Revision Rhinoplasty in Asians

There are rhinoplasty cases, and then there are cases like these.

Case 1

A foreign male patient came to me with concerns about a high radix following two previous rhinoplasty procedures. His history was telling - a silicone implant placed over ten years ago, removed one year prior and replaced with a dermofat graft taken from his groin. He now complained of a prominent radix, a wide nasion, and a bulbous tip.

Before committing to surgery, point-of-care ultrasound showed significant scar tissue in the soft tissue envelope, so a POCUS-guided steroid injection was offered first. The response was minimal. After further consultation, revision rhinoplasty was agreed upon. He however, was adamant against an open approach and insisted he would only accept it as a last resort. I agreed to try with a closed (endonasal) approach, but with conversion to open if it became necessary.

Intra-operative Findings

After endonasal incisions and dissection (see picture below), the left lower lateral cartilage (LLC) was nowhere to be found. There was some hint of it, but this was completely integrated with the overlying skin, most likely from previous inflammation and scarring. The right was just about identifiable. Developing the dorsal pocket was met with dense scarring throughout.

Schematic of various endonasal incisions in closed rhinoplasty (from Perkins & Patel, 2009)

During dissection, there was an inadvertent buttonhole through the dorsal nasal skin. This is a known risk in scarred revision tissue where normal tissue planes (to facilitate dissection) no longer exist. In a nose with this history, that was not a surprise.

Once sufficient access was established, soft tissue (including scar) was debulked at the radix and nasofrontal angle, to address his primary concern of a high radix. I then worked downwards along the dorsum and supratip in order to harmonise the overall projection and contour. The radix was then rasped and osteotomies were performed to narrow the nasion. Attention then turned to the tip.

With no left LLC available, the plan was to use septal cartilage for structural tip support. In a large male patient, the septum would normally yield more than enough cartilage. Instead, it was flimsy and of very limited volume. This was quite unexpected, and unexplained at the time. Tip-plasty was therefore performed with suture-only techniques, as he had not consented for rib or ear cartilage harvest. The remaining dead space was then closed with the technique that I recently published on to improve his tip outcomes. He was recovered and the findings were explained to him post-operatively.

Precision is not an option, but a necessity. In this case with significant structural compromise, anatomical reconstruction requires meticulous attention to detail. My focus is on restoring form and function through structural preservation (as much as possible) and reconstruction.

The History That Changed Everything

Given the septal findings, I asked him directly whether he had ever snorted drugs. He then admitted that he had. That single admission explained every intra-operative finding. Chronic intranasal drug use causes progressive destruction of the nasal septum and mucosa through ischaemia and direct toxic injury.

Taken together, the flimsy septum, absent left LLC, and the distorted tissue planes, was basically a recipe for disaster, especially in the context of two previous surgeries. All of this was consistent with years of repeated surgical and chemical insult to the nasal lining and structures, never disclosed until it was already inside the operating theatre.

The Second Stage

With the columella and alar rim now structurally vulnerable, the decision was made to return the following day under local anaesthesia to place conchal bowl cartilage, harvested from the ear, to support the columella and restore the left alar rim. Local anaesthesia was also the more appropriate choice given that he had nearly self-extubated under general anaesthesia (GA) during the index procedure, making a return to theatre under GA undesirable.

The Challenges of Cosmetic Tourism

My blog here documents the real problems that arise when patients return from surgery abroad. This case is now the reverse as this was a foreign patient who had come to Singapore for surgery with me.

He left three days post-operatively, which was more than safe from a physical point of view. However, even before his departure, he was already in a state of complete mental dissonance. He was texting me incessantly even from the same evening, unable to accept my reassurance over messages, fixating on changes in his nose that he was assessing through selfies. The anxiety escalated over the following days until he finally returned in person at day 6 for stitch removal. Of note, he had already removed the splint and steristrips himself before then.

When I showed him photographs that I had taken after my in-person review, he went silent. There was no real issue. The results that he saw in his selfies was a combination of unnatural camera angles and lighting exposure, not surgical outcome (bar the expected post-operative swelling).

This IS the challenge of cosmetic tourism in both directions. Without accessible in-person follow-up, post-operative anxiety has no outlet except a phone screen and text messages to a surgeon (or a concierge/coordinator) who can only do so much remotely. A result that looks excellent in clinical photographs and in person can and will look entirely different from a selfie.

Outcome

Even at one day post-operatively, the photographs showed a meaningfully improved nose with the radix now lower, the nasion narrower, and the tip shape much refined compared to what was there before. The one genuine finding at the 1 week review was mild left alar retraction (see picture below), not unexpected in revision tip work within a compromised soft tissue envelope (especially in this case). On last follow-up (remote), the alar retraction had more or less resolved at 2 months out based on pictures that he had sent across.

Worm's eye view of patient at 1 week post-op, with small area of left alar retraction (yellow arrow).

What This Case Teaches

A closed approach in revision rhinoplasty is a genuine technical challenge. The operative field may be severely distorted, and without the full visualisation that an open approach provides, the surgeon must be ready to adapt at every step, doing what can be done safely, abandoning what cannot, and in rare instances (like this), staging what remains. Deep anatomical knowledge and reconstructive experience is non-negotiable here, otherwise one would risk collapsing the whole nose ie a saddle nose.

