Revision rhinoplasty planning considering nasal tip skin condition and necrosis risk

Hello, I am Dr. Peter C. Kang.

Today, I would like to introduce a correction case for a patient troubled by a crooked nose and an upturned nose. The patient had undergone multiple rhinoplasties in the past, and an open rhinoplasty was difficult to perform due to the risk of nasal tip necrosis.

1. Patient surgical history and concerns

• Double jaw surgery (1 year ago)

• Nose filler (5–6 years ago, not dissolved)

• Donor rib cartilage + septal cartilage + silicone implant at another plastic surgery clinic

• Autologous rib cartilage + silicone implant at another plastic surgery clinic (10 months ago)

• Nasal tip derotation surgery (postoperative day 5) due to the risk of nasal tip necrosis

• Upturned nose

• Crooked nose

• Wide nose

• Protruding mouth

• Depression and hyperpigmentation of nasal tip skin

2. Preoperative analysis

Front view:

• Excessive nostril show

• Wide, spread-out nose

• Crooked nasal bridge

Profile view:

• The nasal tip is upturned

• The radix appears high

• Observed protruding mouth

Oblique view:

• Wide appearance is clearly visible

Nostrils:

• Skin depression and hyperpigmentation observed on the right nasal tip

• Scar tissue observed on both sides of the columella

• Nostril asymmetry

3. Surgical plan

• Septal reconstruction using autologous rib cartilage

• Correction of upturned tip: septal extension

• Correction of crooked nose: lateral osteotomy

• Improvement of wide nose

• Correction of protruding mouth: nasolabial angle correction

• Improvement of nostril asymmetry: septal reconstruction, lower lateral cartilage repositioning, and suture techniques

• Improvement of nasal tip skin depression and hyperpigmentation: cartilage and dermal grafts

4. Surgical details

The following procedures were performed using a closed approach.

• Severe damage to septal cartilage: The reason this type of nose was upturned was that the septal cartilage had sustained severe damage during prior surgeries. Septal reconstruction was performed using autologous rib cartilage.

• Impaired nasal tip blood circulation: During surgery, impaired circulation was observed at the nasal tip, and briefly, blood perfusion became compromised, causing the skin to blanch. We administered vasodilators and medications to elevate blood pressure, identified and resolved the cause of the compromised blood flow, and confirmed that skin necrosis would have been a significant risk had a closed approach not been used.

• The depressed and hyperpigmented nasal tip skin was confirmed to have resulted from partial skin necrosis during a previous surgery, which damaged part of the dermal layer and led to adhesions with surrounding tissue. This was corrected using cartilage and dermal grafts.

5. Comparison of before-and-after photos

Front view:

• Nostril show has significantly improved

• The previously wide nasal tip looks natural

• The previously deviated nasal bridge is now straight

Profile view:

• The upturned nasal tip has been adequately lowered

• The nasal tip has become softly contoured and natural

• The nasolabial angle was corrected to around 95 degrees, improving the protruding mouth appearance

Oblique view:

• The wide-appearing nose has become slimmer

Nostrils:

• The depressed skin on the nasal tip has improved

• Scar tissue on both sides of the columella is concealed

• Improved nostril asymmetry

6. Photos taken immediately after surgery (day 0)Immediate postoperative photos show swelling and may differ from the final result.

7. Overall review:

This case resolved complex problems that arose after multiple rhinoplasties. In particular, it is notable that in a situation where open rhinoplasty was difficult due to the risk of nasal tip necrosis, the surgery was performed effectively using a closed approach planned with safety in mind.

Through septal reconstruction using autologous rib cartilage, structural stability was established while simultaneously addressing various aesthetic issues, including a crooked nose, an upturned nose, a wide nose, and a protruding mouth. Furthermore, by paying meticulous attention to blood circulation in the nasal tip skin, the surgery was completed safely.

8. Concluding remarks:

When there is a risk of nasal tip skin necrosis due to vascular damage from prior open surgery, using an open approach during revision rhinoplasty can be very hazardous. In such cases, a closed approach may be the most suitable option. In particular, closed rhinoplasty allows the exact same surgical maneuvers as an open approach while minimizing the risk of vascular compromise, making it a reliable alternative planned with safety in mind for these high-risk patients.

For those concerned about complex nasal issues such as a crooked, upturned, or wide nose, there is hope even when revision surgery seems challenging due to prior procedures. I encourage you to consult with a specialist to find the surgical approach best suited to your condition.

NOSELAB always prioritizes patient safety and satisfaction, striving to achieve the intended result through an individualized, tailored approach. We will be with you on your journey toward a beautiful and healthy nose.

This was Dr. Peter C. Kang. Thank you.

Thank you.

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