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

Question

Had a primary septorhinoplasty to straighten, create more symmetry and reduce the bump. Had a secondary a year later to even the tip points. Five years later and the tip of my nose looks twisted with one nostril slightly bowed and the other collapsed. When I spoke to my surgeon, he favored restylane to create an illusion of symmetry. Is this a viable alternative? Given how I healed after the first surgeries, is it realistic for me to expect improvement with a 3rd?

Jeffrey H. Spiegel, MD · Answer

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.

Gianfranco Frojo, MD · Answer

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?".

Mark K. Markarian, MD, MSPH, FACS · Answer

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

Eric M. Joseph, MD · Answer

Based on your photos, you appear to have relatively thin skin along with nasal tip asymmetry and a left nasal tip indentation. You also have a slightly over projected tip appearance on profile, and a small profile bump. Depending on your examination, microdroplet Silikon-1000 nasal injections may be considered for improving the appearance of your nasal tip by filling the indentation and by camouflaging edges of visible cartilage. Permanent bridge raising may be considered for profile improvements as well. I hope this helps! Sincerely, Dr Joseph

John L. Burns Jr., MD · Answer

With each subsequent procedure, a rhinoplasty become more difficult.  You'll need to seek the care of an experienced rhinoplasty surgeon.  However, your situation is fixable in the right hands.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. Based on your photograph, you are a great candidate for a revision rhinoplasty. Maneuvers for your surgery would include dorsal hump reduction, placement of a mastoid fascia tip graft to improve the smoothness of your tip contour, nasal tip deprojection, tip elevation, among other maneuvers.. 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

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