3rd Revision Rhinoplasty for Under-Projected Nose

Underprojected, Flat, and Asymmetric Nasal Tip – Tertiary Revision Nose Job

A female patient presented to our clinic having previously undergone rhinoplasty twice at different clinics; she complained of nasal tip collapse, asymmetry between the nostrils, nasal obstruction, scarring on the columella, irregularities on the nasal dorsum, and a tendency for the nasal tip to shift laterally and downward when smiling. Following the previous surgeries, it was observed that the nasal tip had flattened and moved closer to the face (under-projected and flat nasal tip).

Findings from the patient's examination included:

- under-projected nasal tip

- significant nostril asymmetry

- previous incisions and visible scarring on the columella

- flattened and wide nostrils

- a very soft nasal tip lacking cartilaginous support

- nasal tip ptosis (nasolabial angle approximately 60–70 degrees)

- hanging columella

- thick nasal skin characteristics

- nasal axis deviated to the right

- narrowing and collapse in the left nasal valve region

- bulbous nasal tip

- irregularities on the nasal dorsum

We performed a third revision rhinoplasty using an open technique.

Patient's Surgical Details

The operation was initiated under general anesthesia. A temporal fascia graft was harvested from the right temple region. An incision was made at the site of the previous columellar scar, and the scar tissue in this area was excised. Deep dissection revealed residual septal cartilage, from which cartilage grafts were prepared. Irregularities on the nasal dorsum were corrected using a micro-drill with a tungsten burr. Bilateral osteotomies were performed using an ultrasonic device. A septal extension graft was placed along the vertical axis using the "tongue-in-groove" technique. The alar cartilages were sutured to this graft. Cap grafts were placed. Left marginal rim grafts were positioned. Temporal fascia grafts were placed on the nasal dorsum and nasal tip. The incision sites were sutured.

A comparison of the patient's pre- and post-operative images revealed that nasal tip projection had increased and normalized, the flattened appearance of the nasal tip had been corrected, the nasal tip looked much more natural in the frontal view, the nostrils were more symmetrical, and irregularities on the nasal dorsum had been eliminated.

The patient's nose was taped, internal silicone splints and an external thermoplastic splint were applied, and the operation was concluded.

Why Nasal Tip Projection Is Important?

Maintaining normal nasal tip projection and support is crucial for our patients; it prevents a flattened, wide appearance and nasal tip drooping. A loss of cartilaginous support and the resulting decrease in projection can lead to a nasal tip that simultaneously widens and droops when viewed from the front, while also causing narrowing of the nasal valve area and associated nasal congestion. As seen in the patient presented here, an under-projected and wide nasal tip—often resulting from surgery—can create an appearance resembling a "boxer's nose" or alter the facial structure to look more ethnic. It can also give patients a more irritable or aged appearance.

You can read articles related to "underprojected nasal tip" prepared by Dr. Murat Enöz and published on this website via this search result link (you can see the articles by clicking on "more posts" at the end of the page) >> https://www.ent-istanbul.com/search?q=underprojected+nasal+tip

Murat Enoz, MD, Otorhinolaryngology, Head and Neck Surgeon

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