Re-Shaping the Nostril: Correcting the Cookie-Cutter Nose Job


The nose has multiple functions, with the main being breathing. There are two components to the nasal valve, an external component and an internal component.

The nostril is made up of cartilage (lower lateral cartilage) sandwiched between skin and nasal lining. The nasal skin can be thick and stiff providing a significant amount of external nasal valve support or the skin can be thin. Likewise the cartilage within the nostril can be thick or thin.

Ignoring skin and cartilage quality in a “cookie-cutter” rhinoplasty (nose job) can lead to significant deformity and external nasal valve collapse.

  • Cookie-Cutter Rhinoplasty (Nose Job): Dorsal Rasping, Cartilage resection, Cephalic Trim and Tip sutures

What causes external valve collapse and nostril deformities?

  • Over resection of lower lateral cartilage or a cephalic trim as part of a closed rhinoplasty (nose job)
  • Cartilage grafting with on-lay free grafts
  • Tip suturing on stiff cartilage causing bowing
  • Closure of the nasal incisions causing alar rim notching

Common Nostril Deformities Include:

  • Notching of the nostril shape, this should be a smooth shape with a rounded dome, collapse causes an angle at the dome
  • Reverse S secondary to weakening of the cartilage, or suture and/or grafting on the cartilage causes it to bow into the airway
  • Collapse from over resection of the lower lateral cartilage in a Cephalic Trim

External Valve collapse impedes the airway with airwflow because instead of opening with inspiration it collpases  and gets sucked in with nasal air flow.

Correction involves identification of the issue which is usually only identified at the time of the secondary rhinoplasty. It is imperative to discuss goals of the secondary rhinoplasty procedure before hand with Dr. Trussler in Austin Texas.

  • Ideal shape is individual and derived through facial and nasal analysis.

When should I consider a revision rhinoplasty (nose job)?

Typically wait one year after the rhinoplasty to have a revision or secondary procedure. This allows for softening of the scar tissue in the nose so that the layers of the nose can be identified and structures freed for the scar tissue

How is the nostril shape corrected and collapse prevented?

  1. Identification of the problem in the pre-operative or operative period.
  2. Scar Release of the tethered skin
  3. Skin grafts for over resection, if scar release is not enough
  4. Cartilage Grafts:
  • Lateral crural strut grafts. A long strip of cartilage is placed from the nasal dome to a pocket within the nostril to help straighten and support the nostril
  • Alar strut grafts which are more anatomic and sit under the native cartilage which is more appropriate for thicker cartilage
  • Alar rim grafts placed in the nostril edge to help prevent alar notching.

Turnover grafts can be used if there is available nostril cartilage. Dr. Trussler in Austin Texas has published an article on this technique often used in primary rhinoplasty

Janis JE, Trussler AP, Ghavami A, Marin V, Rohrich RJ, Gunter JP. The Lower Lateral Crural Turnover Flap. Plast Reconstr Surg. 2009 Jun;123(6):1830-41.

Nostrils can be narrowed with alar base excisions

Nasal tip suturing and positioning can have an effect on the nostril shape

Recovery after secondary rhinoplasty (nose job) is similar to any rhinoplasty with one week for sutures and splints

  • Swelling can be persistent and may take upwards of 3 months to one year for resolution of swelling.

Andrew P. Trussler MD is an experienced plastic surgeon in Austin Texas with advanced training in complex rhinoplasty including secondary rhinoplasty, including cartilage grafting with costal cartilage for secondary deformities.

Dr. Trussler’s Austin plastic surgery office can help guide you in correcting commonly seen issues after rhinoplasty in Austin including nostril deformity and external and internal ansal valve collapse. Secondary rhinoplasty can help your nose not only  look better, but function better.


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