What revision techniques are used to fix a nose made too short in primary rhinoplasty?

Dear no277 in Beverly Hills, California:
If the tip is elevated too much, cartilage can be grafted to the inside to push the tip down.  These are standard techniques.  Also, some people are helped without having a surgical procedure, whereby temporary or permanent filler is placed under the skin just below the tip of the nose to drive the profile “downward.”  It is important that you achieve satisfaction and that is why you should look at all possible alternatives. 

You want to do your homework before consultation.  Prepare well for your consultation.  When you search, look for rhinoplasty super-specialists.  These are surgeons whose practice is the majority or entirely devoted to rhinoplasty, septoplasty, and related procedures.  This would include both primary and revision rhinoplasty surgery.  Why not have the most specialized talent in your service?  Consider how much experience the surgeon has doing the procedure you are considering. We all get better at what we do with time and so those surgeons who have a long run of experience are the ones who have learned the most from experience. Residency and fellowship are where the learning begins, but for all of us, time and experience is where the education continues.

Part of your preparation for consultation should be preparing a list of questions beforehand.  Bring a notepad or ipad or laptop with you and take notes as the surgeon answers the question you are asking.  You should spend more time with the surgeon than with the office administrative staff, because you need to get a sense of whether you are comfortable with the doctor.  You should not feel rushed that you are on a consultation conveyer belt.  If the presentation by the office staff seems a bit to “salesie” that is a bit of a yellow or red light.  Take a friend or relative along since two heads are better than one in gaining information and understanding.  In the end, the purpose of the consultation is for you to be educated and be comfortable, not to be “ sold”.  Ask yourself two key questions: “Is this surgeon teaching me or selling?” And secondly, “Can I put my life and my face into this particular surgeon’s hands? Can I trust him/her?”

There are excellent books out there that you can read and use to study up. It is worth the homework time you put in up front so that you make the right decision with respect to choosing a surgeon who has the talent, experience, and degree of super-specialization that you certainly want to have. 

When you visit doctor’s websites, the most important feature on the site is the before and after gallery.  If there are just a few examples of rhinoplasty or revision rhinoplasty, you wonder how much experience the surgeon has performing such surgeries.  There need to be dozens and dozens of examples.  The more examples there are, the more likely you will see one or more that demonstrate situations similar to yours.  Look closely at the photos for natural results.  That is what you want.  Nobody wants to carry a sign saying “I have had a rhinoplasty.”

Reviews on review sites, particularly RealSelf are very important and should be carefully digested. The larger the number of reviews the most accurate the picture of the practice and particularly the doctor. A consensus is generally correct.

A consultation without computer imaging is, in my opinion, of much less value.  Why shouldn’t you see the predicted result of the procedure the doctor is proposing?  At consultation, photos are taken of you and loaded into a computer system that morphs your present appearance into the anticipated “after” based on the nasal surgeons input.  Imaging is an incomparable learning tool because it provides a forum for doctor and patient agreement on what would satisfy the patient and what is, in the doctor’s opinion, achievable.  After all, cosmetic surgery is 100% visual.  It is about appearance, so without a visual evidence of what is planned, how can you make a decision as to whether or not you might be satisfied.  Talking about it is worthless.  To anticipate a successful outcome, there must be a meeting of the minds between surgeon and patient.

Best wishes,

Robert Kotler, MD, FACS

Over 4,500 nasal procedures performed

Your revision surgery will likely require several structural cartilage grafts to increase the length of your overshortnened nose. Septal extension grafts and extended spreader grafts are used to lengthen the nose and de-rotate the tip. In addition, tip grafts and shield grafts can be used to project and define the tip. Lateral crural strut grafts and alar rim grafts can be used to strengthen the alar cartilages if they have been over-resected. I recommend you consult with a very experienced revision rhinoplasty surgeon. 

Depending on the degree, this can be challenging to fix.  Typically, we would use a technique involving extended spreader and grafts, and possibly a caudal septal extension graft.   In any individual case however, there are many variables that may lead to a different plan. So I would definitely recommend that you seek out a very experienced surgeon to discuss your concerns with.