Will I need a rib graft for tip derotation?

My nose was overrotated during primary :( It has an extended strut graft. I have 2.5cm dorsal strut and 2cm caudal strut remaining. Will I need rib? I had a otoplasty previously and don't want my ears being changed. Desired result shown.

Doctor Answers 10


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This is a very good question. Most surgeons consider the minimum dorsal and caudal strut that one may leave in the nose and still offer adequate support to be 1 cm at the very minimum. Many surgeons would elect to leave more, especially in patients where the septal cartilage may itself not be as strong. One could not be sure that there is enough left to further counter-rotate your nose until opening the nose. Additionally, although your operative report may state the above measurements, they are typically estimates and not measured with a ruler during surgery. I would recommend proceeding with surgery only if you are comfortable with the concept of a rib graft, as it may be required. Ear grafts typically are not strong enough for this purpose. Lastly, know that counterrotating a nose is challenging and every patient’s result will vary depending on the amount of scar tissue. If you pull down on your nose and it counterrotates easily this will bode well for you. If, however, it is more stuck in a rotated position the amount of counterrotation possible will be limited. If you proceed with revision surgery be sure that you seek a revision rhinoplasty specialist as this is a high level case. 

San Diego Facial Plastic Surgeon
4.0 out of 5 stars 8 reviews

Rib graft or not

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Your nose isn't that bad so most likely you don't want to go through a rib graft for a subtle change. To derotate your tip, you would not need a rib graft. I would also consider an alar contour graft to make your nostril less visible. Often times there is enough septal cartilage left to harvest additional cartilage. Make sure that your surgeon has a lot of experience with rhinoplasty and revisionary rhinoplasty. You want it done right the first time, and revisions require more experience and expertise that primary rhinoplasties. Best of Luck.

Paul E. Chasan, MD
Del Mar Plastic Surgeon
4.9 out of 5 stars 46 reviews

IS rib needed for tip derotation?

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That's good to know that you have at least some residual septal cartilage available for harvesting. There's a chance that you wouldn't need rib cartilage as a result but it's hard to say for certain in advance. 

You can learn more about upturned tip correction at my web reference link below.

Thomas A. Lamperti, MD
Seattle Facial Plastic Surgeon
4.9 out of 5 stars 22 reviews

Tip Rotation

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It is clear you will need cartilage to accomplish that degree of tip derotation. There is a very good chance you have enough residual septum available to create stacked grafts to accomplish it or to place a septal extension graft. I would doubt that rib would be needed for your procedure although it is always hard to argue with the amount of cartilage obtained from that donor source.

Nasal tip rotation after rhinoplasty #plasticsurgery

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Based on the 'morphed' image that you posted, I'm having a hard time determining if there are any issues with your current nasal tip - the dorsal profile in the morphed image appears to be more refined than in your 'actual' photo. An in-person exam is required to sort these issues out.

You appear to have an appropriate nasolabial angle after rhinoplasty surgery.

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Your morphed photo appears to reveal a 90 degree nasolabial angle which would be difficult to achieve, and may not be worth the expense and uncertainty associated with revision rhinoplasty.

I understand you're not happy with your rhinoplasty result, but a single profile photo is not a substitute for an examination.

Your nasal tip may lower spontaneously, depending how far into your healing you are. And gravity may derotate your tip gradually with age.

Hope this helps, and wishing you well.

Dr Joseph

Eric M. Joseph, MD
West Orange Facial Plastic Surgeon
4.9 out of 5 stars 435 reviews

Tip derotation after rhinoplasty.

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Tip derotation after rhinoplasty. There are several other ways to do this but often in met 35 years of rhinoplasty revision i have seen septal cartilage still remaining in the septum.I have never had to use a rib graft in this time! Look at various surgeons results since that is what u will be getting.

Toby Mayer, MD
Beverly Hills Facial Plastic Surgeon
4.8 out of 5 stars 38 reviews

Nasal tip de-rotation

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Thank you for your pictures and question.  

You will need some cartilage to lengthen the tip and de-rotate the tip down.  The first choice is the septum.  You need approximately 1cm width of septal cartilage dorsally and 1cm caudally to support itself.  It is possible that you may have enough septal cartilage to perform the lengthening however, an examination can only tell for sure.  The second choice is the ear. The conchal portion is what is usually used.  Depending on what kind of otoplasty you had done, it is possible to use some of the concha without disrupting the otoplasty. If all is exhausted then there is plenty of rib cartilage available.  Keep us posted.  Best of luck, Dr. Michael Omidi

An in-person exam with a board-certified plastic surgeon is the best way to assess your needs and provide true medical advice. The response to the question does not constitute a doctor patient relationship or formal advice.

Michael M. Omidi, MD, FACS
Beverly Hills Plastic Surgeon
5.0 out of 5 stars 122 reviews

Over rotated tip

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Your options for grafting include septum, previously harvested  and currently used, ear or rib.  All options have pro's and con's.  Your previous otoplasty wont affect the procurment and it wont change your ears.

Ernest Robinson, MD
Aliso Viejo Facial Plastic Surgeon
5.0 out of 5 stars 11 reviews

Sources of cartilage for nasal de-rotation

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Thank you for the question and photos.  There are three main sources of cartilage for de-rotation of the tip:

These are also the order of usefulness and ease of removal.  If you need more de-rotation you may need additional cartilage but sometimes re-working the existing "trip-pod" cartilage framework that supports the tip may also be useful and sometimes all that is needed.

All the best,

Dr. Remus Repta

Remus Repta, MD
Scottsdale Plastic Surgeon
4.9 out of 5 stars 173 reviews

These answers are for educational purposes and should not be relied upon as a substitute for medical advice you may receive from your physician. If you have a medical emergency, please call 911. These answers do not constitute or initiate a patient/doctor relationship.