In 2009 i had my first surgery. They've placed a nose implant but afterwards you could clearly see the tip. It was to large so in 2010 I had a second surgery where they've shorten the implant but now you can see the tip again. I've spoken to them and they've given me some options: remove everything, shorten it and use some fat as filler for the tip, or use some body material (ear) instead of the implant. What would you recommend and what are the risks?
3rd Surgery for Nose Implant, What to Do?
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Doctor Answers 8
Removing Nasal Implants
In our experience, nasal implants are prone to movement that may cause problems over time, especially at the tip where a hard edge of the implant may show through the skin. For that reason, we prefer augmenting the nose with cartilage. From the photos you show, your profile looks pretty good aside from the area of concern at the tip. One option would be to cut back the implant to just lay over the bridge alone and do a tip revision using your own cartilage. Septal cartilage would be best for this.
Alternatively, you could revise the entire nose by removing the implant and using cartilage to reshape your nose. The odds are you would need rib cartilage to obtain appropriate height and definition.
It is hard to give a best answer without a more thorough examination of your nose. In general, fillers or fat in the tip do not provide real definition and are not preferred. If you decide with your surgeon to remove the implant and replace with cartilage, you could accomplish that in one operation.
All the best,
Removing nasal implants
In my experience, if you would like to avoid a 4th surgery I would remove the implant and reconstruct with your own material, namely rib cartilage. This would give you the most predictable control and very small chance of further problems. On top of that, it would be very reasonable to place a fascia onlay graft to the tip and dorsum after the rib cartilage is placed to soften contour and prevent there being any issues moving forward.
Removing nasal bridge implant
Given your history and photos I would recommend removing the implant and augmenting the area with your our tissue. Usual this would mean septal, ear or rib cartilage. You seem to require quite a bit of cartilage in which case rib may be the best way to go.
In the long run I find that autogenous grafts provide a safer, more durable result with no risk of rejection (since they're your own tissue). Using careful carving techniques I've not found an issue with graft warping.
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Revision options for implant
Based on your photos it appears that you had a low bridge and most likely will require removal of the implant and use of a rib cartilage graft - ideally your own
Revision rhinoplasty requiring grafts to replace a visible implant
From the pictures, it appears that you originally had quite a low nasal bridge, a condition we call saddling. Such a large dip in the nose requires a lot of cartilage. If you still have cartilage left in your septum, there should be enough to replace your now visible implant. If not, a rib graft may be necessary so that the bridge looks uniform. The problem with ear cartilage is that it is difficult to make it appear straight since most ear cartilage is curved and over time irregularities may appear as the swelling goes out of the nose. Your nasal tip on the side profile also looks like it needs to be filled in a small amount just below the tip defining point and would require grafts also. If you want to learn more about rib cartilage grafts, please go to: Kridel RWH et al.: Long-term Use and Follow-up of Irradiated Homologous Costal Cartilage Grafts in the Nose in Arch Facial Plast Surg. 2009;11(6):378-394.
You will always have these problems as long as you have synthetic implants in your tip. You need to have the tip redone with your own cartilage. Implants on the dorsum alone are better tolerated but still risky.
3rd Surgery for Nose Implant, What to Do?
Remove the implant. Allow the pocket to heal and after 6 months use rib cartilage to reconstruct the dorsum.
Secondary rhinoplasty corrective procedure
it seems you are facing your initial problem again. One of the down sides of prosthetic nasal implants is that they can protrude. On the long run, cartiladge grafts might be the better solution .. but the surgery is more involved and a donor side will be needed. Looking at your preop pictures you will need a sizable graft, ie rib.