In spite forehead and eyebrow lift is commonly requested and indicated in middle aged and older patients, there are cases in their 30s and even 20s which, due to inherited familiar factors, are naturally born with very droopy and low forehead and eyebrows, like the patient shown in this case; her eyes look sunken more due to forehead droopiness rather than eyebrow lowering, actually the tail of the eyebrow is only slightly droopy unlike aging cases in which low eyebrows tail is the prevailing issue.
Considering the heavy forehead and the aims of the patient to obtain a refreshment in her upper facial third with a natural outcome and non detectable stigmata, she underwent a supraperiosteal lift of the upper two thirds of the face, covering an ambitious lift of the forehead, a subtle lift of the tail of the eyebrows, and a moderate but noticeable lift of the cheekbones, the cheeks and a remarkable smoothening of the nasolabial folds; all the former with undetectable and concealed short scars at the temporal fossa or temple. Final result is a natural face of unnoticeable surgical signs, youthful, not anymore looking chronically tired, feminine and fresh.
The nose underwent a very poor quality rhinoplasty once previously leaving major deformities and technically complex issues, among them an excessive trimming of the caudal septum which leads itself to a short nose, piggy nose or upturned tip, nostrils exposure, poorly supported and underprojected tip, collapse of the tip and an unsightly polly beak deformity; additional problems are the alar notching and alar rim retraction, poor tip work, under resected osseous dorsum with a remaining hump, open roof deformity due to missing osteotomies, inverted V deformity and overall a very poor outcome.
Revision rhinoplasty was approached via open access applying structure rhinoplasty maneuvers, beginning with debridement or removal of unstable structures and fibrosis; the key and most difficult maneuver in this case was the septal lengthening, to restore the too much trimmed caudal septum which was the underlying cause to many of the deformities; this was accomplished harvesting a deep septum graft and an one on one lengthening assembly since the missing portion was not massive and there was good support at the remaining septum stump; on this newly lengthened support pillar the whole lower third of nose and tip was assembled by means of tongue in groove maneuver securing of the medial cruras to this grafted portion of the septum which acted as well as strut for the columella and tip in order to restore tip projection and secure the new nasolabial angle of rotation, the lateral cruras cephalic excess was adjusted and made even to each other, finally the tip received scoring plasty and interdomal fixation.
The dorsum received two small spreader or spacer grafts at the soft portion to correct the inverted V deformity; the supratip prominence was leveled with the new tip to get rid of the polly beak deformity and the remaining hump shaven; finally osteotomies were applied to close the open roof.
Final outcome shows a perfectly balanced nose, straight dorsum line, good nasolabial angle with slight upwards rotation to enhance patient's feminity but not as much as a piggy nose, all the alar, columellar, tip and supratip deformities are eradicated and the nasal pyramid is well closed and stabilized.
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