, exam, specific areas of concerns from your photographs include the curvature along the supratip and tip, asymmetric nostril show, tip over-projection, and a step-off at the surgical incision along the columella.

I would offer a third rhinoplasty.

The rhinoplasty would involve tip refinement with multiple cartilage grafts. Specifically, the tip refinement would likely involve excision of any scarred tissue/cartilage/sutures along the tip, and tip deprojection with medial crural resection secured to a columellar strut graft, if one is not already placed from your prior surgeries. Other cartilage grafts entailed would likely include extended spreader grafts and extended alar contour grafts. I would also place a mastoid fascia tip graft between the reconstructed tip complex and your skin to (1) reduce cartilage prominence (tenting up of the nasal tip skin by cartilage) and (2) to also create a feminine tip-defining point (subtle natural upturn).

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.

Since you are 5 years out from your last rhinoplasty, the skin has likely healed and is healthy enough to undergo a third 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, 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