Alar notch after graft, is there more that can be done?

You have a challenging problem to correct.  Elevated nostrils even without previous grafts can be difficult to lower because the tissues are delicate, and the problem is often one of cartilage, soft tissue  and scar tissue.  Adding structure to force the nostril down can bring the undesirable side effect of increase bulk and he impact of scar tissue is not always possible to completely overcome.  You need to have an in person consultation and bring a copy of your previous operation(s), and old photos. I would consult with an experienced revision rhinoplasty surgeon.

This is a complicated issue. There are multiple options to address and notched ala. Another composite graft can be attempted but also an alar rim graft or alar repositioning technique might be appropriate options too depending on the individual factors and exam findings.

 Revision rhinoplasty is much more difficult the primary rhinoplasty, therefore a full set of facial photographs from all angles and copies of the previous Operative reports would be helpful to understand how to proceed. An in-person examination is going to be required as well. Composite grafts composed of both  cartilage and skin can be harvested from the ear to help with alar-notching. It's also important to reduce any hanging columella as well.