Difficulty Breathing after Rhinoplasty. What’s the best graft to make my nose bigger and restore my breathing? (Photos)

Question

Hello I had a rhinoplasty almost 2 years ago and I’m unhappy with my breathing and appearance of my nose . I believe my doctor made my nose too small . I had a tip, hump , and nostril reduction. My nostrils collapse and and my breathing feels restricted. My nose feels so flimsy I’m scared it will eventually collapse . What’s the best graft to make my nose bigger and restore my breathing ?

Lexie Wang, MD · Answer

you have clear evidence of what we call a pinched tip. Most likely you are correct that your surgeon overly reduced your tip in attempt to making it smaller, and now you can't breathe because your ext nasal valve is very collapsed. to address this, you need to get new cartilage put in to support the valve area. the type of graft you may be looking at is something called an alar batten graft or a lateral crural strut graft. make sure you go to a good rhino expert if you plan to get a revision and while I am biased, I would recommend you specifically find someone who is ENT trained bc you are looking at improving both cosmetics and functional outcomes.

Donald Groves, MD · Answer

Hello and thank you for your question and pictures. You have a pinched tip and collapsed internal and external nasal valves- resulting in the appearance and poor function. A revision rhinoplasty can best address both your functional issues and your aesthetic concerns with your nose. I would be able to open up and solidly reinforce your internal and external nasal valves to improve the airflow through your nose (and to prevent distortion and retraction from scarring forces over time)! I'd also be able to adjust the size, shape, and definition of your nose.

Revision rhinoplasty is truly a surgery of millimeters- they are the most technically challenging procedures in all of plastic surgery! Because your nose is the DEFINING feature of your face- I would only recommend seeing a surgeon who specializes in revision rhinoplasty procedures, and who has significant training and experience performing these surgeries. I actually trained under one of the world leading revision rhinoplasty experts (who performs 1,000+ nosejobs annually).

If you are unhappy with the appearance of your nose, I recommend for you to setup a formal consultation with me (or another plastic surgeon who is extremely comfortable with revision rhinoplasties) to thoroughly discuss your surgical goals, undergo a formal examination, evaluate your options, and develop a personalized plan just for you. I hope this helps!

Dr. Donald Groves
Aesthetic Plastic Surgeon

Gianfranco Frojo, MD · Answer

I would recommend a revision rhinoplasty with rib autograft (using your own rib). It appears that the nose has completely collapsed on itself (visible inverted V deformity) and alar collapse. I would recommend using the rib graft to fix all the collapsed aspects of the nose which also includes the internal/external valves that permit airflow.

Lucian Ion, FRCS · Answer

Thank you for your question and for sharing your photographs.

The characteristics you are demonstrating appear to be due to a combination of muscle activity around the nostrils and some flexibility in their structural support. Controlling muscle activity in this area is more challenging, so the focus is typically on reinforcing nostril support.

This is often achieved using ear cartilage grafts, though in some cases, stronger support may be required, necessitating rib cartilage. If your previous surgery did not use cartilage from the septum and it remains available for grafting—though this is uncommon—it can also serve as a good source for reinforcing nostril support.

Gerald Minniti, MD, FACS · Answer

You have both internal valve and external valve collapse. The internal valve will need to be strengthened with spreader grafts with upper lateral cartilage overlayed on tension; additionally the lateral crura of the lower lateral cartilages need to be reset to a 90 degree resting angle, which would occur with a proper tip complex reset. The lateral crura of the lower lateral cartilages may also need batten grafts, as well. The external valve would also be strengthened by above maneuvers but would also benefit from alar grafts.

Kyle Kimura, MD · Answer

This is a great question and thank you for attaching these photos. 
It looks like you have something called 'nasal valve collapse or nasal valve stenosis'. This happens when the cartilages are too weak to support the tissues of your nose when breathing and can sometimes be secondary to excess tissue removal during your initial surgery. There are many different techniques to fix this issue, but most focus on utilizing cartilage from within your nose (if any left from initial surgery), ear, or rib. This cartilage is then shaped and placed where your nose needs the most support during a revision surgery (open or closed). Your best bet is to schedule a consultation with a plastic surgeon who focuses on both cosmetic and functional outcomes to ensure you can achieve a good breathing result after a revision surgery.
Hope this helps and best of luck!Kyle Kimura, MD

Zeshaan Maan, MD · Answer

Based on the photos and information provided, you will require rib cartilage grafting as part of your revision rhinoplasty to strengthen both the middle vault and the tip complex. This can be done through various strategies, such as spreader grafts or a caudal septal extension graft with spreader graft extensions and articulated rim grafts. The most important thing is to find a skilled rhinoplasty surgeon, clearly identify your goals and let them guide you on what works best in their hands to help you achieve those goals.

Tanveer Janjua, MD · Answer

Lateral Alar baton grafts using septal or ear or rib cartilage should work. Spreader grafts will make the mid nose broader. 
Regards
Dr. J

Gary M. Horndeski, MD · Answer

One alternative is a cadaver graft. A large piece of cadaver graft can be harvested from the rib or possibly the septum, if still intact. You will need grafts to open the nostrils and it looks like your medial lateral crura angle is too acute and will need to be enlarged. Your lateral cartilages have collapsed inward and will need to be pushed outward.

Best Wishes,

Gary Horndeski, M.D.

Best Wishes,

Gary Horndeski, M.D.

Zoran Potparic, MD · Answer

It appears that your lateral wall is collapsing due to over-resected lateral cartilages. Only on the basis of in person evaluation an experienced, board certified plastic surgeon, expert in rhinoplasty, can give you a more detailed evaluation and ways of correction using multiple cartilage grafts. Good luck.

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