Should My Revision Rhinoplasty Be Done Open Or Closed?

Q: D. Eppley, I am contacting you because you are the only surgeon I found that discusses Medpor implants extensively on your blog. I had a rhinoplasty with a tip rotation/refinement using Medpor in my columella topped with ear cartilage. I was healing well; the nose seemed narrowed/slightly more projected. But I was injured and the nose seems to have swollen, derotated, and healed unnaturally. It is more swollen on the left and the entire tip is bulbous.

I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty. He said he could reset the “wings” of the implant that is intended to pinch the sides of my nose closed, remove excess cartilage, and remove “soft tissue”.  

I’m seeking a revision because after the injury the nose changed shape. The tip/dorsum is higher, rounder, and tilts leftward due to prolonged swelling and possible shifting of ear cartilage). I have what appears to me to be pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball away from my bridge. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose with a ball of tissue projected by the implant in my columella. The tissue is soft but fibrous and based on everything that happened I feel I am looking at scar due to prolonged swelling, not curving ear cartilage. The skin on the “injured” parts of the nose is whiter and oiler than the “healed part of the nose which went through no trauma. I make this comparison because there isn’t a surgeon I’ve consulted that sees scar tissue, but I know how the nose was shaped and oriented before injury and don’t know that scar can be removed in a closed rhinoplasty.

Any advice on whether a closed rhinoplasty is really likely to help would genuinely be appreciated. I am caught between the appeal of not going through another open rhinoplasty and the thought that I will pay a hefty price for something that will not actually help much at all.

A: While I have not examined your nose, the question for your revision rhinoplasty is what is the source of the tip problem and what is the best way to solve it. Between the implant and the scar, it is hard to know the bigger source of the problem but in my opinion but need to go. This is best accomplished with an open rhinoplasty with replacement of the implant with a septal cartilage graft.

Dr. Barry Eppley

Indianapolis, Indiana