Revision Rhinoplasty in Denver, Colorado

She came to me wanting a more deliberate, artistic result than she had achieved with her first surgery. She wanted a more sloped bridge, greater tip rotation and support, narrower nostrils, and elevation of the infratip.

Her biggest functional-aesthetic concern was what happened when she smiled: the tip lost support and the nose dropped downward, obscuring her upper lip. She wanted a sharper, more defined tip and a nose that would hold its position both at rest and in motion.

Her prior transcolumellar incision was well healed, but the underlying tip structure was profoundly weak. I could palpate almost no meaningful tip support, and the tip complex collapsed easily into the surrounding scar tissue.

She also had:

• A heavy soft-tissue envelope with thicker tip skin
• Wide nostrils and alar bases
• A reasonably good native tip-defining point, but almost no structural support beneath it
• Weak internal nasal valves
• A large residual left-sided bony septal spur
• Insufficient remaining septal cartilage for the degree of reconstruction required

This was not primarily a problem of refinement. It was a problem of architecture. Before I could create a sharper or more feminine tip, I needed to rebuild the structure that would hold it there.

• Open revision septorhinoplasty
• Removal of the residual septal spur and posterior perpendicular plate
• Autologous rib cartilage harvest from rib #8
• Dorsal reduction to create the desired slope
• Right-sided septal extension graft extending to the nasal spine to reinforce the weakened caudal septum and create durable tip support
• Crushed cartilage onlay in the supratip
• Osteotomies to narrow and straighten the nasal bones
• Bilateral alar base reductions

At 14 months, the entire nose has a slimmer, cleaner silhouette. The nasal bones are straighter and narrower, the nostrils are smaller, and the tip is more refined and significantly better defined.

But the defining feature of this case is structure.

Her tip is no longer defenseless against her facial expressions. It no longer drops over the upper lip when she smiles. It stays where we intentionally placed it, supported by strong autologous rib cartilage rather than scar tissue alone.

For a revision nose with thicker skin, the definition of her new tip is exceptional. The bridge now carries the feminine slope she wanted, with a distinct supratip break and sharper domal highlights.

Those highlights change the way light moves across the center of the face. Instead of the nose dominating the expression, the light is redirected upward toward her eyes, allowing the rest of her face to come forward.

He wanted a more elegant, feminine nose with cleaner symmetry, greater tip rotation, a defined supratip break, a sharper tip-defining point, and narrower dorsal lines. He was also bothered by the way the unsupported tip dropped with smiling.

His goal was not subtle refinement. He wanted the nose to look more intentional: narrower, more sculpted, and more feminine, while still fitting naturally within the rest of his face.

The dominant problem was over-resection.

Too much of the original tip cartilage and supporting tissue had been removed during his first rhinoplasty. Instead of creating refinement, the loss of structure had left the lower third of the nose pinched, weak, and poorly supported.

On examination, he had:

• A well-healed prior open rhinoplasty scar
• Severely weakened and over-resected tip cartilages
• A bulbous but structurally unsupported tip
• A pinched appearance through the lower third
• A parentheses deformity of the tip
• An inverted-V deformity
• Bilateral alar retraction
• Wide, poorly supported nostrils
• Broad dorsal aesthetic lines
• A crooked nasal axis on frontal view
• Thick skin and a heavier soft-tissue envelope
• Significant internal nasal valve collapse
• A severely deviated septum

Facial asymmetry also mattered when judging the frontal result. The center of his Cupid's bow sits to the right of true facial midline, with additional rightward asymmetry through the lips and jaw. A nose cannot be evaluated in isolation from the face around it.

This was not a nose that needed more cartilage removed. It needed support restored.

The challenge was that there was almost nothing left to work with.

I performed an open revision septorhinoplasty with septoplasty.

Interestingly, despite his previous rhinoplasty, a formal septoplasty had not been performed. When I exposed the septum, however, nearly all of the remaining septal cartilage was ossified and unusable for grafting.

I was able to harvest only a 9 × 9 mm piece of usable septal cartilage.

I used that small piece to create a left-sided septal extension graft, strategically placing the limited cartilage where it would have the greatest structural impact. No rib cartilage and no additional structural grafts were required.

The operation included:

• Open revision septorhinoplasty
• Septoplasty and correction of the severe septal deviation
• Left septal extension graft using the limited remaining native septal cartilage
• Conservative cephalic trims
• Dome-defining sutures
• Dorsal hump reduction
• Narrowing and refinement of the nasal bridge

This was a case where doing more did not mean adding more grafts. The important decision was knowing exactly where a very limited amount of cartilage would have the greatest effect.

At only three months, the change is already striking.

The bridge is narrower and more elegant, the dorsal aesthetic lines are cleaner, and the nose sits substantially closer to the facial midline. A slight residual leftward axis remains, particularly when viewed against the natural rightward asymmetry of his lips and jaw.

