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.

A third revision rhinoplasty requires a careful assessment from both aesthetic and functional perspectives of a nose that has already undergone two previous surgeries. In particular, insufficient forward projection of the nasal tip can cause it to appear recessed relative to the rest of the face and result in a nasolabial relationship that deviates from the desired outcome. Consequently, inadequate nasal projection is a significant issue when planning a third revision rhinoplasty.

In revision surgeries, the septum cartilage, lower lateral cartilages, and natural anatomical structures supporting the nasal tip may have been partially weakened or altered in shape due to prior procedures. This situation complicates the use of certain techniques in revision surgery that might otherwise be applicable in primary rhinoplasty. The primary goal of the surgery is not merely to advance the nasal tip, but also to establish robust structural support capable of maintaining the achieved projection over the long term.

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.

Why Might Nasal Tip Projection Be Insufficient?

There are several reasons why nasal tip projection may appear insufficient. These include excessive reduction of the nasal tip cartilages during a previous rhinoplasty, weakening of septal support structures, inadequate support of the columella, or the nasal tip retracting backward during the healing process.

In some patients, even if nasal tip projection is initially adequate, the tip may appear more recessed and droopy over time due to a loss of cartilage support following repeated surgeries. Therefore, in a third revision rhinoplasty, it is essential to evaluate not only the external appearance but also the anatomical support of the nasal tip and the procedures performed in previous surgeries in detail.

Why Is Nasal Tip Support Important in Third Revision Rhinoplasty?

One of the most critical aspects of correcting insufficient projection is re-establishing the structural support of the nasal tip. Rather than merely shaping the nasal tip superficially, a more robust structure can be created in suitable patients by utilizing cartilage grafts and supportive techniques.

Particularly in noses that have undergone multiple previous surgeries, options such as columellar struts, septal extension grafts, tip support grafts, or various cartilage grafting techniques can be considered based on the surgical requirements. The technique to be employed is determined by the patient's available cartilage reserves, nasal tip anatomy, skin thickness, and the changes resulting from previous surgeries.

Why Is Cartilage Reserve Important in a Previously Operated Nose? 

One of the significant challenges a surgeon may face in tertiary revision rhinoplasty is a lack of sufficient usable cartilage. Portions of the septal cartilage may have been removed during previous surgeries. Furthermore, existing cartilage may be deformed, weakened, or encased in scar tissue.

Therefore, it is crucial to evaluate the patient's existing septal and other cartilaginous structures prior to surgery. Alternative graft sources, such as ear or rib cartilage, may be considered when necessary. Rib cartilage can be a viable option, particularly in complex revision rhinoplasty cases requiring substantial structural support.

Correcting Insufficient Projection in Thick-Skinned Noses

Thick and oily skin can complicate the assessment of the nasal tip's shape and projection. Cartilage contours created beneath thick skin may be less defined, and the resolution of postoperative edema may take longer.

Consequently, simply reshaping the cartilage may not suffice for a patient with thick skin. It is essential to construct a robust structural framework for the nasal tip, avoid unnecessary cartilage excision, and incorporate skin and soft-tissue characteristics into the surgical plan.

The Goal of Tertiary Revision Rhinoplasty Is Not Merely to Advance the Nasal Tip

In a nose with insufficient projection, the objective is not simply to project the nasal tip as far forward as possible. Nasal tip projection must be evaluated in conjunction with the nasal dorsum, nasal base, columella, upper lip, and overall facial proportions. While excessive projection can cause the nasal tip to appear overly prominent on the face, insufficient projection can make the tip look flat, weak, or recessed. Therefore, the goal in tertiary revision rhinoplasty is to create a nasal anatomy that is balanced and harmonious with the patient's facial features.

Why Are Records of Previous Rhinoplasty Surgeries Important?

When planning a third revision rhinoplasty, knowing the details of the patient's previous surgeries is invaluable for surgical planning. Previous operative reports can provide information regarding the grafts used, the amount of cartilage removed, and the surgical techniques employed.

However, it may not always be possible to access detailed surgical records. In such cases, physical examination, photographic analysis, and when necessary imaging techniques help assess the existing anatomical structure. Revision rhinoplasty differs significantly from primary rhinoplasty in that the surgery is based on "re-interpreting the existing anatomy." With many patients, we often have to discover almost all the details during the surgery itself.

Are Insufficient Projection and Nasal Tip Droopiness the Same Thing?

Although insufficient nasal tip projection and nasal tip droopiness (ptosis) may appear similar, they are not the same anatomical problem. Projection refers to how far forward the nasal tip extends relative to the plane of the face, whereas rotation and droopiness relate to the vertical and angular position of the nasal tip.

A patient may have a nasal tip that is both droopy and lacks sufficient projection. Conversely, another patient might have a nasal tip at the correct angle but one that does not protrude sufficiently forward. This distinction is crucial for determining the surgical technique to be used when planning a third revision rhinoplasty.

Why Might Recovery After a Third Revision Rhinoplasty Be Different?

Scarring and fibrosis can develop in the subcutaneous tissues of a nose that has undergone multiple surgeries. This situation can complicate surgical dissection and may also affect postoperative edema and the process of tissue remodeling. Consequently, evaluating the final outcome of a third revision rhinoplasty may require a longer recovery period compared to primary rhinoplasty.

Particularly in patients with thick skin, it can take time for edema at the nasal tip to subside and for the newly constructed cartilage framework to become defined beneath the skin. Therefore, the early postoperative appearance and the long-term result should be evaluated separately.

Patient Selection and Realistic Expectations for Third Revision Rhinoplasty

Successful planning for a third revision rhinoplasty involves more than just surgical technique. The patient's existing anatomical characteristics, changes resulting from previous operations, available cartilage volume, and skin quality must all be assessed together.

Especially in patients who have undergone multiple surgeries, the goal is not to achieve perfect symmetry or an entirely new nasal shape, but rather to create a more balanced, structurally supported, and functional nose within the existing anatomical constraints. Clearly discussing the limitations of revision surgery beforehand is crucial for aligning expectations between the patient and the surgeon.

Tailored Revision Planning for Patients with Insufficient Nasal Projection

The anatomy of every third revision rhinoplasty case is unique. Therefore, there is no single standard surgical technique for correcting insufficient projection. A personalized surgical plan is developed by evaluating factors such as the existing cartilage support of the nasal tip, the condition of the septum, the shape of the nasal dorsum, skin thickness, nostril structure, and procedures performed during previous surgeries.

In such complex cases, the primary goal is not merely to make the nasal tip appear more projected; The aim is to strengthen the anatomical structures supporting the nasal tip, create a projection that harmonizes with the face, and achieve a result that is as permanent and balanced as possible.

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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