Two years after my rhinoplasty, it's officially a bad result. What can be done? (Photos)

Question

I had rhinoplasty two years ago, unfortunately it left me with obvious issues: 1- unsymmetrical nostrils where the right nostril is higher than the left. 2- alar retraction where my nostrils show more. 3- collapsed bridge (hour glass nose shape) and polly beak 4- longer upper lip. Also I always had lower mouth corner in the right than left, and the higher right nostril after surgery made my right side uglier because it increase the space between mouth corner and nose, less balanced face features

Alejandro Nogueira, MD · Answer

I deal reagularly with revision rhinoplasty cases, and these are my comments about your preop nose, the rhinoplasty received and the suitable corrections:
-the assymmetry: was pre-existent, as in any human face and nose both halves are uneven, in your case slightly and this has, unfortunately, no feasible or realistic correction; however, it is true there is a iatrogenic assymmetry added on top of your natural assymmetry, due to assymetrical work on your alar cartilages (lateral cruras) which may deserve attention and revision; causes are unclear until direct intraop visualization of the problem, however it is likely there was a kind of over or random resection of the right lateral crura; solution is open structure rhinoplasty technices like alar batten grafts
-alar rim retraction and columellar show: this was also pre-existant, and also true was slightly aggravated due to the resection of the cephalic excess of the lateral cruras, probably a bit of over resection associated to a natural born nostril rims prone to be retracted which were unaddressed; the solution is quite standard: batten grafts mounted as caudal extension push grafts, eventually with rim grafts or long caudal grafts inserted into the rim pocket; regarding the columellar show you may benefit of a very cautious sink (never totally sunken) with the tongue-in-groove securing of the medial cruras sutured to the caudal septum
-open roof deformity + inverted V deformity: a typical duet; your surgeon failed to perform competent osteotomies to close the roof after the dorsal hump removal, so you ended with open roof and the always associated and linked to open roof inverted V deformity, due to dislocation between the bony (nasal bones) and cartilagenous (upper lateral cartilages) nasal walls; solutions are also way standard: perform osteotomies and widen the pinched middle vault with, in your case, very finely calibrated and extremely thin spreader or spacer grafts (you have a thin nose and it is a real risk over correcting the spreader grafts ending in a broad dorsum)
-irregular dorsum: the dorsum does not show any polly beak deformity, however the profile is not straight, and IMHO is still a bit too high, so regularization by shaving down a bit further (I am not talking about a sunken dorsum) can be the solution, and if not enough a temporal fascia graft would provide the definitive smooth dorsum
-the tip is almost virgin: oversized, poorly defined, still overprojected; all this needs revision and primary tip work, eventually with tip Sheen's graft and maybe others.
-the long upper lip was pre-existent and not aggravated by the rhinoplasty, however if you wish to shorten it you could opt for an indirect lip lift and philtrum shortening (aka bullhorn lift), however do weigh the involved scars
You need to find a real expert in revisions, yours is a 8 out of 10 scale of difficulty in revision rhinoplasties; your goals are high and the defects, all obvious, are fine and minor, therefore not only experience and skills count, also the ability of the surgeon to preform fine and tiny adjustments, since your run a real risk of ending in good and expert hands but unable to calibrate narrowly. Surgical time 4-5 hours; donor sites of cartilage will be septum and, if necessary, ear's concha bowl and fascia temporalis from the temple.
Most surgeons will tell you the nose is acceptable, you have to be realistic, they may feel willing to comply with one or two adjustments, etc, and this is very reasonable and understandable, we all try to offer our patients what we know and master, and very honestly we try to avoid gestures or committments we can't comply with or keep. I would accept you without hesitation for a complete overhaul revising every and each of your nasal pitfalls down (or up) to the right point of calibration.Final comment, I could not help (based on my experience) to let you know you are a perfect case for a three dimensional osseous genioplasty in order to perform:-moderate vertical increase-slight anterior increase / projection-moderate horizontal narrowing The former would provide a magnificent facial balance and and awesome feminization effect.
If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, also underneath the nostrils.
Feel free to request any additional information from me.

John Michael Thomassen, MD · Answer

The nostril asymmetry is not very apparent.  I would consider a revision to address residual dorsal hump and to refine your tip for better symmetry.

William Portuese, MD · Answer

Your nose is not as bad as you think it is. The nostrils are quite symmetrical and are within tolerance. There's no alar retraction. There is a small amount of residual cartilage the lower one third of the nasal dorsum which can be shaved down to give a better side profile. The upper lateral cartilages appear pinched creating the hourglass appearance from the frontal view, for which spreader grafts can accomplish improvement. Your perceived  increased upper lip distance is due to head positioning in the photographs. The hanging columella can also be reduced. Revision rhinoplasty is more difficult than a primary rhinoplasty, so it's important to choose your surgeon very wisely based on extensive experience. It's  even more important to have realistic expectations about what can AND cannot be accomplished with  a revision  rhinoplasty procedure. There is no perfect nose. For more information and many examples of revision rhinoplasty, please see the link and the video below. Remember there is no perfect nose, only improvement!

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