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

Question

I had cartilage grafted to my tip 8.5 months ago, and ever since I walked out of the operating room, my nose had been too upturned in my opinion, exacerbating my mid facial deficiency issues. What procedures can help de-rotate my nose to prevent it from looking so projected? Feel free to be as anatomically/surgically technical in your answers. Thank you for your time!

Gerald Minniti, MD, FACS · Answer

Hello,You will need very stiff cartilage to make a graft to push the nasal tip downward.  Whether an extended spreader or a caudal septal graft is used, what's more important is the quality of the cartilage. If your septal cartilage is too thin or insufficient, a small piece of rib should be used, which has the most stable result. Best of luck!

Toby Mayer, MD · Answer

Denotation of the upturned nose can be done using a combination of alar grafts as well as a septal extension graft many examples of this can be seen on my website. Look at surgeons before and after photos and compare results of this procedure.

Marcelo Ghersi, MD · Answer

Hello. I think you have an acceptable result, however, if you want to de-rotate the tip you will need a revision. This will require additional grafts in the form of extended spreader, caudal extension, or infratip grafts.

Aric K. Park, MD · Answer

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.

Robert S. Schmidt, MD · Answer

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!

Arian Mowlavi, MD, FACS (license on probation) · Answer

I do appreciate your concern and ideally your angle could use derotation; however, you need to consider that derotating your nose will also make your nose longer to the point that it doesn't look as nice. You may have to compromise a nose that is too long for a nose that is slightly over rotated. You should consider having morphing imaging to make sure that the trouble of undergoing further extensive surgery which will require an extended septal graft probably using rib cartilage would even be worth it.

Frederic H. Corbin, MD (license restricted) · Answer

Thank you for your question and your nose can be derotated with extended spreader grafts.  So see some experts in your area familiar with this technique Dr Corbin

Richard W. Fleming, MD (retired) · Answer

Unfortunately I've had many patients referred to me for this problem after rhinoplasty surgery. Excess rotation can be reversed with septal extension grafts or grafts inferior to the tip projection point depending on the severity of the problem.

Francis R. Palmer, III, MD (retired) · Answer

Hi, I have performed and taught Rhinoplasty for 30 years.  Once the tip has been over-rotated, it's very difficult to undo.  You can have the lower portion of the columella tucked in which gives the illusion of less tip rotation.  Hope this helps.

Donald Nunn, MD (retired) · Answer

If you are unhappy with your nose you could have a revision.  It may require additional cartilage grafting to lengthen the tip.  It could possibly require ear or rib cartilage harvest if all nasal septal cartilage has been exhausted.  I would wait at least one year from the original surgery.  Good luck.  Donald R. Nunn MD  Atlanta Plastic Surgeon

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