Is my skin too thin for revision rhino? Can projection be reduced? (Photo)

Question

I’m in my late twenties and has initial rhinoplasty 5.5 years ago. I’ve been wanting a revision rhinoplasty for a few years but I always wanted to be 100% sure before I took the next step and actually sought it out. Two surgeons I really admired both recommended against me getting a revision rhinoplasty (both had only seen photos, though I’m sure for an experienced eye that might be enough) without asking me what my wishes were. What are your toughts

Steven M. Denenberg, MD · Answer

I am stimulated by your question and photos to provide a small rant, which I hope will be helpful also to anyone else reading this post. The problem, as with most rhinoplasties, is finding the right surgeon. Many of the revisions that I do involve, in part, de-projecting a tip that was left too projecting in the first operation. Often, as in your case, it's not that the surgeon was a little off in his judgment of how much to deproject your tip and left the tip *slightly* too projecting; rather it's that the tip is just far too projecting after surgery and the surgeon either didn't know that was a factor or didn't know how to correct it. It's not okay to agree to operate on a nose if the nose requires significant deprojection but you as surgeon don't know how to accomplish that. And if you can't tell that before surgery, it's not okay to be performing rhinoplasties.

Associated topic: you sent photos to two surgeons who said you should not have a revision. Well, *clearly*, you should. Those two surgeons: if you don't know how to accomplish what the patient wants and needs, the correct answer is not "you shouldn't have a revision." The correct answer is, "You need a lot of deprojection, but I don't know how to accomplish it. You can find someone who can do this, and be happier with your nose." These people.

Finally, to your face. Yes, the tip is much too projecting. Having said that though, you can handle a strongly projecting nose better than most, because you have the tall strong chin, and great lips, and really pretty facial features, so the nose doesn't get in your face's way as much as it might someone else's. But still, you notice it, and I do, too, and the other surgeons should have as well.

There are some subtleties that the revision surgeon needs to understand. One, for example: when you deproject a nose a lot, it makes the nose *look* longer, as if the tip had actually dropped, so it's crucial in a nose like yours to elevate the tip at the same time. The morphs would prove that to you. In fact, you did it yourself, in your own morph.

So the upshot is, keep looking for a surgeon and get your revision. But the surgeon must be able to prove to you that he can deproject a tip, by showing you photos of his patients where the tip was deprojected meaningfully. And he needs to prove to you that he understands what you want, and that he understands about noses, by making morphs himself, morphs that you love and that address all of your concerns.

Richard G. Reish, MD, FACS · Answer

Hello and thank you for your question. Based on your photographs, you may benefit from a a Revision with a nasal tip deprojection to shorten the entire tip complex. A mastoid fascia tip graft can be placed at the same time to prevent asymmetry and camouflage the tip. With good surgical technique, you could have an outstanding result. I recommend that you seek consultation with a qualified board-certified plastic surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon

William Portuese, MD · Answer

From the photographs presented, you have an over projecting nose, and an under projecting chin. Give strong consideration to placement of a chin implant to augment your chin forward for better facial balance and proportions, especially with respect to your nose. You can project the chin further outward with a chin implant procedure, than you can de-project the nose backward with a rhinoplasty procedure. Revision rhinoplasty is more difficult and less predictive than a primary rhinoplasty. It's also very difficult to decrease the overall projection of the nose and keep the entire nose itself looking great in a three-dimensional fashion.

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