How can I get a more natural looking nose?

Question

I had surgery in 2014 to remove a bump. I never had an issue with my nose from the front, but always hated my profile. Unfortunately, now I'm dissatisfied with both. Ideally, I'd like some width/stability added back, for the sharp line down the middle to be corrected, and for it to be less pointy/projected. In addition to being dissatisfied with the appearance, I experience sinus pain & bloody noses. I'm terrified of it ending up worse, but I feel like a revision is necessary.

Umang Mehta, MD · Answer

So sorry to hear you had a negative outcome from your primary rhinoplasty. You definitely would benefit from an open revision rhinoplasty to correct both the inside and outside of your nose. Your breathing would improve and your nose would look smoother and more natural. You have an inverted-V deformity which can be corrected with spreader graft placement. Spreader grafts are long, thin pieces of cartilage taken from your septum (or rib if a lot of septal cartilage has been removed). Placed along each side of the top of the bridge, they help to prevent that sharp line down the middle that is bothering you. This inverted V deformity happened because your upper lateral cartilages fell in against your septum. Your nasal bones can also be narrowed to smooth and refine your bridge. The key with spreader grafts is to make sure they are not too wide, as to avoid making the bridge look wide. I use them in nearly every first-time rhinoplasty to avoid this complication. Your sinus issues and nosebleeds may be related to this valve collapse. Secondly, I agree that your tip should be made less pointy and more natural in appearance. Your tip is a bit off-center as well. I would suggest a combination of suture techniques to refine your tip in a more natural appearing way. Additionally, your columella is hanging a bit. The medial crura of the lower lateral cartilages can be secured to the septum with a suture to avoid this complication as well. If your skin is too thin over the tip, it can be cushioned slightly with temporalis fascia. I use this commonly in revision rhinoplasty as well, to ensure that the tip is not unnaturally sharp/pointy. Overall, I'd suggest consulting with 2-3 revision rhinoplasty experts to determine your best course of action. During this time of social distancing, we are performing virtual consultations via Doxy.me, an app similar to FaceTime/Zoom. Computer imaging can be done virtually as well, to help you communicate your aesthetic desires and understand what's possible given your anatomy. Insurance coverage should help offset some of your costs, as the collapsed bridge/internal valve correction (nasal vestibular stenosis repair) is medically necessary. Wishing you all the best! Stay safe!Dr. Mehta

Steven M. Denenberg, MD · Answer

You have some significant problems with the nose, but from these photos at least, it appears that your nose has sufficient structure still to allow a good addressing of those issues. Your nose is very strong in its forward projection from your face. The tip can be brought back substantially closer to your face. We call that "de-projecting" the tip. 
The woman in the short video that I posted with this answer had the tip of her nose de-projected a large amount, though in a primary operation.
Then, when a nose is de-projected, it tends to *look* longer, as if the tip had drooped. So it's important to elevate the tip. Your nose is already long, so the goal would be a big elevation.
There's a side benefit from doing that, too: when the nose is made smaller in any dimension, then any asymmetries or issues  that still bug you after revision would reside on a smaller, less prominent nose, and thus would probably bug you less.It appears that your nasal bones need to be narrowed further.There's more. It seems that your bridge is strong up at the top of the nose -- in front of your eyes, or just below your eyebrows. When the nose is strong there, if the tip and bridge are de-projected (brought closer to the face), it's important to reduce the strength of the bridge up there at the top, or your profile would resemble the profile of a Roman statue, where the profile of the forehead slides right down onto the nose, without that little dip we like to see in front of the eyes. Search for Roman statue profile to see what I mean. Your surgeon must pay attention to that, too.
How *much* to elevate the tip, or deproject the nose, or make the other 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 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 always 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 only the surgeon has that information and judgment. Another aside: I also recommend that you not show morphs made by one surgeon to a different surgeon. If a surgeon makes his *own* morphs, you get to see whether he understands the important issues of your nose, and how your nose should be changed. But if you show the surgeon someone else's morphs, and he says "Of course I can make your nose look like that," then you don't really know if he fully understands, or even recognizes, the important changes shown in those morphs. And you don't know if he can make those changes during surgery.)
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. For most noses, it's much better to not have surgery than to have inexpertly-performed surgery. Read my essay on how to stay out of trouble while selecting a rhinoplasty surgeon. And for those who have had previous surgery, it also discusses how to tell whether your first surgeon should be performing your revision. And it also discusses how to take photos that are best for online evaluations.
Your nose is also a perfect example of why computer imaging by the operating surgeon is mandatory in rhinoplasty. You need to know exactly what the surgeon is planning to accomplish -- what features he thinks he can change, and by how much he thinks he can change them. I always email morphs to my online rhinoplasty consultations. When you see the surgeon's goals in the morphs, you'll know whether he has an eye for an attractive nose, and whether he shares your opinion of what constitutes an attractive nose. You'll also know whether the changes he proposes are large enough to be meaningful to you, and whether he understands your wishes enough to address all of your priorities. How would you ever get that figured out without the morphs?

Toby Mayer, MD · Answer

Revision Rhinoplasty to correct pinched tip, mid nose collapse, hanging columella, etc. All of these issues can be corrected by a very experienced revision rhinoplasty surgeon. Look for many examples of the surgeons work and do not rely on Imaging.

Richard Mark Winters, MD · Answer

you have a classically over-resected dorsum which has been left unsupported at the keystone area resulting in an 'inverted v' deformity.... your thin skin accentuates this.... your tip cartilages have been over-resected as well yielding nostril retraction and poor tip support while your preoperatively over-projected tip was not addressed and is likely more obvious nowthese issues are remediable by way of an open revision rhinoplasty with structural grafting.... bilateral spreader grafts (to support your dorsum) and a septal extension graft (to support a properly projected/rotated tip) at the very minimumthese maneuvers are not overly complex IF they are performed by a revision rhinoplasty expert.... start with surgeons who have been in practice a long while, are focused on rhinoplasty and have done many revisionsgood luck...

William Portuese, MD · Answer

The photographs demonstrate an inverted V deformity, wide nasal bones,  collapsed upper lateral cartilages, and a hanging columella. All of these issues can be addressed with a closed revision rhinoplasty approach with all incisions placed on the inside of the nose. Revision rhinoplasty is more difficult in a primary rhinoplasty, so it's very important to choose your surgeon based on extensive experience. It's also important to know how much cartilage is left over on the inside of the nose for spreader graft placement to help with the inverted V deformity. Sinus related issues must be sorted out with a CAT scan, while nosebleeds are usually cauterized in the office setting

How can I get a more natural looking nose?

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How can I get a more natural looking nose?

Answers (5)

Answer: Indeed....

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Answer: How can I get a more natural looking nose?

Answer: How can I get a more natural looking nose?

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Everything you need to know about Revision Rhinoplasty

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