Revision Rhinoplasty and the ala
Alar rim grafts are quite useful for lowering the height of the ala, smoothing out the contour of the alar rims, and reducing the columella show on lateral view. The thickness of the ala can also be thinned. All of these maneuvers in rhinoplasty can have very nice results when everything heals just right, but, I would recommend caution in performing too many modifications of the ala rim at the same time. Thinning alar rims can lead to scarring and unwanted alar retraction even in the presence of rim grafts. I would suggest the rim grafts without too much alar thinning to help with contour.
Correction of columella and nostrils is possible, but difficult
I see the following problems in your nose:
1. Rounded, isolated tip
2. Poor transition from tip to nasal base (deep shadowing on each side of the tip)
3. Overly arched, retracted alar margins (nostrils show)
4. Over-rotated (up turned, short) nose
5. Thick alar side walls (nostril base)
6. Retracted columella and hooded ala
If you were my patient i would recommend structural cartilage grafting using septal or rib cartilage to lengthen the nose, push down the columella, strengthen the alar margins (yes rim grafts), and improve the transition from the tip of your nose to the base--restore triangularity and make the tip less isolated. I would also consider removing the implant and replacing with cartilage so as to minimize risk of infection.
Correcting nostril and columellar asymmetries
Correcting nostril shape and thickness can be accomplished with cartilage grafts referred to as alar rim grafts when placed along the ala and nostrils. In addition, you most likely will need plumping grafts to the columellar labial angle to bring the columella forward as well as columella struts and perhaps septal extension grafts. This is based just on one view and other views could change the recommendations. If you have had previous rhinoplasties there probably is a paucity of cartilage left in your nose and you would most likely need rib grafting for structural support of your columella and tip but you might get by with conchal or ear cartilage. I would recommend a surgeon experienced in revision rhinoplasty. I hope this information helps.
Alar rim grafts to shape nostrils and columella
It is very difficult to decrease the alar thickness. This is nearly impossible to do. An upturned nose can be pushed down. Alar rim grafts can bolster the sidewalls of the alar rim if they are flail and herniate in and downward. Composite skin grafts of both skin and cartilage can be taken from the ear and inserted up into the nostril rim to bring the alar rims downward so that there is less columellar show.
Alar Rim Graft to reshape nostrils and columella
You are currently seeking a fourth rhinoplasty. Each time a revision rhinoplasty is performed, there is a potential for improvement but there is also a potential for creating a greater deformity of the nose. Cartilaginous ala rim grafts are used to give a better structural contour to the rims of the nostrils. They will not necessarily reduce the thickness of the nostrils and they will not, by themselves, address the columella.
You should consider a Non-Surgical Rhinoplasty instead of a fourth Nose Job.
I have had wonderful success in lowering the height of retracted nostrils following Rhinoplasty Surgery using Silikon-1000. Whenever I mention this permanent, Injectable Filler, I suggest finding a dermatologist or facial plastic surgeon experienced in the serial puncture, microdroplet technique of silicone injection.
In your case, I would try to lower the height of your nostrils, and fill the pinched areas where your nostrils connect to the sidewalls of your nose.
I am a passionate Rhinoplasty Surgeon, and I strongly suggest you avoid any further non-essential nasal surgery.
I've attached photos for your perusal.
I hope this is helpful for you.
Alar rim grafts can be used to improve the retraction of the notstil (alar) rims. If the nose "seems pointed up" cartilage grafts are necessary to lengthen the nose. It may be helpful to get a second opinion from an experienced revision rhinoplasty surgeon.
Alar rim grafts and Rhinoplasty
With this many prior surgeries, each additional surgery becomes more challenging. Alar rim grafts may help, but in the setting of scar tissue from your prior surgeries, this may not produce a dramatic enough result for you to justify an additional surgery. I would suggest seeing a surgeon who has extensive experience with revision rhinoplasty surgery in order to obtain an honest opinion about your possible results.
I think that the alar rim grafts may help but you may also need to deproject the tip of your nose to get better curvature of your nostrils. A profile view would help in assessing your condition.
Alar rim grafts will correct the pinch of your nose.
I would see an experienced revision rhinoplasty surgeon. If the doctor wants to do rim grafts, why weren't they done with the first surgery? Also you will need septal or ear cartilage grafts too lengthen the nose.