BACKGROUND There have been relatively few articles in the English language on secondary Middle Eastern rhinoplasty. This article analyzes the cause and treatment of secondary Middle Eastern rhinoplasty. METHODS A prospective study of 40 consecutive female secondary Middle Eastern rhinoplasty patients was completed. RESULTS The majority of secondary rhinoplasty patients were older than 25 years. Half of the patients had undergone a single prior rhinoplasty and the other half had undergone multiple operations, ranging in number from two to five. A wide variety of surgical techniques was necessary because of the broad range of presenting deformities, patients' requests, and the author's preferred procedures. CONCLUSIONS The principal reasons for secondary rhinoplasty in Middle Eastern patients were a failure to correct the original deformity and the presence of visible surgical stigmata. The persistent complaints were a poorly defined tip and a long, droopy nose. Surprisingly, most secondary rhinoplasty patients had thin skin (55 percent), which necessitated fascia or dermis grafts to conceal surgical stigmata. At the time of secondary surgery, there was an absence of structure in these noses as evidenced by the prior 0 percent insertion of spreader grafts and the 10 percent use of columellar struts in prior open cases. Also, there was little evidence of other structural grafts, including alar rim, alar battens, or lateral crural strut grafts. Insertion of structural support appears essential to control primary deformities and to repair secondary deformities.