Closed rhinoplasty for nasal valve repair
Surgeons experienced in closed rhinoplasty should be able to place spreader grafts using closed rhinoplasty techniques as well as perform other functional improvements such as septoplasty and turbinate reduction. Closed rhinoplasty is our preferred method for most patients including revision rhinoplasty patients.
Mid-Vault Nasal Reconstruction After Primary Rhinoplasty
Yes, the endonasal approach can be used to reconstruct a collapsed nasal mid-vault. In most cases, this would involve harvest of nasal septal cartilage for spreader grafts and placement of these spreader graft to support the internal valve. If there is also posterior dislocation of the upper or lower lateral cartilages, then these cartilages would have to be repaired or supported.
What you're describing is called Nasal Valve Collapse. NVC is a weakness or lack of supporting cartilage in your nose that is responsible for keeping your nose open during inspiration.
Whether a surgeon chooses an open or closed approach will depend on his/her experience with that particular technique. I prefer the open approach because it allows me to see the nasal valve collapse directly and repair the collapse using cartilage grafts from the ear or the septum.
Open rhinoplasty for internal valve collapse
To directly answer your question, a secondary closed approach can be used after an initial open approach. However, my suggestion to you is to revisit open rhinoplasty.
First, it sounds to me like your collapse is the internal valve, not the external valve. If it is the nasal sidewalls, roughly the middle third of the nose that bellows, that is the internal valve. If it is the nostrils that collapse, then think external. The fact that you mentioned nostril flare to me suggests internal.
If that is the case, a spreader graft is often suggested. Yes, they can be placed through a closed rhinoplasty. However my experience has led me to realize that there is more precision in their placement when and external approach is utilized. Plus, an additional "flaring stitch" as described by Stephan Park (you may want to look that up on scholar.google.com) is also added to ensure an improved airway. That requires an open approach.
You have come this far with your decisions, including the original open procedure. Don't let the revision approach drive your decision. Decide on the surgeon and his or her proposed solution as your next step.
Closed rhinoplasty to repair valve collapse
It sounds as if a valve collapse has occurred due to the open rhinoplasty.
Structural grafting with cartilage from the inside of the nose and placing spreader grafts to the upper lateral cartilages will dramatically help with this. Alar batten grafts and supra-alar rim grafts can also help with the nostril rims if they are collapsing as well. These can be accomplished through closed rhinoplasty.
Nasal Valve Collapse and Surgical Approach
The only thing harder than revising an open rhinoplasty with a closed technique is doing it open again.
If you only require cartilage grafts (onlay or spreader grafts) to strengthen the midportion/sidewalls of the nose, then there is no need to perform an open rhinoplasty and dissect through the tip again. If extensive grafting is required for the tip cartilages as well (batten grafts), then an open may be indicated. In my experience, there is more scarring of the nose after a previous open approach. Re-opening the nose can be very challenging and can increase the risk of the procedure.
While open approaches are sometimes necessary for revision surgery, the majority of maneuvers for opening the nasal valve can be done using a closed approach, which will minimize the complication profile of your revision.
Best of Luck!
Functional rhinoplasty to repair valve collapse
You are correct that 'closed' (or as we call it, endonasal) rhinoplasty can repair lateral wall insufficiency (collapse). However, it is often best accomplished with an external ('open') approach. Since you have already had this done (the first rhinoplasty was 'open'), it would probably increase your chances of success to have it done externally. This would give your surgeon the best chance to assess the issues and accomplish structural repair. Of course, without examining you this is only a best guess.
Typically, the repair of the lateral nasal wall is done with either grafting (cartilage from another area, such as rib, ear, or septum). Another alternative is to use bone-anchored sutures. This is typically only done when your native cartilage is intact. This can only be assessed in person.
Good luck to you.
You are correct that you lack support for the nose on inspiration. This will likely call for grafting, or changing the internal anatomy of the nose. The biggest concen is if there is enough cartlilage to reinforce the structures.
A closed approach may be possible if you get a surgeon experienced and confident that he can fix the problem, after an exam.
The thing is that you already had an open procedure so why not go that way again, as it gives best exposure and ability to correct the anatomy?
Nasal wall collapse can be treated with Closed Rhinoplasty
Nasal wall collapse is usually caused by internal nasal valve weakening in the area where the upper lateral cartilage attaches to the nasal septum and nasal bones. This area can be approached with closed rhinoplasty and rebuilt with cartilage grafts usually taken from the nasal septum. Some doctors are more comfortable with an open approach but a surgeon skilled at closed rhinoplasty can treat this even after a prior open rhinoplasty.
While a closed rhinoplasty can certainly correct nasal valave collapse, I prefer to perform the procedure open to perform a controlled correction of the problem.