What can be done to de-rotate an upturned nose?

I agree that your nose is slightly over rotated. To correct this requires strong cartilage to push the tip downwards against the contractile force of the skin. Whether your surgeon uses extended spreader grafts, caudal extension grafts or others to counter rotate you, what is important is the cartilage is strong and will resist torquing or twisting as healing occurs. This typically means irradiated rib or your own rib as most Asians have very little extra septal cartilage and you have already had a graft placed. An alternative is to use camouflage grafts (shield / crushed cartilage) to make the infratip look heavier. This works if you do not want a significant amount of counterrotation. In my hands I do this with an open technique to give me the best possible visualization of the field. There are a few surgeons who will attempt it with endonasal (closed) technique but this is much more technically difficult an thus an increasingly rare skill. What matters most is what your goal is- how much counter rotation and if you want any subtle changes to the tip such as more columellar show or a fuller infratip. Hope this helps.

Here are ways that we de-rotate a nose:1) Extended middle vault spreader grafts- these grafts are great because they will open your middle vault, improve your breathing, and will push your nasal tip down. Depending on what you've had done to your nose before, this might be the best strategy for you.2) Medial crural overlay- the medial crura are the portions of the lower lateral cartilages that live in the columella. By incising them and overlaying them- like telescoping them on themselves- you shorten this portion of the nasal tip tripod and bring the tip down. This maneuver also de-projects the tip. 3) Tip graft- a piece of cartilage would be placed along your columella. It would need to be thin at its base and thick at the part that goes in the infra-tip region. This maneuver can add to your tip projection as well.From these pictures, your projection looks good. Depending on your height, your nose is borderline overly rotated. In my hands, option #1 above in a revision procedure would probably do the best. Good luck!