Overprojection and Hard Tip Resulting from Columella Strut

Question

Hi, I had an open revision rhinoplasty approximately 3 months ago consisting of: 1. A dorsal rib cartilage/perichondrium graft. 2. Spreader grafts. 3. A columellar strut to correct a droopy, under-projected tip. My nose has a hump, is stiff, feels over-grafted, over-projected. I am dissatisfied with the aesthetics. My tip is also hard as a rock from the strut and very painful. Are these issues correctable and is it possible for me to regain a natural looking/feeling nose?

Gerald Minniti, MD, FACS · Answer

It is completely normal to have a stiff nose/tip after a rhinoplasty, especially after a revision rhinoplasty where a rib graft is employed.  Post operative swelling is significant for a year or more in all rhinoplasties, and more so in revisions.  The rib graft is a stiff type of cartilage which will also contribute to your symptoms.  Further, it is not uncommon for a small metal wire to be inserted inside the rib graft to prevent a common problem of these type of grafts: warping.  If this is the case, you will always have a very stiff nose/tip. 

	The other issue you are describing may also need attention too: persistent hump.  If after one year you are still dissatisfied with the appearance and stiffness of your nose, a revision may be necessary.  If that is the case, removing the wire along with shaving the graft may be the remedy.

	Be patient, and folllow up with your surgeon regularly.

	Best of luck!

Toby Mayer, MD · Answer

Overprojection and hard tip after rhinoplasty is normal and should go down over the next 9 months. If not it can be corrected by a revision rhinoplasty experienced surgeon. Wait at least 3 more months before evaluation.

Ramtin Kassir, MD, FACS · Answer

The stiff tip and your other concerns are not uncommon after rib grafting in revision rhinoplasty. Wait at least 6-9 months before you assess the final result. If necessary rib grafts can be trimmed and modified but hopefully that won't be necessary.

Peter E. Johnson, MD · Answer

By definition, the rib graft to the dorsum will be stiff in order to provide the support to the bridge after revision rhinoplasty. The rib cartilage is the least 'natural' of cartilage graft material, and can feel or behave much like a nasal implant, though the results over time are far better. Your nose may indeed be over grafted and the aesthetics may be 'all wrong'. Despite all this, it is best to wait it out six to twelve months and let the grafts settle in. Revision may be the answer but the graft will offer a working framework to soften and adjust the result.
	Best of luck,
	peterejohnsonmd

Gregory J. Vipond, MD, FRCSC · Answer

After a rib cartilage graft and placement of spreader grafts, especially in an open, revision case will almost always result in a firm nose which may feel overprojected. Swelling will tend to build up in the tip area and can take up to two years to completely resolve. You should start noticing some softening of the tip over the next few months. I would not rush to perform any revisions before the swelling has come down. For revision nose surgery, the nose is often weakened from the initial procedure and rib cartilage used to add structural support to avoid further weakening and possible collapse in the long term.

Barry L. Eppley, MD, DMD · Answer

After a major revision using a rib graft, your nose is initially going to look abit overprojected and the tip most certainly is going to feel hard as a rock. It may well turn out that it has too much projection but that is not an issue for revision at this point in time. You should wait at least a year and then make your decision. You may be surprised that your feeling on the tip may change. If it does not, de-projecting the tip as a revisional rhinoplasty is relatively simple compared to your last revision.

Steven Wallach, MD · Answer

It is always helpful to know exactly what was done.  Howver, at three months, it is fairly common to have a firm tip and this should soften up over time.

Erel Laufer, MD · Answer

3 months after secondary rhinoplasty is not enough time  for soft  tissue final prediction but it is enough time to have a good idea of the nasal shape.If you're not pleased by now you will probably  seek another revisional surgery .

	Look for a very good rhinoplastic surgeon,it is a very tough procedure third time around.

Vincent P. Marin, MD, FACS · Answer

Revision rhinoplasty is one of the most complicated operations we perform, and a rib graft is a major revision. Not liking the aesthetics of the nose can only be determined by looking at the before and after images one year from your surgery. Some of your complaints may improve with time. If the nose has been made too large then a revision may be needed, but was your nose made that large to accommodate the amount of skin? Firmness is often related to excess swelling that should improve as the nose heals. This surgery requires patience and frequent visits with your operating physician. Photos can be helpful, but no formal decision should be made until you reach a year.

Best of luck

Vincent Marin, MD, FACS

San Diego Plastic Surgeon

Best of luck

Vincent Marin, MD, FACS

San Diego Plastic Surgeon

Michel Siegel, MD · Answer

This are all excellent questions. Because of the timing after your revision surgery it is hard to give an accurate opinion about what the final result will be. Three months after a revision rhinoplasty I would expect for the nose to be stiff, and bigger than I would wanted to look. However you should not have pain at this stage, so you may want to follow up with your surgeon for him to examine you.

	The appearance of your nose will change in the next several months as the swelling subsides, but it will take months. I would be patient and at 12 months from your surgery, i would re-assses how your nose looks and feel. If at that time your are still very unhappy, another revision may need to be performed.

	Best of luck, 

	Michel Siegel, MD

Overprojection and Hard Tip Resulting from Columella Strut

Answers (12)