Q: Dr. Eppley, I had a minor rhinoplasty (for instance family and friends did not notice) three years ago.  I am happy with the result, but I cannot breathe at all out of the left nostril.  I believe it is nasal alar valve collapse.  I have to wear breathe right strips at night, and I have a product called Breathe With Eez – a small nasal expander that is a tiny stainless steel thing that I insert.  I have to use this constantly – needless to say, this is uncomfortable and inconvenient.  I cannot breathe well out of the right side either, but the left is much worse.  I do not want to alter the shape of my nose at all because I am very happy with the outcome aesthetically, but I need to be able to breathe.  When I told my surgeon, he told me that he could not believe I would complain because most people would just be happy to have such a nice looking result.  When I complained that he is an ENT and I can no longer breathe out of my nose correctly, he told me he could try and fix it but it would leave scars on my face (he would go through the undereye area)…he treated me like I was crazy to expect to be able to breathe right again, and I did not trust him, so I did not go back for this operation – he explained it in a manner that made it sound terrifying. I would like to discuss possibilities on how to remedy my poor breathing problem.

A: Nasal breathing difficulties after rhinoplasty are not historically rare, particularly when significant tip narrowing modifications are done. If not enough support is left to the lower alar cartilages, they can become weak and bow inward causing internal nasal valve collapse. This problem can be modified if there is also middle vault collapse from a profile reduction as well. While an examination would have to be done to be certain as to the exact reason for your breathing difficulty, there are some standard manuevers for secondary rhinoplasty improvement. These include alar batten grafts to stiffen up the bowed lower alar cartilage on the affected side as well as spreader grafts to the middle vault. These cartilage grafts may have some slight effect on your current aesthetic result but should be relatively minor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking revisional rhinoplasty. I have had two prior procedures in 2001 and 2007. I am seeking to make the following changes to my nose. First I want to eliminate the ethnicity of my Middle Eastern nose. I am seeking a more European looking nasal appearance with significant improvement in the nasal tip and narrowing of the nostrils with less nostril show. Second, my septum as a result of my last rhinoplasty is slightly off midline with a deviation to the left. This will need correction. Cartilage from the right ear was used to support my tip in the past. My left ear is intact and can be uaed for further reconstruction. Lastly, my columella requires shortening without flattening my nose. Thank you for your kind assistance.

A: Thank you for sending your pictures. Based on your two prior surgeries (which appear to have been done via closed rhinoplasty ??) and the thickness of your nasal skin, any tertiary rhinoplasty is challenging in terms of achieving your goals. Your skin thickness makes it impossible to truly have a classic European nose which is more thin-skinned. As you experienced, removing cartilaginous structure underneath is not a guarantee that it will be well reflected on the outside. While you have room for some improvement, I am not optimistic that it can ever achieve the degree of tip narrowing and refinement that you desire. The purpose of your ear cartilage graft used in the past is mysterious to me as such tip grafting will only cause it to become thicker not thinner. Columellar shortening is not possible without causing a downward tip pull and is almost never done anyway except in cases of large projecting nose reductions.

While I think certain features of your nose can be improved (septal straightening, some limited tip narrowing) I have concerns about achieving your goals in a nose that is already scarred and grafted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very unhappy with the result of a rhinoplasty that I had done two years ago. It was a closed rhinoplasty and I wanted to have a more refined and pretty nasal tip. It has ended up, however, being just a balled up fat tip with nostrils that now look bigger. What type of rhinoplasty do I need now to fix it? And can it be fixed?

A: Thank you for sending your pictures. What appears to have happened is that you have lost cartilaginous support of the tip due to overresection of the lower alar cartilages and the caudal end of the septum. The thick overlying tip skin has now just contracted inward without adequate support, resulting in a ball-like tip with excessive nostril show. Your nasal problem most definitely can not be fixed by any closed rhinoplasty method. It will need a rhinoplasty revision using an open approach and cartilage grafting to restore support for the tip to create a more natural shape and decrease nostril show. You will need a columellar strut graft and alar rim grafts to help correct the retraction as well as tip reshaping. These type grafts are best placed through an open rhinoplasty, particularly in the face of a nose that has scar from prior surgery. Presumably these cartilages grafts can be harvested from the septum and the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have a problem from a previous closed rhinoplasty. I am very unhappy with the tip of my nose. It has been lifted too high and this has exposed my nostrils unfavorably. It also makes my face look flat. What I want is correction through a closed rhinoplasty. Will that work for me and my nose problem?

A: When the nasal tip becomes too shortened after a rhinoplasty,  it will produce a set of classic aesthetic issues including an obstuse nasolabial angle with excessive nostril exposure. It can be corrected through tip lengthening/de-rotation through cartilage grafting. This is not best done through a closed rhinoplasty. The grafts would be hard to place and secure through such limited visualization. An open rhinoplasty would provide much better exposure to accurate place tip grafts and/or septal extension grafts to create a de-rotation effect. The one exception to this approach is if the amount of tip lengthening needed is small. Then the placement of limited tip grafting could be done through a closed approach. I would need to see photos of your nose to determine which rhinoplasty approach may work for your revisional surgery. The only question I would ask is what is the basis for your deference to an open rhinoplasty? The scar is inconsequential and the results are more consistent and superior.

Dr.  Barry Eppley

Indianapolis, Indiana