Revision rhinoplasty for open roof nasal deformity
Thank you for submitting your photos. They are very helpful in recommending the most appropriate treatment. Based on the excessive width of the nasal dorsum, I agree that lateral osteotomies are needed. I cann't comment on the necessity of spreader grafts based on the photos. The open vs closed approach depends on the surgeon's preference in dealing with the tip asymmetry. I think in your case, a conservative nostril narrowing will also be useful.
Surgical plan for revision rhinoplasty.
Ginncha, although an accurate complete analysis requires an in-person evaluation, based on your photos I do feel that you need lateral osteotomies to close and narrow the roof of your nasal vault. Other maneuvers including tip refinement would likely also be helpful at the time of revision rhinoplasty. My assessment based on the photos alone is as follows:
RADIX. The area just above and below the nasion or "break point" the upper bridge of your nose. This area appears to be fine.
DORSUM. The middle segment or bridge of your nose appears to be too wide both across the top and at the bony base. Open roof deformity. Usually the bridge width across the top is recommended as being approximately the same width as the tip defining points (6-8 mm in women). Presently, the dorsal width is significantly greater than your tip width. This is contributing to an unfavorable nasal dorsal aesthetic line drawn along either side of the bridge from the brow to the tip. The bony base width across the middle segment of the nose is currently wider than both the inner canthal width and the alar base width. Ideally the bony base width should be slightly narrower than these. Although hard to tell without full face views, I have the impression that the dorsum is over-projected on profile view.
TIP. The nasal tip is asymmetric with irregularities in the underlying cartilages. Again, it is hard to tell without full facial views but the tip appears to be slightly over-projected.
NASAL BASE. One could argue that there is too much alar flare, particularly if the tip is deprojected during future surgery. The caudal septum is displaced into the right nostril.
Based on this analysis, my recommendations are as follows:
Small additional reduction of the dorsum and smoothing/rounding of contours with a rasp.
Small deprojection of the nasal tip.
Decreasing tip volume, smoothing contours and refining by removing cephalic strips and using suture shaping techniques.
Repositioning the caudal septum.
Smoothing the dorsum.
Possible alar base and nostril sill reduction.
Sincerely, Mario J. Imola, MD, DDS.
Nothing "needs" to be done == It all depends on what bothers you. It is important to discuss with an experienced rhinoplastic surgeon what you don't like about y our nose and then formulate a plan. From what I see, the open roof and dorsal deformity can be corrected and a tip revision would be in order. Open or closed depends on the experience and preference of the surgeon.
What Needs Done During Revision Rhinoplasty?
Both approaches may be right. :the osteotomies will result in a narrower nose while the added graft will close the open roof and possibly give the optical impression of a narrower nose.
Based on the photos, I'd recommend osteotomies to close the open roof and narrow the currently wide nasal dorsum. The tip is over projected and pinched. The thin nasal skin is allowing the tip irregularities to show more than they would if the skin was thicker. I'd recommend tip reshaping, de-projection and temporalis fascia graft to give the appearnace of thicker nasal skin.
Options for revision rhinoplasty
The good news is, you have options! The most important question is, "what are your goals?" To just treat the tip? To make the dorsum smoother? More narrow? How aggressive do you want the next procedure to be?
The least invasive option would be a non-surgical rhinoplasty which may treat the dorsum and tip, improving the contour and symmetry of the nose. This is a great option for treating open roof deformities in under 5 minutes.
Osteotomies are very helpful in narrowing the bridge and improving the nasal contour. Sometimes, placing grafts are nicer because you don't have the potential problems osteotomies include.
You may need to continue to interview surgeons until you get a good feeling. I know it's frustrating with so many different options, but as important as your nose and face are, it's worth the effort!
Good luck in your search for information!
Open revision rhinoplasty
The approach depends on your surgeon's preference. There are pros and cons to both osteotomies and onlay grafts
Revision rhinoplasty to correct open roof
I agree that you do appear to have an open roof deformity that would be helped with osteotomies. The tip asymmetries/bossa can also be addressed at the same time.
I would do a case like your using an open approach. Other surgeons may use an endonasal approach depending on their preferences.
Discuss your options with a few surgeons experienced in more complex revision cases and assess their before and after results in other patients. Inquire about how long after surgery the postoperative photos were taken. You obviously want a durable, long-term result. Often a rhinoplasty result can look fine for many months before asymmetries and other problems become evident.
What could be done to your nose with revision Rhinoplasty
From your photos, it does appear that you have an open roof deformity of your nasal bones as well as very asymmetric tip cartilages. The open Rhinoplasty, with possible ear cartilage tip graft is required to make the nasal tip more symmetric. The two opinions: osteotomies to close the open roof deformity or the use of an onlay graft to cover the deformity over are the two recognised ways to treat an open roof deformity.
IMHO, the onlay graft to cover the open roof deformity is reserved for those patients, in whom the vast majority of the nasal bone height has been removed during previous Rhinoplasties. In that scenario, the short nasal bones lack adequate height to meet in the midline and thus can't close the open roof deformity. This however, does not appear to be the case in your nose which still has adequate nasal bone height.
For this reason, IMHO the osteotomies to in fracture the nasal bones would be the preferred method of closing your open roof deformity.
Revision rhinoplasty would require osteotomies to repair an "open roof" deformity
Revision rhinoplasty would require osteotomies to repair an "open roof" deformity. With regard to imprving the symmetry and appearance of your nasal tip as well as possible deviation of the columella (suggested by your photos), an endonasal (closed) or open (external) approach are both reasonable depending on the experience and preference of your surgeon.
Stephen Weber MD, FACS