Septoplasty and/or rhinoplasty can both be done through a closed technique
The swelling that you're experiencing intermittently is normal interstitial fluid shift in the nose and face. It becomes more noticeable after a rhinoplasty procedure. Kenalog shots that are placed in the internal portion of the nose help with dissolving scar tissue and removing lymphatic edema that gets trapped in the supratip area of the nose. Cortisone injections do come in two different strengths, Kenalog-10 and Kenalog-40. A septoplasty and/or rhinoplasty can both be done through a closed technique, not an open technique. A septoplasty will not affect any edema of the supratip area of the nose.
For many examples, please see the link below to our rhinoplasty photo gallery
A revision won't help swelling
I don't think you can expect any improvement if your revision surgery is aimed at helping your swelling improve. Rhinoplasty is a delicate procedure and each revision carries with it more risk, in particular for a bad cosmetic outcome.
The operation needs to be focused on correcting a specific anatomic problem, and if this cannot be identified before the procedure, I would avoid any more surgery. It does sound like the kenalog injections have helped-- this, with time (sometimes 12-18 months for some open rhiniplasties) may be what it takes.
Swelling is normal in revision rhinopasty
There are some general observations on revision rhinoplasty
that can be made applying to your situation. It is not possible to give an
exact assessment of your situation without seeing some pre-op photos to see
where you started.
Swelling after any rhinoplasty can take years to resolve.
Typically the bulk of the swelling is gone by 3 months though most noses get a
little smaller and refined over the next months to years. A revision nose will
typically take longer as there is more trauma and scar tissue to deal with.
Thicker skin swells more and takes longer to heal than thin skin. Male noses
also take longer to heal and swelling can last much longer.
One of the biggest factors in swelling after surgery is how
much size reduction occurred. The more the nose was reduced the longer the
swelling will last. Drinking, exercise and salt heavy diet can all cause temporary swelling in a healing nose.
At 10 months it is too early to jump right in and do another revision surgery. Share your concerns with your surgeon or consult a rhinoplasty expert.
Good luck and I hope this helps.
Swelling after rhinoplasty can occur
The skin soft tissue envelope is one of the most important elements in rhinoplasty surgery. An experienced rhinoplasty surgeon has great respect for the skin and soft tissues, since they realize that this is the most difficult element to control. If this is damaged or the lymphatics disrupted it can be difficult if not impossible to re-mediate perfectly. This can be a difficult problem to get a satisfactory result.
It is most likely to be cartilage.
Chances are that it will not resolve after this amount of time and steroid injections. It is probably cartilage or excess scar tissue and this will require a revision. You may seek another opinion from an experienced revision rhinoplasty surgeon.
Be careful of steroid injections
Five steroid injections may have helped with some swelling, but steroids have a way of thinning skin and causing vascular proliferation (additional blood vessels). Your skin is thick, not uncommon for a 44 year-old man. No matter how little swelling you have, the thick skin will not allow the underlying architecture to show like you see in young women with thin skin.
I am not sure that surgery will help you any more. I would also be very careful with more steroid injections. Your nose looks relatively straight and it is not uncommon to have it pull down when your smile. There is a small procedure that can cut a muscle that predisposes to pulling down. It can be done from within the mouth, but the results can be variable. Ask your doctor about it, and consult with someone used to doing multiple revisions.
It sounds as if you are still healing.
With revision rhinoplasty, a surgeon typically reopens previously operated upon tissue. This can place even more scar into the surgical space than before. Also, the lymphatics or fluid draining vessels may be slower to recover creating prolonged edema. The fact that steroids are helping indicates that the inflammatory process that is part of normal healing is being controlled.
A revision for swelling will probably only make things worse because the tissues would get traumatized for a third time. It is very easy to create a lumpy, amorphous nose from too much surgery. Unless your breathing is severely restricted, I would stop touching the nose for a long while to let your body settle itself down. The steroid injections can certainly continue but only if the benefits outweigh the risks.
Surgery does not help swelling
It is unclear what your problem really is. If it is truly swelling, then surgery will not help. It can take a very long time for swelling to resolve after rhinoplasty and it sounds like the steroid injections are slowly working. If the issue is anatomic (residual hump) and not truly swelling then you may need revision surgery. Good luck.