Secondary Rhinoplasty After 20 Years, Are My Issues Fixable?

Yes, you can still consider a revision rhinoplasty after 20 years.  There are liimits based on your thick skin but you do have areas that can be addressed with surgery.

From looking at your photos I can see that your tip is under-projected which has led to a less defined tip. Reprojecting your tip into your relatively thick skin would help refine its appearance and actually make it appear smaller. Your bridge could also be augmented to strengthen your profile. Cartilage grafts would be needed for these manuevers. If you don't have adequate septal cartilage then ear or rib cartilage may be needed.

Visit with a few revision rhinoplasty specialists to get a complete assessment and to discuss your options further.

I read your question and reviewed your photos:

It's not clear from your concerns exactly what you would like to achieve with your nose. You don't have a "terrible" nose, and your thick skin makes it difficult to tell you've had previous rhinoplasty surgery.

You should consult several revision rhinoplasty experts to determine what you could achieve with further surgery.

Regards from NJ.

The best thing is to have a personalized consultation (would be better in person) so that the nose can be properly evaluated.  At this point, the most important issues are 1) getting a result that satisfied your aesthetic desires and 2) ensuring that you will still be able to breathe after your revision.  The skin is something we all take into consideration with any rhinoplasty patient.

You have an attractive natural appearing nose now.  Could you improve its looks with another revision? Yes, you could increase the height of the bridge and give the tip some more refinement with cartilage grafts.Getting good revision rhinoplasty results often requires the skill of a surgeon with many years experience with revisions. Be sure to see many before and after pictures of cases similar to yours.  

In the hands of an experienced rhinoplasty specialist, you should achieve a significant improvement. In my opinion, you need moderate dorsal augmentation to increase the height of your bridge, and smooth the irregularities. In addition to the thick skin, it appears that the skin envelope along the tip has contracted has a result of your previous surgeries, causing the round apperance. Restructuring the tip with cartilage grafts would improve on the shape of your tip. While every surgeon has different preferences, I would use rib cartilage to achieve the goals previously mentioned.

I am not sure what your concerns are, but remember thick skin can mask alot of things and can limit the definition that you may/may not want and can not change.

You are doing the right thing an in person consultation. Nothing beats a person to person consult and exam. feel the tissue, feel the person , both doctor and patient.

 Then you decide. In the pictures noted. You have a good nose, start with this idea. Any more surgery will give you small improvement, may be getting worse.

If you were my patient i would ask you to accept your nose and not do any surgery. (I may loose a patient and $$$)

Dear Sadhonker: Your nose can always be improved.  It is important to realize that with a triple revision surgery that the goal is modest improvement and that perfection is an impossibility.  But you should feel comfortable that you can always seek improvement.  Often with the type of issues you are concerned about, they stem from over resection of the dorsum and lack of tip support.  To my eye the best options for improvement would be to prepare yourself for grafting from either the septum or rib if septal cartilage does not exist.  Based on your photos I would recommend further tip grafting to create more tip projection and some degree of dorsal augmentation to prevent the reoccurence of polly beak deformity.  I also see a slight persistent widening of the bridge of the nose where lateral osteotomies would help.  So in short... project the tip slightly with refinement and narrowing of the tip laterally, dorsal augmentation to prevent polly beak and allow slight lengthening of the nose to appear more elegant and subtle osteotomy to narrow the width.  Hope that helps!  Dr. Shep