Do I Need Revision Rhinoplasty for Supra Alar Pinched Tip?

Unfortunately you are in good company. Most rhinoplasty patients out
there are very unhappy with their results in 1-2 years. The explanation
for this is very simple: Most surgeons performing rhinoplasty do not
have advanced training or experience, they perform the rhinoplasty of 50
years ago. Decades ago thought process of rhinoplasty was to remove
cartilage to refine the shape of the nose and perform it through an open
approach. An open approach makes it easy for neophyte surgeons to
access visualize and manipulate the structures but also unnecessarily
destroys two arteries and veins that are important for nasal
vascularity. The open approach thus ensures that patients have 1-2
years of risidual swelling which hides the final result. Most
rhinoplasties out there I consider cartilage robbing thus when the
swlling resolves there is inadequate structure to provide aesthetic
appearance and fight the cicatriacial forces or the continued scarring
that results from the lowered oxygen tension and fibrosis of tissues.
One additional problem it that most rhinoplasty surgeons out there
inadvertently break the connection between the bony nose and the
cartilagenous nose. this can cause irregular narrowing and what we
calll "the inverted V deformity" which means the outline of the nasal
bone becomes visible through the skin particularly in flash photography
under certain lighting conditions.In my opinion, an expert
level rhinoplasty is always performed in a closed technique and ALWAYS
involves grafting to add to the structural integrity of the nose. The
act of opening the nose even under the closed technique causes healing
and some contraction, thus for a long term beautiful result the nose
must be left more structurally sound than it was found. This is missed
upon most rhinoplasty surgeons. In secondary cases such as
yours it is even more crucial that sound grafting techniques are used.
Definitely do not consider any rhinoplasty procedure that does not
include grafting preferably by an experienced Plastic and reconstructive
training with ddition fellowship level craniofacial and aesthetic
training. Of course this is my bias because it is my training but I
think this level of training is very necessary for success in secondary
and tertiary rhinoplasty because there is delicate nuance involved and
every patient requires different maneuvers. I hope this helps!All the best,Rian A. Maercks M.D.

I am sorry to hear that you are not fully satisfied with the results of your procedure. It is difficult to say for sure what you should do without seeing your results in person through an examination. Swelling can take up to a year to resolve so you should wait at least 12 months for final results to show. After that time you will be able to better determine whether or not a revision procedure is necessary. In many circumstances your results will continue to improve and you will become personally adjusted to your new look. 

A pinch tip or supra-tip could be the consequence of per-existing pinch, suture techniques or excessive reduction of the nose cartilages specially on a patients who have convex tip cartilages that are oriented upwards. The solution is surgical correction of the problem for a permanent improvement after about a year following the initial surgery. Unfortunately, waiting is not going to correct the pinched tip or supra-tip pinch. Actually, it may get worse over time as the swelling subsides. The reason for waiting for about year is that with the healing other imperfections may develop and an early surgery my necessitate a second revision because of the other problems that cannot be seen at this time. If the pinch deformity is troubling you enough, it can be corrected temporarily with the fillers until you are ready for the final operation. You may consult your surgeon about the use of fillers to allow the final correction when the time is right.

It's VERY important to realize that there are some features of a nose that cannot be changed -- and therefore some people will never get the ideal nose that they dream about. In other words, you can't make any nose out of any nose. Two of these unalterable features are the overall length of the nose from the brows down to where the columella attaches to the upper lip. Another is the vertical height of the lateral ala (the part that attaches to the face), the shape of which is made up of and determined by fibro-fatty tissue, not just cartilage and skin (like the tip and medial ala). In your case, both of these anatomical features are proportionately too long, and therefore you will never have ideal nasal features and proportions. My concern is that you are seeing things that you still don't like about your nose, but not really knowing what they are exactly. I suspect that what you are "sensing" are the disproportions I just described.The message is this: There are some things about our bodies that cannot be made ideal through surgery -- and we all just have to try to learn to live with those things and love them as much as we can. Beware the Michael Jackson syndrome -- where you keep trying to chase an ideal that cannot be achieved -- and end up with something worse than what you started with.

My advice to patients is simple:  Rhinoplasty result takes a year to fully develop and consideration is usually not given to a revision for 12 months.  Rhinoplasty is a complicated procedure and revision Rhinoplasty more complicated still.  It is best to undergo surgery when the conditions are optimal for the best result when inflammation has subsided.

I think the best thing to do is wait. The healing process is still very active at the three months, and things may change. I know this can be very difficult, but I think it is in your best interest in the long run.

Samra

It would be helpful to have multiple views of your nose to give you more specific advice related to your “pinched tip”.   That being said, your nose appears to have some collapse of the lateral alar wall.  Tip swelling can accentuate this contour problem. 

In any case, It is always best to wait 6 to 12 months after your primary surgery to consider a revision rhinoplasty.

Usually, the cost is more and recovery is longer for a revision rhinoplasty.

In some cases, the judicious use of HA fillers can improve contour problems.

Dear Samra,

First of all, I would absolutely concur with the other surgeons who have previously answered your question. You should wait until around 12 months after your rhinoplasty before considering revision rhinoplasty. As things settle out, you may find that you are no longer bothered by the appearance of your nose...

Obviously, I would need to examine your nose, both inside and out, to give you an accurate diagnosis. However, based purely on your photo, my suspicions are that you may be headed in the direction of having a pinched tip. Additional photos would certainly be helpful. This pinched tip may be a result of sutures which bind the tip cartilages, or "domes", together, changing the natural contour of these cartilages. In these cases, it's a matter of removing these sutures and reshaping your tip cartilages in a more normal, aesthetically pleasing way. I would do this through an open rhinoplasty approach. 

This type of nasal shape can also be due to your lower lateral cartilages being weaker than they need to be. This problem can be corrected with lateral crural strut grafts, which are cartilage grafts placed under your tip cartilages to support and strengthen them. 

You should bring up your concerns with your surgeon but be patient before proceeding with revision surgery. Good luck!

Kind regards,

Dr. Mehta

Rhinoplasty is a meticulous surgery that addresses an aesthetic feature of the face.  If you feel that your nose does not have the natural appearance you would want, that can only be determined by you.  I would speak to your surgeon about correcting the elements that you are not happy with.  This is a matter of personal preference.

After open rhinoplasty, there will be tissue swelling in the tip of the nose up to about 1 year after surgery. It would be best to wait until this time to make an assessment on whether you feel you'd like to improve upon the results. 

It can be very difficult to make an assessment from non-standardized photographs. Lighting, shadowing and perspective can make it difficult to get an accurate impression of the nose so a face to face examination is important. 

Regarding the use of fillers in the nose, I would strongly dissuade you from pursuing this. Having fillers placed in the area can make any future revision procedure much more complicated. Also, there are numerous reports of permanent injury to the skin when injected in the tip of the nose.