Revision to lengthen the nose, derotate AND improve natural flexibility?

Question

I know the first instinct is to say 'that's impossible, you need rib grafts to re-lengthen the nose and have derotation, otherwise the scar tissue will draw up the bridge again". But the lack of flexibility, particular downward (lateral movement happens, but I want the nose to move down/inward when touched) is driving me crazy with my current SEG. New therapeutics try to induce scarless healing (e.g. in the ROBO2 pathway). I am sure more therapeutic and AI-guided surgery approaches are on the way. This means scar tissue can be removed with great detail, and after surgery, newly forming scar tissue can be prevented or remodeled to be flexible. Another approach could be vascularized tissue engineered skin grafts, to add skin if the current skin limits expansion (though the sutures need to be hidden). In any case, such approach could allow the lengthening and expansion of the skin, and allow the lengthening of the nose as well, with strong, but flexible cartilage grafts (that may also be tissue engineered), allowing flexibility. The other method would be anisotropic 3D printed osmotic expander grafts, or, more experimental: ligament reconstruction with e.g elastin/collagen/fascia-cell-biosutures, to suspend the nosetip, combined with previous scar removal/new scar inhibition, so the nose anatomy is regenerated. Anyone experimenting with techniques to make a flexible, downward and lateral moving nosetip possible like this? Any other approaches that are possible now?

Kadri Ila, MD · Answer

Your question reflects a very advanced understanding of nasal biomechanics. Let me approach it from a structural standpoint rather than a futuristic one.
Lengthening and derotating the nose are technically possible. In revision cases, this usually requires revising or replacing the existing septal extension graft and rebuilding tip support in a different vector. In many cases additional cartilage support is necessary and depending on available septal cartilage rib cartilage may be considered. The objective is to restore proper projection, length and rotational balance in a controlled and stable manner.
The issue of flexibility is a separate biomechanical concept. A septal extension graft is designed specifically to stabilize the tip. Reduced downward mobility is often the direct consequence of creating structural control. In other words rigidity is not necessarily a complication. It is frequently the byproduct of strong tip fixation.
That said achieving both stability and a natural tactile feel is absolutely possible with current surgical techniques. Modern cartilage shaping methods allow the construction of tip support structures that are strong yet physiologically responsive. When excessive rigidity occurs it is usually related to case specific planning or graft configuration not a limitation of today’s technology.
Scar tissue does have the potential to influence long term positioning particularly in noses that were previously shortened. For that reason revision lengthening must be carefully supported to resist contractile forces. However this is a matter of structural strategy and surgical experience not experimental biotechnology.
With proper planning, combination of right techniques and adequate experience, it is possible to achieve a lengthened, derotated and naturally feeling nasal tip. The key lies in understanding vector control, soft tissue dynamics and balanced graft architecture.
To help illustrate what is realistically achievable today I have included a video below showing rhinoplasty cases and the different nasal tip frameworks that can be created using current surgical methods and technology.
I hope this gives you clarity.

Eric M. Joseph, MD · Answer

Unfortunately, your questions are impossible to answer without examining you, or without looking at photographs. It is true that septal extension graphs can make somebody's nasal tip immobilized. Whether or not somebody could achieve more length to your nose, and lower your nasal tip, would require an examination during a consultation. Thank you. Sincerely, Dr Joseph

Revision to lengthen the nose, derotate AND improve natural flexibility?

Answers (2)

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