The lower third has changed even more dramatically.

The tip is now supported, rotated, and sharply defined. He has the feminine slope and distinct supratip break he wanted, without sacrificing structural integrity to achieve them. The alar retraction is significantly improved, and the nostrils appear dramatically narrower and more controlled.

Importantly, I did not perform alar base reductions.

Much of the apparent nostril width was not truly an alar-base problem. It was the consequence of a collapsed, inadequately supported tip. Once the central architecture was restored, the nostrils narrowed with it.

That is one of the most important lessons in revision rhinoplasty: sometimes the feature that appears too wide is not the structure that needs to be made smaller.

Sometimes it needs to be better supported.

This is a striking early result from every angle. More importantly, the nose now has an architecture capable of holding the shape we created.

This patient had a history of intranasal cocaine use when she was younger, resulting in destruction of the nasal septum, a subtotal septal perforation and progressive collapse of the bridge—a deformity known as a saddle nose.

She presented with significant asymmetry on frontal view, a collapsed and washed-out appearance of both the bridge and tip, essentially no tip support, and severe difficulty breathing through her nose.

Although this was technically her first rhinoplasty, the complexity was much closer to a major revision reconstruction.

A saddle nose develops when the load-bearing septum has been severely weakened or destroyed. Without that central support, the bridge begins to collapse inward and the nose effectively starts sinking back toward the face.

Her subtotal septal perforation left almost no usable septum. On examination, I could not identify meaningful remaining septal cartilage. She also had essentially no functional internal or external nasal-valve support.

This meant there was very little native framework left to modify. I would essentially have to rebuild the structural foundation of her nose from the ground up.

The existing septal perforation also added another layer of complexity. Opening and manipulating the mucosal edges surrounding a large perforation can jeopardize the reconstruction and potentially increase the risk of graft exposure, infection or failure.

Small and even some large septal perforations can occasionally be closed by mobilizing healthy nasal lining from around the defect, or placing a dissolvable plate wrapped in fascia. She did not have that problem. Her perforation was subtotal, the surrounding tissue had been damaged by prior cocaine exposure, and there was simply not enough healthy local septal tissue to reconstruct something approaching a normal septum.

At the extreme end of reconstructive surgery, it is technically possible to bring entirely new vascularized tissue into the nose using procedures such as a large pericranial flap or even a microvascular free flap. But that would represent a massive reconstructive undertaking simply to close the perforation and, in my opinion, would have been completely disproportionate to the objective of her operation. This was not a realistically repairable septal perforation.

• Open structural rhinoplasty
• Confirmed complete absence of usable septal cartilage
• Left the mucosal flaps surrounding the septal perforation undisturbed
• Harvested autologous seventh-rib cartilage
• Reconstructed the dorsal and caudal septal framework with rib cartilage
• Created an extended dorsal/spreader construct and secured it directly to the nasal bones through hand-drilled fixation holes using 4-0 nylon
• Created double-stacked caudal septal replacement grafts, secured inferiorly to the nasal spine and superiorly around the reconstructed dorsal strut
• Harvested rectus fascia and wrapped it around a rib-cartilage laminate to create a smoother dorsal contour
• Performed a small left-sided sill excision to improve nostril symmetry

At 8 months, she has had a dramatic structural and aesthetic improvement.

The saddle deformity has been eliminated. Her bridge is straighter, stronger and much more naturally defined. Her dorsal aesthetic lines are substantially improved on frontal view, and her tip now has shape, projection and structural support. Her alar retraction, columellar position and relationship between the nose and upper lip have also improved significantly.

There was, however, an important limitation to this reconstruction.

Because she had essentially no native septal cartilage remaining, I had to create an entirely new L-strut and rely heavily on the strength of her nasal bones to stabilize that reconstruction. For that reason, I could not safely perform osteotomies—the controlled bone cuts typically used to narrow or straighten asymmetric nasal bones.

Her nasal bones were significantly asymmetric before surgery, and that asymmetry therefore remains visible to some degree after surgery.

Correcting it would have required destabilizing the same nasal bones I was relying on to hold her reconstructed nose together. That would have been a poor trade.

This is exactly the type of decision that matters in complex revision and reconstructive rhinoplasty. The question is not whether every remaining imperfection can technically be changed. The question is whether changing it would make the nose better overall.

In her case, the answer was clear.

She went from a severely collapsed, poorly supported nose with essentially no septal framework to a nose that looks and functions like a normal structure again.

It is not perfect. It is dramatically better—and now she has a normal, strong and genuinely attractive nose.

That, to me, is an excellent example of the goal of complex revision rhinoplasty: meaningful improvement without sacrificing the reconstruction in pursuit of perfection.