Short, up-rotated nose following revision rhinoplasty.
If rhinoplasty is the most difficult facial plastic surgery procedure, then elongating the over-resected nose is the most challenging rhinoplasty. Unfortunately, I think that your case bears this out and although further surgery can result in improvement, it will be very challenging and you will need to seek out a highly experienced revision rhinoplasty surgeon. The decision to proceed with another surgery will not be any easy one and should not be considered until 1 year has passed in order to allow full tissue healing.
I agree with your assessment that the tip is overly up-rotated and that the columella hangs down, both of which result in excessive nostril show. In addition, it appears that the dorsum has been over-resected resulting in a low nasion point, a scooped out or concave dorsal profile and a shortened nose.
Elongating the over-resected nose will require that attention be paid to the 3 layers of the nose, all of which may be contributing to the small, short appearance:
Internal mucosal lining - potentially scarred and shrunken.
Cartilage framework - usually depleted and weakened.
Outer skin cover - invariably will have some degree of scarring with a shrink-wrap effect.
Successful enlargement may require that maneuvers be performed to address one or more of the 3 factors above, depending on their contribution to the problem. The principal causes of failure in attempted elongation of the nose during revision rhinoplasty are a) underestimating the amount of cartilage grafting necessary and b) underestimating the effects of an extensively scarred skin cover which can overcome even the best efforts to restore the cartilage framework in the long term.
In your case, at 3 months following surgery, my guess is that inadequate cartilage grafting was performed because the skin envelope has not yet had the time to shrink the nasal framework. Following a 1 year waiting period, if the nose has not continued to get substantially smaller, then the existing skin envelope may still allow for nasal enlargement. I would recommend harvesting rib cartilage to provide material for the following grafts: a) dorsal onlay graft to reverse the scooped appearance, b) extended spreader grafts to lengthen the supratip region, c) septal extension graft to push the anterior septal angle ineriorly, d) nasal tip onlay graft and possibly e) alar rim grafts to decrease the amount of nostril show.
Too short noses can be improved by raising the bridge and lowering the nostrils
When the dorsum is lowered and the tip cartilages are reduced, the nose shortens.
The same principle also works in reverse. If your bridge is raised so it is straight, your nose will lengthen.
If a surgeon takes a "composite" graft of cartilage and skin from one of your ears (if there is any cartilage left) and puts the grafts inside your nostrils, the nostril edges will come down. This technique is very reliable, and many patients is your situation need it; I published a group of 100 patients like you in about 2000.
As always, find a surgeon whom you trust and who has corrected problems like yours and can show results that you like. That is the best insurance for a good result this time. Good luck!
Lengthening the nose in revision rhinoplasty often requires rib cartilage
Hello and thanks for the question. I agree with your assessment of your nose after your revision rhinoplasty. Your nasal tip needs to be counter-rotated or brought down so that your nostrils are not so visible on front view. Your infratip (the area of the nose below the tip) needs to be lengthened as well.
Obviously examining you in person would be ideal but based on your photos, I believe you would need extended spreader grafts to push the tip down and forward and possibly a shield graft in front of your tip cartilages. Depending on the length of your septum, a caudal septal extension graft or columellar strut may also be appropriate. Lastly, rim grafts may be needed to bring down your nostril rims.
I would guess that there is not enough cartilage left in your septum to create these grafts based on the fact that you have undergone at least two prior rhinoplasty surgeries. In my opinion, you would need rib cartilage to have enough straight and strong cartilage to resist the forces which would cause the tip of your nose to rotate upward again. Rib cartilage is taken from the right side of your chest by making a small, inconspicuous, 3-4 cm incision underneath the right breast. This portion of the surgery takes approximately 30 minutes to perform and is actually quite common for physicians who specialize in revision rhinoplasty. The additional grafts could also be carved from your rib cartilage.
If you are in good health, it should be safe for you to undergo another revision rhinoplasty. I would highly recommend that you discuss your concerns with your previous surgeon and consider seeking out consultations with a few revision rhinoplasty specialists. Ask to see photos of noses similar to yours which they have lengthened through revision rhinoplasty. Computer imaging can be quite helpful to make sure you and your surgeon are on the same page in terms of your aesthetic goals. Lastly, you should wait until 10-12 months have passed from your last surgery before undergoing a revision to allow the last bit of swelling to resolve.
Revision rhinoplasty to improve columella and shortened nose
Revision surgery is a possibility but I would allow your nose to heal further first. Waiting about a year for your nose to stabilize would allow for a better assessment of what changes need to made. It also allows the nasal tissue plans to soften as the scar matures in the area.
Hanging columella and alar notching
You can safely get correction/improvement of these , but as stated by other wait close to a year before seeking revision.
Short upturned nose after Rhinoplasty
Yes, from your photos the nose is upturned, with a scooped bridge, upturned (shortened) nose and hanging columella. This is a tough nose to revise with Rhinoplasty but it can be done. You need a columellar tuck as part of any future Revision Rhinoplasty IMHO.
Short Nose and Hangng Columella 3 Months after Revision Rhinoplasty
At 3 months it appears your nose does need to be lengthened, but the hanging columella may improve as swelling resolves. It is best to wait another 9-12 monjths before considering another revision.