Off-Centered Columella and Uneven Nostrils

At this point you will need a revision rhinoplasty +/- septoplasty to improve the asymmetry - the good news is that there is room for improvement

The best photograph for this problem is the so-called "worm's-eye view" taken with your nose pointing up toward the ceiling. In addition, you did not say whether you had uneven nostrils before your first surgery or if you had nostril reduction surgery at that time.  That being said, usually uneven nostrils is due to a deviated caudal septum.  The best treatment for this is straightening of the caudal septum.  If you had Weir excisions and the alar lobules are uneven, then a revision of the nostril reduction surgery is required. 

An off-centered columella is often due to a deviation of the caudal (anterior most part) septum which pulls the columella along with it. An in depth examination would be in order to better determine the cause. With revision surgery the asymmetry should be correctable, however.

It may be possible to either advance your nostril inferiorly or bring up your columella depending upon the position of your other nostril as well as whether or not the higher nostril is retracted or not. I would seek the advice of a rhinoplasty expert before proceeding.

It would be helpful to see a more inclusive photo to judge the asymmetry, because it does not appear to fall into the range of “extreme.” That said, to answer your question, your issue likely involves the caudal septum. An in-person examination would be best advised to provide you with the proper diagnosis and plan of action. Keep in mind that no two sides of a nose, face or body are every perfectly symmetrical, so please don’t overanalyze yourself as humans have a tendency to do! I recommend following up with your original surgeon to discuss your concerns and options. You might also wish to consult with a board certified plastic surgeon who specializes in revision rhinoplasty.

There are several reasons for crooked nose. From your picture, it appears that one obvious reason is deviated septum to the left and is pulling the lower part of your nose to that side. Septal reconstruction should correct this problem.

Hello, Thailand friend.

The off-center columella is usually such because the front part of the septum is not in the midline. That requires surgery, although it is not complicated and takes less than half hour.

The nostril assymetry may be due to prior nostril narrowing and if so, surgery will be needed to create a better match. In your case, that seems the case. Your right ala or lateral nostril wall sits higher on the face than your left. 

While some nostril asymmetries can be corrected with fillers, those best suited for that technique are nostrils that have the top or peak elevated more than ideal. The fillers are placed through the skin to fill and " drive down" the edge.

Suggest consulting with a specialist with long experience doing noses.

-Robert Kotler, MD, FACS

Beverly Hills, CA

No two nostrils are exactly the same.  There will be some asymmetry. As  for the columella tipping to one side, I would need to perform an exam to figure out what is the issue.

A deviated columella is frequently secondary to a deviated septum, which can be  corrected with surgical intervention. The sharp vertical lines in your tip may indicate tip collapse, which also can lead to nostril asymmetry.  If that is your problem cartilage grafts will be necessary. Although perfect nostril symmetry is not necessary, consult with an experienced rhinoplasty surgeon to discuss your options. 

Having had a lot of experience in this kind of revision work I can tell you that this is a very difficult problem to correct. Much more so that most surgeons and patients think. The problem can be one of three things or a combination of all. 1) the caudal septum may be deviated more to one side than the other pulling the columella with it and making the nostrils assymetric. This would be the best senario and the easiest to correct. 2) The lower lateral cartilages have been poorly resected in the first surgery and have healed in an assymetric fashion. 3) there may have always been some assymetry to the nostril sizes that wasn't noticed or made apparent until you had the rhinoplasty......However your particular problem may be any combination of the above....go see someone who has the experience and skill to sort this out and correct it, if not you'll be chasing your tail forever.