Second revision rhinoplasty: I don't have much cartilage left, what are my options?

Hi Tila.gh,
Great question!  Don't be devastated, as there are multiple options for you.  Looking at your photos, it appears that you still have some excess height of your dorsum (the so called "bump"), some tip asymmetry, a "pinched" middle vault of the nose, and perhaps a slightly overprojected tip.
Having had several prior rhinoplasties, it is not uncommon that there is not enough septal cartilage remaining.  When this is the case, those of us who are experienced with revision rhinoplasty turn to three main options: autologous (your own) rib cartilage, cadaveric rib cartilage, or else ear cartilage.  Each of them has their unique characteristics and benefits.
I would suggest that you set up a consult with a facial plastic surgeon who is experienced with revision rhinoplasty to discuss your options and your nose in greater detail!
Hope that helps.
Dr. Paquet

Overall your nose has a nice shape, but I agree that it could use refinements on symmetry, profile, and a pinched middle portion of the nose.  Some additional cartilage is going to be necessary to achieve the result you desire (spreader grafts and a columellar strut.).  Often even after previous rhinoplasty there is some residual cartilage from the septum that can be used. Not a great deal is needed.  Although ear cartilage is a possible source it is too soft and floppy to be ideal.  In order to do your nose, you would have to be open to the possibility that rib cartilage would have to be harvested. Since only a small amount is needed a very small incision could be used, and just a part of the rib could be shaved.  If it were needed it would add 30-45 minutes to the operation.  It is best to seek out an opinion from someone experienced with revision rhinoplasty and the use of rib cartilage.

Revision rhinoplasty is tricky even in the best hands. The pictures do show some convexity to the bridge and possible slight pinching. I recommend a consultation to discuss these issues in detail and learn your goals to make the best possible plan. Best wishes

 A second revision rhinoplasty will be a difficult endeavor, so it's important to choose your surgeon wisely based on extensive experience. The dorsal hump that is present appears to be mostly composed of cartilage which can be used for spreader graft placement to widen the nose. The hanging columella is composed of both skin and cartilage, which can be reduced  and the cartilage can be used for other grafting purposes. Ear cartilage can also be used when necessary. 

It is often the case in revision rhinoplasty that there is disruption of normal anatomical relationships, scarring, cartilage deficiency and skin retraction which can result from the destructive maneuvers of prior surgery....  in my experience doing revision rhinoplasty, I have found the most limiting factor to be the quality of the skin envelope.... provided the skin is permissible, there is almost always the potential to improve nasal aesthetics and function.... septal cartilage is usually the 1st choice given its high quality, ease of harvest and proximity to the surgical site..... although ear cartilage has a role, my go to choice is rib cartilage when septum is insufficient... a single site yields abundant grafts of all shapes and sizes....other than a modest inframammary scar and additional temporary discomfort, there are no significant drawbacks in younger patientsGood luck

Cartilage shortage is not an issue.  We can access ear cartilage or rib.  Both are excellent donor sites.  A complete surgical plan addressing your concerns will be developed during your in-office consultation.  Seek out a board-certified revision expert.  Best wishes.

Based n these pictures a second revision does seem appropriate. Harvesting from the nasal septum , the ears, or finally the ribs there is an adequate source of cartilage to augment and reconstruct your nose.