What can i do to fix this asymmetry? Is a rhinoplasty still possible? And what can be done about the crushed right nasal bone?

Hello, 

Rhinoplasty after a septoplasty is certainly possible. In fact, many of the rhinoplasties that I perform are after a failed previous septoplasty. Sometimes, a septoplasty can provide enough improvement on its own for breathing reasons. Most of the time, however, with the amount of deviation that you have (which is visible on the outside) a septorhinoplasty is necessary. This procedure would aim to straighten out the entire septum (particularly the portion that is deviated high up where the septum meets the nasal bones). Additionally, the nasal bones could be fractured and straightened at the same time to improve the depression. 

You are right that the amount of cartilage removed during your previous procedure is an important factor. Sometimes, in order to have more cartilage to use for structural grafts (to build up support in the nose) ear or rib cartilage can be used.

Good luck.

Dr. Jamil Asaria

FACE Cosmetic Surgery

Rhinoplasty and Facial Plastic Surgery

Toronto, Ontario

Rhinoplasty can be safely performed after septoplasty but seek an experienced surgeon. An experienced Facial Plastic or Plastic Surgeon will be able to deal with the increased risks of revision septal surgery. The main limitation in performing rhinoplasty after prior septoplasty if finding adequate cartilage to rebuild the structural support of the nose. If this cannot be obtained from the nasal septum it can be readily obtained from the ear, cartilage portion of a rib or cadaveric donor tissue (my last choice due to some issues with warping and resorption). Fillers are a temporary solution and not without risk such as skin necrosis when used after prior nasal surgery. Further, fillers are camouflage. They are not a structural or permanent solution to your concerns.
Thank you for your question.Stephen Weber MD, FACS

Fillers are easy to balance a crooked well functioning nose. A revision surgery will do this permanently IF you choose an experienced revision rhinoplasty surgeon.

Rhinoplasty after septoplasty can be tricky. It has to be handled the right way by someone with experience in cosmetic and functional surgery in order to avoid the issues you describe. It sounds like you had a submucus resection type septoplasty where the non-structural cartilage is removed. That is unfortunate but no uncommon either. What is left is the structural parts of the septum, also referred to as the L-strut.

That L strut can be manipulated, provided the surgeon appreciates what your margin of safety is. The deviation can still be addressed and further straightening of your airway should be possible. If cartilage grafts are required, then ear cartilage is likely required, since your septum can no longer be used for that purpose. There can be limitations on profile reduction, depending on how much cartilage is left on the top of the nose.

If the majority of the septum is not instrumented again, then your risk of perforation should be very low. There is no real reason to re-do the septoplasty, unless crooked cartilage is still present. If that is the case, then the perforation risk is not particularly high.

Found the right surgeon and your goals should be achieved.

Best of luck

thank you for the photos  .  a profile view would be helpful.    the nose can be re operated on  but secondary surgeries are more complex , take longer and need a more skilled and experienced surgeon.. grafting may be needed.  an open method preferred.

a filler such as juvederm can give an idea as to how much it will help.   if this is adequate  a longer lasting filler such as radiesse can be used.

so ,  there are several options depending on your needs and budget

 

Provided you are now breating well, your chief complaint is aesthetic.  The nose must then be evaluated from the front, sides, and nostril view to determine which structures are causing and/or contributing to the crookedness, and any other existing aesthetic problems.  A surgical plan must be developed, and adjusted depending on intra-operative findings.

These can be challenging procedures, because all nasal structures are interconnected, and generally, complete mobilization of all deviated parts is required, modification to straighten everything out, and then secure the straightened parts to stabilize in the midline. 

The easy solution is injectables to fill your unilateral concavity.  Aquamid is ideal, or Radiesse.  The correction of nostril view or profile problems may be limited.  Since no profile or nostril view is submitted, I assume these are not huge issues for you.

It is possible to have a rhinoplasty done after a septoplasty, although it is best to have them done at the same time so that the removed septal cartilage can be used to rebuild and reshape the nose during rhinoplasty. The nasal wall dent or deformity that is apparent in your picture can be corrected by cartilage grafting to the area of the upper lateral cartilage which would most likely be done in a form of a "spreader graft". If you don't have much septal cartilage left after a septoplasty, then you might need to have ear cartilage used to repair your nasal deformity.

If it were my nose I would have fillers used.  A physician who is experienced in non-surgical rhinoplasty techniques could straighten your nose in 15 minutes in the office.  You could have this done first with temporary fillers which last a total of a year, with about half of the effect gone after 6 months. 

If you are happy with the doctor's technique you could then try a permanent filler like Artefill if you want.  I personally like the temporary fillers like Restylane and Perlane.  Because you only need a small amount, (especially for your nose) the remainder can be used in other places like under the eyes or in the cheeks or chin.

The advantage of avoiding the risks and side effects of surgery would outweigh the disadvantage of needing to repeat the treatment.

Good luck in your search for information!

The septoplasty operation is specifically designed to improve airflow dynamics through the nose, not to correct a crooked nose.  The concaved appearance of the upper lateral cartilages on one side or the other is best addressed by harvesting residual septal cartilage and placement of a spreader graft on the concave and flail side that has herniated into the airway.  If the nose is cartilage depleted, then a small ear cartilage graft can be employed.  Any irregularities in the bone will be addressed through osteotomies to make the nose more symmetrical.  

Hello;

If the septum is still deviated, particularly if it's causing a nasal blockage, then the septum must be re-operated on. 

It sounds like it's needed because if it is distorting the lower portion or tip portion of the nose, then it does need to be corrected.  The revision rhinoplasty surgery will reveal that.

With respect to the outside of your nose: if straightening the septum straightens the outside, bravo! 

If it does not, however, another option may be, not necessarily a revision rhinoplasty, but rather  fillers instead to correct the depression, particularly on the right side. 

Only when the septum is straightened will the surgeon know exactly what it has, or has not, done.

My advice: have a very detailed re-consultation with the original surgeon.  Also, a second opinion is always worthwhile. 

Each surgeon must do a very thorough examination of the nose, particularly by anesthetizing and shrinking the inside so the existing architecture can be seen, as well as whatever tissues may have been removed in the original surgery. 

The more information a surgeon has, the better the choices that will be available to him and to you. 

Do not dismiss the filler option because it is very difficult often to get an ideally straight nose that is a bit crooked, and particularly if there is some depression of the bony or cartilaginous elements. 

Good luck!

Robert Kotler, MD, FACS
Facial Plastic Surgeon
Author, SECRETS OF A BEVERLY HILLS COSMETIC SURGEON
Author, THE ESSENTIAL COSMETIC SURGERY COMPANION