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Revision rhinoplasty exists because the perfect primary rhinoplasty technique does not. The benefit of revision surgery is that it offers us the opportunity to study and identify what did not work well during previous surgery. Thoughtful approaches to technique and outcomes allow us to recognize which maneuvers are dependable and worth repeating, and which are not reliable and therefore worth avoiding. As surgeons seek safer, more predictable results to improve patient outcomes, new techniques emerge which we then apply, study, and modify again, based on what works and what does not over the short term and the long term. There is no substitute for experience or for learning from trusted surgeons' experiences. Revision rhinoplasty presents many challenges including surgically induced anatomical changes, weakened structural support, a lack of available tissue for reconstruction, tissue remodeling responses, and other iatrogenic and wound healing complications. The septum, as the primary source of structural nasal integrity, forms the foundation for functional and aesthetic rhinoplasty. Herein, we describe strategies in septorhinoplasty for patients who have undergone prior nasal septal surgery. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.Nasal obstruction is a common presenting symptom of patients seen by primary care physicians, otolaryngologists, and facial plastic surgeons. A variety of treatment strategies, both surgical and nonsurgical, have been used with success in improving nasal obstruction and quality of life. In a subset of patients, many of whom have either attempted these common treatment strategies or are intolerant of them, nasal obstruction remains a significant symptom. find more In these patients, there may be an identifiable problem, but it is simply not repairable or there is no identifiable anatomic issue. The management of these patients is discussed in this article, with an emphasis on a sensitive approach that takes into consideration a patient's mental health. While the need for diagnostic testing is generally not necessary for most cases of nasal obstruction, endoscopy and imaging should be considered in these patients. Validated patient-reported outcome measures are particularly helpful in providing an objective measure to a patient's frustrating symptoms. A variety of medications can be either contributory to the patient's symptoms or therapeutic if used appropriately. A variety of surgical interventions can also result in a functionally crippled nose and diagnoses including nasal valve stenosis, septal perforations, and empty nose syndrome are discussed. Importantly, further surgical interventions may not be appropriate if a deformity is minimal, and a surgeon should resist the temptation to proceed with surgery in those situations. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.An ideal nasal osteotomy should deliver precise, predictable, and reproducible cosmetic and functional results while minimizing soft-tissue trauma and postoperative complications. In addition to closing an open roof deformity after hump reduction, other common indications for osteotomies include the crooked nose and a wide bony vault. The literature has reported numerous and diverse osteotomy techniques as well as differences in timing of osteotomies. Each has its own merits and indications, and its proponents. In this article, we review the anatomy and nomenclature relating to osteotomies. We review the locations and paths of the osteotomies-lateral, intermediate, medial, and superior/transverse. We consider the percutaneous and endonasal approaches, as well as timing of osteotomies and other considerations. We also discuss technical considerations in the selection of instrumentation for osteotomies. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.Rhinoplasty can be a key part of facial feminization for transgender women. Commonly, the required results necessitate significant deprojection of the nose in addition to the reduction of contour irregularities and shaping of the nostrils to a more round appearance. Pitfalls can include disproportion of the tip anatomic subunits, inadvertent creation of epicanthal folds, soft tissue pollybeak creation, and hanging columella among others. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.Across ethnicities, patients seeking rhinoplasty have similar goals-a natural looking nose that fits and complements the rest of their facial features. Beyond a harmonious nose, patients of African descent have a particularly strong desire for ethnically congruent results in spite of individual aesthetic rhinoplasty preferences. This strong appeal for ethnically sensitive alterations is fueled by the desire to maintain physical identification with one's African ethnicity. There are psychosocial penalties when rhinoplasty outcomes stray toward complete racial transformation. Consequently, rhinoplasty in patients of African descent requires a fundamental understanding of acceptable beauty norms, associated psychological underpinnings, as well as unique facial and nasal features among Africans. Beyond these ethnically sensitive nuances, classic rhinoplasty techniques of framework modification with cartilage contouring, grafting, and bone remodeling are applicable in reshaping the African nose. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.Refinement of the unsightly nasal tip lobule is one of the most common, yet also one of the most challenging aspects of cosmetic and functional rhinoplasty. In addition to meticulous analysis and precise surgical modification of the tip complex itself, successful tip refinement must also take into account the surrounding nose, especially the adjacent alar lobules. Unless the modified tip complex harmonizes with the adjacent alar lobules to form a symmetric, aesthetically pleasing, and fully functioning nasal base, tip refinement will inevitably fail. Structural interdependency between the alar lobules, the tip cartilages, and the nasal septum (and the myriad individual variations therein) make controlled alar complex refinement a formidable and complex undertaking. Long-term success is contingent upon understanding the full scope of structural tip dynamics, including not only the primary effects of tip refinement, but also potentially undesirable secondary effects that may deform the alae and thus compromise the surgical outcome.