Nose still downward turned after revision? (Photo)

In the revision operations that I perform, the most common problem is that the nose was left too long in the previous operation(s). Plastic surgeons are often taught that it's "easy" to elevate a tip (just shorten the septum, do some other stuff), but in fact, shortening a nose--raising the tip--requires rather complicated work on the tip cartilages, something that the great majority of plastic surgeons never learned or can't handle with skill and judgment. Especially if the tip needs to be elevated a large distance, as with your nose (no offense!).

The good news is that, in skilled hands, elevating the tip is one of the most predictable changes to accomplish, even in a revision.

What about the swelling? The reduction in swelling that occurs after seven months can make the nose look less wide, but it does not cause the tip to elevate at all. So, even though you wouldn't be a candidate for another operation until another five months or so have passed by, I can state with some certainty that your nose will not shorten to your satisfaction during that time.

How *much* to elevate the tip, or make other needed changes? We figure that out with morphs, well before surgery. I'd love for you to see some excellent professionally-designed morphs of what could possibly be done with your nose. Morphs could also help you identify better just what's bothering you, and help you set a goal for the rhinoplasty that's accurate for your tastes. Profile and three-quarter views would be particularly important in morphing your nose. (Side note: in my opinion, morphs should really be done by the surgeon, or he should direct an assistant as she makes the morphs. Morphs should be made with a constant eye to what actually *can* be done in surgery, for that particular nose, and the surgeon has that information and judgment best.)

Finally, remember that rhinoplasty is an exquisitely difficult operation to get right, and you should only have surgery if you are able to make yourself very confident in your surgeon's skills. The changes that your nose needs require advanced techniques, and skill that most plastic surgeons don't possess with expertise. It's much better to not have surgery than to have inexpertly-performed surgery. My web site teaches some good advice on how to determine whether a surgeon is good enough for you. I know, sounds totally self-serving, but you have to be taught this stuff. You don't learn it in 3rd grade; the government doesn't send out a pamphlet.

My two cents.

What did your surgeon say? Without knowing hwat was done, there is too much guesswork in terms of what is going on and whether you can "easily" fix this or if it requires another surgery. It does not look like it is just swelling, however.

Hello, Each part of the nose and each aspect of it's aesthetic is dependent not only on itself, but also how it relates to the other features. The example is that if someone 5'6" stands next to a 6'0 person they will look short, while if they stand next to a person who is 5'0" they will look short. So how does that apply to your nose?Your photo at rest shows that the rotation is approx 90 degrees, but this decreases when you smile. There are a few reasons for this. When we smile, the lip, the cheeks and the sides of the nostrils go up, making the tip appear even lower. There is also a small muscle called the depressor septi that can pull down on the tip during smiling, but I find this is rarely a major component of the problem, if any at all. This tip drop with smiling happens to everyone but to different degrees. So what can we do about it?In your case, it seems the two biggest factors are columellar support and the rotation itself. The rotation of your tip can be increased at rest, which will also give it a better appearance when smiling as well. BUT this can to be done very conservatively to avoid over-rotation, which will create a much worse problem. And the entire shape has to be evaluated to make sure the change is natural. It's usually not just one point that we are changing, but several points of the tip dimensions to make sure everything looks good relative to each other. This is better explained when discussing while morphing the images on a computer, so that the surgeon can demonstrate the changes. Adding a stronger support to the base of the columella at the nasolabial angle will prevent the lip from "digging in" under the nose when it elevates with smiling. This is a bigger factor for what I see in these photos. Hope this helps!Good luck!

Hello and thank you for your question. Based on your photographs, you will benefit from a revision rhinoplasty to better support and elevate your tip. Nasal tip deprojection should also be performed at the same time. With good surgical technique, you could have an outstanding result. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon