White Nasal Tip after Multiple Rhinoplasty Surgery
Q: Dr. Eppley, I’ve attached a picture of my nose. This is how it looks every time I smile today – I get a distinct white spot at the tip of my nose. It’s extremely embarrassing in any social situation, because it looks so unnatural and weird. I’ve had three rhinoplasties already. The two first ones were to lengthen my nose, with rib graft. After the first rhinoplasty I didn’t have this problem, but after the second when the nose was lengthen further – that’s when the problem arose. The third surgery was made as an attempt to correct this issue, but with no real success. My surgeon told me he just shortened it 1-2 mm and put some skin grafts on the sides of my tip in order for the tip to not look so pointy and white when I smile. But as I said, it didn’t help. Maybe the tip got a bit rounder, but that’s all, the whiteness every time I smile is still there as you can see on the photo. My last rhinoplasty was a little over a year ago. Now to my questions:
1) Do you think this issue can be fixed by shortening the nose back to the length it was after my first surgery (about 3-4 mm shorter than it is now)? Or do you think it can worsen the problem, since I’ve already had three rhinoplasties done to my nose?
2) Do you think a skin flap/graft will be needed to the tip of my nose in order to make the skin thicker there – or how would you approach this problem, technically?
30 Have you come across this problem before – is it hard to fix? Do you think my condition is permanent or fixable?
4 My original rhinoplasty surgeon told me to “pull” the skin of my nose tip 10 times x 10 times a day in order to stretch the skin. He thinks this will fix my problem, but I have been doing this for two months now and I can’t see any improvement at all. Do you think this approach is realistic/promising, or just a waste of my time?
A:The blanching of the tip skin after rhinoplasty when smiling is very uncommon but I have seen it before. Since the tip of the nose is the most stretched out portion of the nose, when it is lengthened (I assume cartilage tip grafting was done) excess pressure is created on the tip skin when one smiles causing a temporary loss of circulation. Deprojectioning the tip would be the appropriate solution if one can feel a firm cartilage graft under it which would the source of the aesthetic problem. Since it has been attempted once to deproject it and it has not been successful I would assume that any protruding cartilage graft putting excess pressure in the tip has been removed. Further deprojection may be successful but if it didn’t work the first time I would no have confidence that it will the second time. (although not impossible) I would think that placing a small fat graft under the tip skin many be helpful since such a graft is soft and will help improve the circulation to the skin in the long run.
While the stretching the nose tip skin sounds reasonable and it is harmless, I would not think its continued use ameliorating your nasal tip concerns.
Dr. Barry Eppley