Post Revision Rhinoplasty - Pinching/stiffness in tip and stiffness at the base - what is causing this/how to address? (Photos)

As follow up to your previous question here, I appreciate the posting of the operative report, unfortunately most of it is of scarce value given it contains surgical truisms which surgeons do not normally reflect for being hollow information; for example it is irrelevant which surgical instrument, of the dozens available for each of the 100-200 manual gestures done through a rhinoplasty, is employed, or the tunnels and dissections performed to reach the structures (we all -surgeons- know which ones they are).

The only relevant part is about auto-spreader grafts, this option was popular a decade ago, seems you we caught in the wave, however it is unwise to choose because lacks calibration properties; you deem indicated a pair of spacer grafts? do your job in the less innovative and more reliable way: do harvest good, stratight and custom graftings; yes, indeed the excess of cartilage at the hump can be spared and I actually do re-use it, but never as spacer grafting due to its shape (it is normally useful, after extensive work on its shape and thickness, as Sheen's tip grafting or shield grafting).

The omissions in the technical report are the possible causes for:
-massive loss of support of alar rim, nasal valve, the pinched look (we can speculate with over resection of lateral cruras and untreated concavity in them)
-over projected tip, likely due to a poorly planned columellar strut
-tip deformities and over sharpened shape, might be caused by aggressive transdomal plications, not to rule out some grafting that's misshapen
-open roof and inverted V, clearly lack of closure with the infracturing and insufficiency of the auto-spreaders

Should you go for another try, let it be this time in very meticulous hands, experienced and with passion for difficult cases; do perform dozens of consultations, in person or online, before moving forward.

Or maybe some kind of graft sewn to your tip cartilages, but it's almost certainly not something soft, like scar tissue. To my eye, the tip of your nose is much too projecting, given the position of your bridge. Even the base view indicates it quite strong in its forward projection. And of course we see how that point sits to the right of center on your nose.
If you were in my office, I'd be recommending another revision, where the goal would be to open the nose, identify what that bump is comprised of, and figure out how to make it go, leaving the tip symmetric, less projecting, and drawing less attention.
Boy, I think I would re-evaluate whether to have your surgeon perform the next one. If he's had three tries and the nose is still this far from a range of something you'd be happy with, I just don't know. If you decide to, better get a good explanation of why it didn't work the previous two times, and how the next plan would be different.

Hello and thank you for your question. Based on your photographs, you are a great candidate for a revision rhinoplasty. Maneuvers for your surgery would include nasal tip deprojection to correct the over projection of tip, placement of a mastoid fascia tip graft to give a smoother and softer contour of the tip, among other maneuvers. 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