Q: Dr. Eppley, I would like your opinion on my nose condition. My history is that I have always had a big nose, it being very big and fat particularly at the tip. During my first rhinoplasty, they shortened the bridge between the tip of my nose and the upper lip but the size of my nose remained the same. During a second rhinoplasty, another doctor took out all the cartilages. The nose subsequently increased in size on the top (created like a bump on the ridge). The doctor explained it to me that it was due to the internal scar and the thick texture of my skin. Then I had a third rhinoplasty with the same doctor as the second rhinoplasty. The nose has now increased to an unrecognizable condition. According to the doctor, it is the nature of my thick skin and inner scar. He advised me not to intervene any more, as no improvement is possible with my type of skin. Some time later, I had an injury to my nose and it became bent to the side a little with a hanging tip. The pictures I am sending you shows the nose after the third rhinoplasty and after the injury. After numerous consultations with various doctors, I decided to take a chance with injections of steroids. After 6 injections, my nose has decreased to what you can see in the pictures. But the doctor who has given me injections insists that my nose cannot be any smaller than it is right now. He says that since I need new cartilages to be inserted and the size of the nose will inevitably increase.
So my questions are:questions:
1) Is it indeed possible to make it smaller or at least a little thinner?
2) If new cartilages are inserted, can it still at least become thinner (doctors say that it will be only bigger)
3) Will it be noticeable that I had prior rhinoplasties?
4) How realistic is it to expect a smaller nose with my type of skin and inner scars?
I greatly appreciate you taking the time to look it over.
A: Thank you for sharing your rhinoplasty history and your pictures. While I have no idea what your nose looked like when you started, there is no question now that you have collapse of the lower 2/3s of your nose. Too much cartilage has been removed so the skin has no little support. This explains the nasal appearance after your second rhinoplasty and why it so easily got bent with the trauma. Ironically removing the cartilaginous support underneath the skin, if done excessively, actually makes the skin sleeve look bigger and sag more. A little cartilage tip cartilage removal and reshaping is one thing, a lot removed can turn into a disaster.
The question, of course, is what can you do now? If you are having any breathing problems (and I imagine you might) then rhinoplasty reconstruction with cartilage grafts (probably rib) can be beneficial. That will actually provide some midline nasal support, like a tentpost, and can possibly make the nose look somewhat thinner. When done through an open rhinoplasty, excess skin can be removed from the edges of the incisions which can also be helpful in creating less of a skin sleeve.
As you may have surmised, yours is a very difficult but not an impossible nose problem. All of your prior surgeries and steroids have definitely created scar but that is not a signficant problem in an open rhinoplasty approach. In conclusion, do I think you can be better than where you are right now…yes. You will never have a thin or small nose but it can be better shaped and supported to look less large than it does now.
Dr. Barry Eppley