How Can my Uneven Nostrils Be Corrected and Scars on Columnella Be Reduced?

Rocky, I am sorry you are having these difficulties. Your columellar scar is indeed visible, but based on what your photograph shows, nobody notices this as much as you. Of course, your are your own worst critic, and it is your own reflection you see in the mirror every day, so it is appropriate for you to want things as good as humanly possible. I get that.

But, you need to understand that perfection is not in the cards, especially with what sounds like at least your 4th nasal surgery. (Several means more than two, so I'm guessing 3 or more, with number 4 or higher pending.) Truly, this needs to be your last time if at all possible.

Your nostrils have not been reduced via Weir excisions (scars would be noted from the nostril sills along your cheek-ala interface), so any asymmetry is due to the underlying cartilages being different. Judicious sculpting on the right side can improve symmetry, and if the rim is retracted compared to the left, a graft can help to lower the rim slightly (but also adds scar tissue, which can negate the improvement as scars contract). The rest of your nose (mid to lower thirds, including the tip) seems a bit wide. This can be due to scar tissue, spreader grafts, or your own genetics, but a comprehensive evaluation of all aspects of your nasal appearance needs to be carried out by an experienced revision rhinoplasty surgeon. This should include breathing assessment also, so that any airway concerns can be addressed at this time.

Overall, you need to have realistic expectations as to the goals of revision rhinoplasty surgery. Each time increases the amount and rigidity of scar tissue, and increases the unpredictability of any result. There is NO magic. See one or more expert ABPS-certified plastic surgeons or ABMS-certified ENT rhinoplasty experts for advice, and don't even consider revision surgery until at least 1 year after your most recent one. Good luck and best wishes!

The columellar scar may be able to be revised. It's hard to get a good sense of it from your photo, but in general the scar could be revised by excising the scar itself and reclosing it. Another possibility is to perform dermabrasion to essentially sand the scar to help blend it. Either option could be done under local anesthesia in the office.

Addressing your nostril asymmetry may be more complicated. You do seem to have retraction of your right nostril margin. This can be more difficult to repair under just local anesthesia.

It would be helpful if you can provide a photo looking directly at your nostrils with your head all the way back- also a close-up on the scars would be helpful.  Nostril asymmetry is usually a result of cartilage asymmetry underneat, scarring, or a combination of both.  Most issues are correctable to some point although the more surgery the more scarring which adds to unpredictability.  It's hard to comment on cost without knowing exactly what is involved in your repair.

With the open technique an incision is made across the columella, hopefully near the base where it inserts into the face and is less noticeable. If closed meticulously, these scars usually fade with time. But if the scars are still visible after a few months, a simple in-office dermabrasion with a diamond fraize can easily be done under local anesthesia. If the scar has spread, it may need to be re-excised and re-approximated. If the problem is at the sides of the columella, it may reflect asymmetries in the feet of the medial crura, the cartilages under the columellar skin, which can also be addressed under local. In regards to the asymmetries of the nostrils, the pictures don't reflect that. If one ala (lateral wing) of the nose is higher, it can be re-set under local, also. If the shape of the nostril opening is different at the apex of the opening, the problem is more complex. Nostrils are very difficult to get exactly symmetric, and, unless you are very tall, usually only young children and pets even see that view.

An unfavorable columellar scar can be easily revised under local anesthesia. It appears you have retraction of the alar margin on the right side. A small cartilage graft can be placed to lower that margin. Get a second opinion if your surgeon does not want to address your concerns.