On the question of rib cartilage or cadaveric allograft, autologous rib remains the gold standard for major structural revision and was a legitimate consideration here. Ear cartilage was chosen instead because it was sufficient for the specific structural deficiency in this case, without the added operative burden of a rib harvest in a patient who had already reacted poorly to GA. I do not use nor have experience with using cadaveric rib grafts as resorption rates are documented and unpredictable (depending on the supply source), and in a nose with this much prior surgical history, I am just not comfortable introducing even more foreign material into a nose at high risk of infection.

Finally, I do not offer 3D simulations either, for the same reason I insist on at least two consultations before any cosmetic surgery - both are attempts to manage expectations honestly before a single incision is made. A 3D simulation creates a visual contract that no surgery on a living, healing face can guarantee to honour, especially not in a revision rhinoplasty case like this.

The Revolving Door of Foreign Materials

Silicone nasal implants carry complication rates of 4-36% in published series with issues such as capsular contracture, displacement, chronic pressure-induced ischaemia, skin thinning, and eventual extrusion. The pressure exerted over years causes progressive ischaemic damage that may not declare itself until inflammation, skin changes, or structural compromise appears. When a silicone implant is finally removed, it does not leave a clean slate. It leaves behind capsule, scar tissue, and anatomy distorted by years of chronic pressure.

A dermofat graft placed into that compromised pocket adds its own layer of unpredictability with inconsistent and often excessive resorption, unpredictable volume change, and a soft tissue environment already damaged by what preceded it.

By the time this patient consulted me, the nose had been through over ten years of silicone, a removal, and a dermofat graft replacement. This represented a very hostile surgical field, the cumulative consequence of repeated foreign material and chronic inflammation in a confined anatomical space.

Sadly, this is not a one-off. I have seen this exact destructive cycle play out in other patients seeking revision.

Case 2

Recently, another female patient presented to me for what would be her fourth rhinoplasty:

• She started with a primary silicone implant done locally more than 10 years ago. Predictably, that failed to deliver a natural look.

• She then traveled abroad for a revision two years ago, exchanging the silicone for Goretex alongside nasal osteotomies to narrow her now-widened look.

• Still unhappy, she went back overseas for a second revision a year later, and the surgeon basically threw the kitchen sink at her nose: reintroducing silicone, adding rib cartilage just for the tip but wrapping it with rectus fascia (from the abdomen), stuffing in dermofat graft to address the "skin thinning", performing a one-sided alarplasty, and most inexplicably, attempting a "columella lowering"- which on clinical examination was most likely a direct skin excision in the columella, a cardinal sin and absolute no-no in rhinoplasty.

• That entire silicone-cartilage-fascia construct then culminated in a nasty Pseudomonas infection with pus discharge. She had to fly back for emergency removal and debridement, and then spent the next two weeks admitted in our local hospital for strong intravenous antibiotics.

Now, having barely survived an infected, scarred, and collapsed tissue bed, she presented to my clinic asking for revision number four, while showing me Instagram reels of various K-pop idols' noses. Ironically, these are most probably neither real nor authentic.

The cases above illustrate something I feel very strongly about. I DO NOT use foreign material in the nose - no silicone implants, no Goretex, no PTFE (Surgiform), no cadaveric rib grafts (freeze dried, irradiated etc.) - only your own cartilage. The evidence supports this, and these real world cases above are living examples of why.

For patients considering rhinoplasty or revision rhinoplasty in Singapore, you can read more about rhinoplasty at ZNG.

Written by Dr Ng Zhi Yang, UK & Singapore accredited Plastic Surgeon. Winner of ISAPS Bronze Medal for Rhinoplasty (2025), and Best Abstract Award (2024) at the London Rhinoplasty Course, Techniques in Rhinoplasty with an Integrated ENT-Plastics Approach.

References

1. Perkins S, Patel A. Endonasal suture techniques in tip rhinoplasty. Facial Plast Surg Clin North Am. 2009 Feb;17(1):41-54, vi. doi: 10.1016/j.fsc.2008.10.004. PMID: 19181280.

2. Ng ZY, Liu A, Shoaib T. Tip control in closed rhinoplasty. Eur J Plast Surg. 2026;49:98.

3. Kook WS, Ryu DH, Baek W, Kook HM, Jang YY, Lew DH. Prevention and Resolution of Silicone Implant-Related Problems in Secondary Rhinoplasty Using a Cross-Linked Human Acellular Dermal Matrix. Plast Reconstr Surg. 2023 Jul 1;152(1):45-54. doi: 10.1097/PRS.0000000000010205. Epub 2023 Jun 29. PMID: 36728206; PMCID: PMC10298138.

4. Kim HK, Rhee SC. Augmentation rhinoplasty using a folded "pure" dermal graft. J Craniofac Surg. 2013;24(5):1758-62. doi: 10.1097/SCS.0b013e31828f1b5f. PMID: 24036774.

5. Rettinger G. Risks and complications in rhinoplasty. GMS Curr Top Otorhinolaryngol Head Neck Surg. 2007;6:Doc08. Epub 2008 Mar 14. PMID: 22073084; PMCID: PMC3199839.