Rasping without osteotomy - how many mm do I need shaved? Is it worth going back for rasping post rhinoplasty? (Photos)

Question

If I go back to my dr for local anesthesia and rasping- do you think I will require another osteotomy? How many mm of rasping do you think I would require for my wish nose? The real photos are on the left and my wish noses on right.

Alejandro Nogueira, MD · Answer

There seems to exist some missing points here; let me clarify:-it is true there is a bridge or dorsal prominence, this is undisputable, however this is the lesser of your problems and the simplest to fix; however... can't be simply "rasped", the grade of bone fusion and prominence is not slight (was left unattented and the dorsum very poorly managed, read on to know why in following items), so it has to be "cut", chiseled, leaving an open roof and, therefore, osteotomies are A MUST to prevent open roof and inverted V deformities combo, so... NO local anesthesia AT ALL, you need a full revision under total anesthesia-there are other worse and more deforming issues in your nose, my apologies, I don't wish to be overcritical, they are evident; for example there is a severe over resection, collapse and sunken area at the supratip, with middle valve collapse; the area between the prominent bridge and the tip is sunken and has to be raised (grafting) and the middle vault competence restored by suturing the upp-lat cartilages to the centra septum (with or without additional spreader grafts); you have falled to the pitfall of assumming the right dorsal level is the one of the sunken supratip, and your simulation leaves a sunken saddle nose deformity, error!, your dorsum has 2 different issues due to poor management: the upper half shows a clear excess of bone and needs to be reduced/lowered, and the lower half of the dorsum (the cartilagenous one) is over-resected and sunken (needing grafting to raise it); it happens sometimes the problems are miscellaneous or hybring, and in the same dorsum the revision surgeon may have to lower part and raise the rest, like to elevators going one up and other down meeting somewhere in-between; this is your case; to achieve a straight dorsum we have 3 options in your nose: a) assuming the sunken supratip as righ level, therefore shaving the whole down to it; error leading to a saddle nose deformity; b) assuming the prominent hump as right level, then performing a dorsal raise of the supratip to meet it, leaving a huge nose; the right c) scenario is the actual one in you: upper half excess to be lowered and sunken lower half to be raised; a very tricky but possible scenario, not the first time I meet it in my operating room-additionally your tip has two evident issues: over-rotated, too high at about 30º degrees of nasolabial angle, close to "piggy nose" deformity, this would best be lowered to 15-10º or, if you wished so, lower about 10-5º, by means of shield grafting or others-finally the second tip issue is its over projection, needs deprojecting about 2-3 mm, to be asessed intraop based on the final dorsal balance-I'd say your alar rims are retracted and your nose partially pinched, this may need a look intraoperatively and some grafting to restore support, now your alae look flat and undefined, a sign of support lossWith al that said, I recommend you refuse the treatment proposed, seek other opinions of well experienced revision rhinoplasty surgeons; try to play with the photo editor conducting yourself as previously explained and hereby briefly summarize:-lower the dorsal hump, but only 60% of it-raise the sunken supratip to meet the previously lowered dorsal hump-reduce the nasolabial angle derotating the tip downwards as much as it pleases you-do deproject the tip's legth down to meet the new supratip or just slightly longer than itYou'll understand it fully.Your case needs a complex revision, about 3-4 hours surgery, difficulto 6-7 out of 10 scale of revisions, of course total anesthesia and again a full recovery period.If you wish better grounded opinion well lit, focused and standard images have to be assessed: frontal, both lateral and both oblique views, also underneath the nostrils.
Feel free to request any additional information from me.

William Portuese, MD · Answer

Shaving down the dorsal hump will only make the bridge  wider and create more of an open roof deformity.  Osteotomies are most likely going to be required, but that must be determined at time of the examination and consultation.  In addition, it is not a good idea to try to undergo any type of revision rhinoplasty procedure under local anesthesia, since it will be extremely uncomfortable, painful and  will not be comfortable whatsoever.  In our practice, we perform all touchup revision rhinoplasty procedures under a brief general anesthesia as an outpatient procedure by a board certified physician anesthesiologist for patient safety and comfort.

Steven Wallach, MD · Answer

Looking at your photos most of what you want reduced is probably cartilage, and in that case will not be amenable to just rasping.

Bradford A. Bader, MD · Answer

It looks you do have some residual convexity of the dorsum. Based on your photos, this residual bump is mostly cartilage, not bone. Simple rasping will not improve it as cartilage needs to be cut with a sharp instrument. If additional cartilage is removed here then the upper lateral cartilages will need to be resuspended using sutures and possibly reinforced with additional cartilage grafts. Also, lowering the dorsum further will produce a wider appearance on the frontal view. You might consider adding volume above and below the bump to produce a straighter profile, higher dorsum and narrower appearance on frontal view.

Rasping without osteotomy - how many mm do I need shaved? Is it worth going back for rasping post rhinoplasty? (Photos)

Answers (4)

Answer: Residual bump on nose after #rhinoplasty

Answer: Residual bump on nose after #rhinoplasty

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Rasping without osteotomy - how many mm do I need shaved? Is it worth going back for rasping post rhinoplasty? (Photos)

Answers (4)

Answer: Residual bump on nose after #rhinoplasty

Answer: Residual bump on nose after #rhinoplasty

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Recommended reading

Everything you need to know about Revision Rhinoplasty

Our mission is to create a world where every investment in modern beauty is Worth It.