Revision rhinoplasty is often significantly more challenging than primary rhinoplasty because the surgeon must address not only the patient’s aesthetic concerns, but also the structural consequences of previous surgery. In many cases, tissue support has been altered, cartilage has been removed or reshaped, and asymmetries may become more pronounced over time.
This young patient had undergone rhinoplasty many years earlier and subsequently developed significant nasal tip asymmetry with right-sided alar retraction. While she was generally pleased with the overall profile of her nose, she was bothered by the asymmetry of the nasal tip and the irregular contour of the nostril rims. Her goal was not to dramatically change the appearance of her nose, but rather to restore balance, symmetry, and refinement while maintaining the profile she already liked.
An open rhinoplasty approach was chosen to allow precise evaluation and reconstruction of the underlying anatomy. The procedure began with refinement of the upper third of the nose by narrowing the bony pyramid to create a more elegant nasal framework. The dorsum was smoothed to improve contour, and attention was then directed toward the middle vault where significant narrowing and reconstruction were performed to restore proper proportions and create a more harmonious transition between the upper and lower thirds of the nose.The most challenging aspect of the operation involved correction of the nasal tip. Intraoperative findings revealed significant structural asymmetry from the prior surgery.
- narrow nasal bones
- add spreader grafts for middle vault support
- re-direct lateral crura and reconstruct right intermediate crural fold
- right underlay drawer graft to straighten, support and add caudal extension to the right lower lateral cartilage
The previous rhinoplasty had partially divided the dome complex and created distortion of the lower lateral cartilages, resulting in asymmetry of the tip and alar rims. The right lower lateral cartilage lacked adequate support and contributed to the visible alar retraction.
On the left you can see the asymmetric tip after the previous rhinoplasty. The center photograph shows the tip properly aligned and on the right shaping the after adding the complex graft to create symmetry.
To restore symmetry, a custom-designed catilage graft was created and placed as an underlay graft beneath the right lower lateral cartilage. This graft was specifically sculpted for the patient’s anatomy and served two important purposes. First, it restored structural support to the weakened lower lateral crus. Second, it repositioned and lowered the alar margin, creating a smoother, more symmetric contour of the nostril rim and nasal tip. Additional refinements were performed to balance both sides of the nose and achieve a more harmonious overall appearance.
The graft can be seen on the left, shaped to slide under the lower lateral cartilage and create both support and add cartilage inferiorly to shape tip.
The postoperative photographs, taken approximately one year after surgery, demonstrate correction of the tip asymmetry, improvement of the alar retraction, and restoration of a more balanced nasal shape. Most importantly, these changes were accomplished while preserving the profile that the patient already appreciated, illustrating the importance of tailoring revision rhinoplasty to each patient’s unique goals.
Revision rhinoplasty is not simply a repeat operation—it is often a process of structural reconstruction. By carefully analyzing the causes of asymmetry and rebuilding support where it has been lost, natural and lasting results can be achieved even in complex revision cases.