Should My Revision Rhinoplasty Be Done Open Or Closed?

Q: Dr. Eppley, I need help in determining what type of revision rhinoplasty I need. I had 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 (especially in the tip) than on the right side; the entire tip is bulbous.

I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft/overlay graft in the dorsum. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty (referred to it as a septorhinoplasty). 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 (not excess). I have what appears to me to be a pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball someplace away from my bridge, underneath where the tip used to be before it “dropped” filled out due to injury or naturally, like a tube. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose, with a ball of tissue where the nose used to simply droop down flat. That “ball” is 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 septorhinoplasty.

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, will have a period at least as stressful, and will cause the same problems in the tip. 

A: The short answer to your revision rhinoplasty dilemma is…have an open rhinoplasty and get the Medpor implant out and replaced with your own cartilage if it is still needed. This is the only to ensure that you can get the best result long-term. A synthetic implant in the tip of the nose may or may not be part of the problem…but I doubt it will be part of the cure. With scar tissue in a revisional nasal tip surgery, visualization and removal of all scar tissue with cartilage reconstruction is the only way to successfully reshape the bulbous and overprojected nasal tip consistently.

Dr. Barry Eppley

Indianapolis, Indiana