Why does my nose look worse after a revision rhinoplasty? 1 year 8 months post-op. What are my options? (Photo)

Question

Had standard rhinoplasty May 2017. I was not happy with result, nor was surgeon, did a revision Oct 2018. Surgeon was worried he could not achieve definition, make my tip project less, or make it smaller. He suggested a skin graft, however he changed his mind but assured me he would be able to. 1 yr 8 months later, nose has little definition, still projects too far, and tip is bulbous. I realise swelling takes time to go down but it's been nearly 2 yrs. Any advice would be really appreciated.

Steven M. Denenberg, MD · Answer

As you said, your nose is still very strong in its forward projection from your face. The tip can be brought back closer to your face. We call that "de-projecting" the tip. In expert hands, deprojecting a tip, in a primary or even a revision, is one of the more predictable changes to make.
The woman in the short video that I posted with this answer had the tip of her nose de-projected a significant amount in her operation.
Then, when a nose is de-projected, it tends to *look* longer, as if the tip had drooped. So it's important to elevate the tip as well. you didn't post any direct profile views, but I'm guessing those views would also show that more can be done to make your nose less prominent, make people notice your eyes or your chin rather than the nose.And work on the tip cartilages can make the tip less prominent as well.
How *much* to elevate the tip, or deproject the nose, or make the other changes? We figure that out with morphs, well before surgery. I'd love for you to see some excellent professionally-designed morphs of what could possibly be done with your nose. Morphs could also help you identify what's bothering you, and help you set a goal for the rhinoplasty that's accurate for your tastes. Profile and three-quarter views would be particularly important in morphing your nose. (Side note: in my opinion, morphs should always be done by the surgeon, or he should direct an assistant as she makes the morphs. Morphs should be made with a constant eye to what actually *can* be done in surgery, for that particular nose, and only the surgeon has that information and judgment. Another aside: I also recommend that you not show morphs made by one surgeon to a different surgeon. If a surgeon makes his *own* morphs, you get to see whether he understands the important issues of your nose, and how your nose should be changed. But if you show the surgeon someone else's morphs, and he says "Of course I can make your nose look like that," then you don't really know if he fully understands, or even recognizes, the important changes shown in those morphs. And you don't know if he can make those changes during surgery.)
Remember that rhinoplasty is an exquisitely difficult operation to get right, and you should only have surgery if you are able to make yourself very confident in your surgeon's skills. The changes that your nose needs require advanced techniques, and skill that most plastic surgeons don't possess with expertise. For most noses, it's much better to not have surgery than to have inexpertly-performed surgery. Read my essay on how to stay out of trouble while selecting a rhinoplasty surgeon. And for those who have had previous surgery, it also discusses how to tell whether your first surgeon should be performing your revision. And it also discusses how to take photos that are best for online evaluations.
Your nose is also a perfect example of why computer imaging by the operating surgeon is mandatory in rhinoplasty. You need to know exactly what the surgeon is planning to accomplish -- what features he thinks he can change, and by how much he thinks he can change them. I always email morphs to my online rhinoplasty consultations. When you see the surgeon's goals in the morphs, you'll know whether he has an eye for an attractive nose, and whether he shares your opinion of what constitutes an attractive nose. You'll also know whether the changes he proposes are large enough to be meaningful to you, and whether he understands your wishes enough to address all of your priorities. How would you ever get that figured out without the morphs?

Matthew Bridges, MD, FACS · Answer

It's very hard to tell from the photos what's going on.  There is too much fisheye affect from the selfies.  You may need to get a fresh in-person evaluation concerning what might be done.  There is a fundamental limitation on terms of how much the nose can be reduced.  Not sure what your are talking about in terms of skin graft.  This is NOT a typical maneuver in rhinoplasty.  I'm not sure how a skin graft would ever be appropriate in rhinoplasty.

Why does my nose look worse after a revision rhinoplasty? 1 year 8 months post-op. What are my options? (Photo)

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