Q: Dr. Eppley, I had a revision of my primary rhinoplasty last summer and don’t like the shape of the nostrils and the tip. I also don’t breathe well from right nostril. Do you think I need grafts from ears or rib??
A: In looking at your frontal picture, I see widely spaced domes on the tip and significant tip asymmetry due to the right alar rim being very low compared to the left side. The profile view from the left side show a big step-off at the mid-columellar incision.
Your nose certainly has room for improvement, particularly given that you have had two rhinoplasty procedures. Why you have ended up with this result is a bit puzzling given that you have had open rhinoplasty approaches. I certainly would be tempted to say that further improvement is certainly possible but whether cartilage grafts are required to do it is a bit premature. It would be helpful to have more information if possible such as the operative notes from the two operations. That issue aside, what is needed always becomes evident in a revision when the tip is degloved and anatomy of the tip cartilages become evident. While swelling and scar tissue can obscure underlying tip cartilage anatomy, most external tip deformities are a direct result of how the underlying cartilages are shaped. You have such a significant tip deformity that I would wager the right lower alar cartilage is twisted and rotated downward, perhaps due to lack of support. In that case, cartilage grafts are needed such as a strong columellar strut from the septum and an alar onlay graft from ear cartilage. I would doubt that rib cartilage is needed. But I would leave that as an option to be determined during your revisional rhinoplasty procedure.
Dr. Barry Eppley