LAM FACIAL PLASTICS

Hi Dr. Lam and visitors,

To make a long story short (or at least try to), I'm now 21 and I had a rhinoplasty at 14 to remove a dorsal bump and shave down the lower part of my nose. Today I regret it. I don't blame the doctor as I was young and did not yet develop my aesthetic standards. In my 14-year-old mind, the extent of my thoughts on the matter was a shallow "Just remove this ugly bump".

Today I long to be unique again. I feel my new nose removed the character from my face and I long to look like my ethnic heritage that I'm now unashamed of. I'm not usually an indecisive person and once I revise something ... it's usually final, but can I blame myself at 14? Clearly my judgement hadn't matured.

My goals on the revision rhinoplasty would be to first shave down my very high radix to improve the look of my eyes, though I wish to leave my dorsum mostly alone to return my nose to a convex shape. Furthermore, I would like to rid myself of the upturned tip I acquired post-rhinopasty and derotate it a bit. Can this by done by trimming my columella? Is this a rather straight forward, less complex procedure? My last goal is to widen my alar base. I've always had a narrow alar base; this wasn't changed in my rhinoplasty, but I feel I look better when I stretch my nose base wider from the front and gain longer looking nostrils in my profile view. More importantly, it makes my nasal breathing more comfortable as a mouth breather. Can this type of alternation be done? If not, can SARPE (Surgically Assisted Palatal Expansion) do this for me? I've always had a narrow smile and that too would improve me functionally. I'm just worried the SARPE procedure might also rotate my nasal tip upwards.

Are these goals realistic, feasible, and would a surgeon want to perform my procedure? My main fear is that I'll sound crazy as normally patients wish to *reduce* their nose and slope its shape. I just don't want to scare the doctor away with my unconventional request.

what you are asking for is not easy and straightforward. derotating the nose and projecting it are not reliably easy things to do. widening the alar base is really almost impossible unless you put composite grafts of skin and ear cartilage inside the nose but that leads to unpredictable scarring and i only do that for scarred and contracted ala not for people that just desire the area to be widened. the SARPE technique you referenced i am not familiar with. most likely that is something an maxillofacial surgeon would be doing. taking down the radix is doable as well as augmenting the bridge but i do not think you will be happy unless every component of your nose has been re-altered back to its ethnic appearance. i do not think what you are asking for is unreasonable but i do not think i will deliver what you are looking for.
s.

Thank you for your response!

As I expected, it's not easy. I can easily forget about the alar base widening as that is not my concern.

As far as the nose tip rotating, is it always required to use a caudal septal extension made from the ribs? That seems pretty traumatic to me as long as expensive due to its complexity. Can these grafts be harvested from the ear instead? I also hear sometimes a columella shortening is done for cases like this?

Thank you again for your time; its' greatly appreciated!

you do not necessarily need caudal extension grafts to rotate. you can extend a columellar strut or use a tip graft but if the skin is thin then the latter is not as good a suggestion. if i use ear i can reinforce it with PDS plate (that dissolves) to make the ear stiffer like rib. i also can use donor rib (irradiated rib) to do the job.

Interesting. I haven't seen many cases where the nose is derotated, so I didn't know other options were available.

I now have a good idea of what my options are and how to communicate the types of techniques. Thanks for answering all my questions and clearing this up for me!

my pleasure.