A. To put it simply: post-revision asymmetry is most commonly caused by uneven scar contracture, graft displacement, or pre-existing skeletal asymmetry — and targeted correction is possible once the true cause is identified.

 

Here's why.

 

1. Asymmetric scar contracture. Fibrotic scar tissue contracts as it matures, generating uneven traction forces on the nasal framework. If one side sustained greater tissue damage during a prior surgery, the contracture will be correspondingly asymmetric — pulling the nose toward the more fibrotic side.

 

2. Graft displacement and warping. Cartilage grafts can shift subtly over time, especially if initial fixation was inadequate. A particular concern with carved costal cartilage is warping — a gradual torsional deformation that can manifest as dorsal irregularity or deviation anywhere from 6 months to 2–3 years postoperatively.

 

3. Pre-existing skeletal asymmetry. The nasal bones and bony septum are naturally asymmetric in most individuals. Soft tissue correction alone cannot fully mask underlying bony asymmetry, and in some cases, this becomes more apparent after revision surgery alters the soft tissue envelope.

 

---

 

Why the Closed Approach Makes a Difference

 

The closed technique contributes to asymmetry prevention through several mechanisms. Reduced tissue dissection means less scar formation, which means more uniform healing — lowering the probability of asymmetric contracture. Near-zero electrocautery use eliminates the risk of thermal injury-induced irregular fibrosis. Graft fixation is performed under direct tactile guidance, allowing the surgeon to confirm symmetric placement bilaterally. The overall principle: less trauma = more symmetric healing.

 

---

 

When to Be Cautious

 

- Mild asymmetry is normal human anatomy — perfect bilateral symmetry is neither achievable nor natural.

- Early postoperative asymmetry is often due to differential edema (one side swells more than the other) and resolves spontaneously. Assess at 3–6 months minimum.

- Rushing to re-operate before swelling fully resolves frequently worsens the outcome.

- If alar cartilage damage has caused nostril pinching or visible asymmetry, alar cartilage reconstruction using conchal or costal cartilage may be necessary — this can also be performed via the closed approach.

 

---

 

What I've Observed in Clinical Practice

 

In my experience, a significant proportion of patients who present with concerns about post-revision asymmetry are actually experiencing differential edema — a temporary phenomenon that resolves without intervention. When genuine structural asymmetry is confirmed (typically after 6+ months), I analyze the specific cause and design a targeted correction: scar release and cartilage reinforcement for contracture-related asymmetry, or graft repositioning with enhanced fixation for displacement-related asymmetry.

 

---

 

Surgeon's Note

 

If you notice asymmetry after surgery, allow sufficient healing time before drawing conclusions. As a surgeon who has performed all revision and reconstructive rhinoplasty exclusively through the closed technique, I place great importance on addressing both function and structural integrity in every procedure. If asymmetry persists beyond 6 months, a thorough evaluation can identify the cause and guide an appropriate, measured correction.

 

---

 

Summary

- Asymmetry after revision most commonly results from scar contracture, graft displacement (including warping), or baseline skeletal asymmetry

- Early-postop asymmetry is frequently differential edema — observe for 3–6 months before concern

- The closed approach minimizes tissue trauma, reducing the risk of asymmetric fibrosis and contracture