Can I remove and replace a septal extension graft? (Photos)

Clicking is caused by a very basic technical error any rhinoplasty surgeon has to know, it is ABC of the business: never ever let a columellar strut grafting lay direcly over the maxilla, leads to a bad clicking making the patients neurotic, irritable and unable to cope with it; it is a misconception believing the strut has to stand its base on the bone, untrue, it is floating like the rest of the nose and its properties are creating a reinforcement (when indicated) to the medial cruras (columellar cartilages).

IMHO your nose is now (if I assume correctly the righ one is your current look) oversized and the tip over projected; this is not due to this or that technique applied, don't be wrong, all the techniques can be fabulous or calamitous, it is all a matter of their calibration; don't blame the tecnique but the sculptor, the septal extension graft might have been a good decision (I can't tell for sure, evidently) but maybe was not correctly adjusted.

Since you are only 6 months following your revision surgery, try to be a bit more patient. I do believe that people get used to cartilage crafting, as the nose continues to heal, and I think it's too soon to consider another surgery. If you still have significant dissatisfaction after another 6 months, please consider meeting with another reputable rhinoplasty specialist for a second opinion. I hope this helps. Sincerely, Dr Joseph

As I see it, the "problem" with your nose after your primary was not that the nose was too short, or that the bridge was too low. Rather, the problem was that the tip was very strong in its forward projection away from your face. When a tip is de-projected (brought back closer to the face), *without* taking measures to *lower* the tip (rotate it downward), the tip will still *appear* lower because of the deprojection, and it would not look too high after surgery. (I see that effect all the time in primary rhinoplasty: if a patient has a strongly-projecting nose of attractive length, I need to be attentive to *shortening* the nose by elevating the tip at the same time as I de-project the nose, or else the nose will look too long after surgery.)

Further, the bridge would be *lowered* in that operation, to match the new de-projected position of the tip, making the nose overall look smaller, and a smaller nose just doesn't show off any remaining problems as much as a larger nose.

Further yet, I'm describing a "reduction" rhinoplasty, where we're trying to make things less rather than more, and, while it's still a complicated procedure, the potential sources of risk are much smaller than when you put in rib or SEG's or use other techniques to lengthen or strengthen the nose.

I think you might be able to visualize all of that with a good morph of your pre-revision nose, showing only de-projection of the tip and lowering of the bridge to match the new position of the tip. That's not all just water under the bridge, though: if you decide to have more surgery, I think the plan and the goal should recognize what's going on here: if the surgeon tries to adjust or change grafts, keeping your bridge and tip projection as strong as they are, there's no point in doing it from an appearance standpoint, and if the new structure or grafting *feels* better, it will be lucky, rather than resulting from a specific surgical plan. We're not good at creating how a nose *feels*; it's hard enough to create a specific *appearance*. If you have more surgery, I would recommend exploring the possibility of making the appearance changes I describe above, probably removing and not replacing some or all of those grafts, leaving you with a smaller nose that will bother you less in its appearance and, hopefully, with a little luck, feel better as well.

Hello and thank you for your question. Based on your photographs, you may benefit from a revision rhinoplasty with removal of the SEG. Nasal tip deprojection can also be performed at the same time. . With good surgical technique, you could have an outstanding result. I recommend that you seek consultation with a qualified board-certified rhinoplasty surgeon who can evaluate you in person.

Best wishes and good luck.

Richard G. Reish, M.D.
Harvard-trained plastic surgeon