Diagram sheet for future patients to indicate nasal area(s) of collapsing

Here's a free hand drawing i put together of four different nasal views so you could better communicate with your rhinoplasty specialist where you believe you're experiencing nasal valve &/or nostril collapsing.

After completion hand this to your rhinoplasty specialist

*For more preciseness hold or stand in front of a mirror &  try the cottle maneuver &/or cotton swab to lateralize each nostril  if you're not sure where your weak spots are.  While keeping your mouth closed inhale & exhale with only your nose before and during this exercise.  Note differences on each side.  You can also cover up one nostril with your thumb and notice how the other side changes while breathing in & out.

Diagnosing Nasal Valve Collapse

Examination of the nose and any of the following may help in appropriately diagnosing nasal valve collapse:

• Endoscopy
• Cottle's maneuver - nasal valve area is widened by pulling it in a lateral direction, may be performed. If breathing improves when the nasal valve area is manually widened, it is an indication of nasal valve collapse.
• Bachman's maneuver. During this maneuver, the nasal valve is widened using instruments and then improvements in breathing are assessed.
• Nasal decongestant drops
• Anterior rhinomanometry - measures nasal airflow
• Acoustic rhinometry - uses sound waves to assess changes in the nasal cavity. https://www.verywellhealth.com/nasal-valve-collapse-1191944

A more comprehensive analysis

Diagnosing disorders of the nasal valve area

In addition to septal deviations and turbinate hypertrophy, disorders of the nasal valve often result in an obstruction of nasal breathing and are frequently overlooked and/or not covered in a systematic examination for lack of knowledge. This results in false diagnoses and unsuccessful surgical treatments of impaired nasal breathing [18]. For the evaluation of the nasal respiratory function in the region of the nasal valve area, there is currently no singular examination method that reliably pictures the patient’s symptoms on account of the complex physiological correlations and the multitude of subjective factors [5]. The knowledge of the physiological correlations and the physician’s clinical experience are essential for making the correct diagnosis and selecting a promising therapy. Therefore, the development of reproducible diagnostic parameters is required for the purposes of evidence-based medicine.

The patient's history is very important in the diagnostic investigation of impairments of nasal breathing. It provides an indication of the presence of pathologies in the region of the nasal valve area and in particular of the subjective estimation of the severity of the symptoms. In this context, possible causes of a disorder of the nasal valve have to be explored as well.

Regarding the ENT findings, it has to be found out whether the inspiratory collapse of the nasal valve is a clinically relevant suction phenomenon or whether other pathologies are present as well. The common distinction between physiological and pathological suction phenomena is not always useful since the extent of suffering that varies from patient to patient is the decisive factor for the performance of any possible therapy. The inspection of the nose should be carried out both using instruments and without instruments. While doing so, the following details have to be paid attention to: size and shape of the isthmus nasi, septal deviation in the region II, nasal valve angles smaller than 15 degrees, deformities of the lateral or alar cartilages, elasticity of the cartilages, breadth of the columella, cicatricial stenoses, size of the body piriform aperture. In case of a positive suction phenomenon, it should be examined which parts of the lateral nasal wall are concerned. To this effect, the caudal edge of the lateral cartilage, the lateral crus of the alar cartilage and the lateral lower skinny-membranous portion of the wing of the nose have to be evaluated [16].

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3199841/#__sec5title

Latera: Temporary absorbable nasal implant for nasal valve collapse

In July 2016 Spirox announced it won FDA approval for it's absorbable non invasive Latera implant to help counter nasal valve collapse.

 "A multi-center study of the device, conducted in Germany, demonstrated that patients who received a Latera implant experienced a reduction in nasal obstruction symptoms at 1-year post procedure, without a reported cosmetic downside.

“Nasal obstruction takes a significant toll on patient quality of life, but is often undertreated and underdiagnosed. If we don’t look for nasal valve collapse in these patients, we’re not addressing the entire problem. By providing an intuitive and effective way to support nasal Lateral cartilage, Latera has the potential to improve breathing for our patients,” Dr. Dean Toriumi of Chicago’s University of Illinois said in a press release.

“We have worked with physician leaders to find a solution to a major clinical need. The research and development behind the innovation is complex, but the technique is elegant and intuitive. Latera gives physicians a new option to support Lateral cartilage, enabling a more complete means for addressing their patients’ nasal obstruction symptoms,” CEO Duke Rohlen said in a prepared statement.
 https://www.massdevice.com/spirox-wins-fda-nod-latera-nasal-implant/

http://www.spiroxmed.com/

Q-tip swab for nasal valve collapse

Here's video demonstrating how to use Q-tip swab as an internal nasal dilator.  Note description section and disclaimer.

Update:  Unfortunately after about a month's time the Q-tips in the box start to break making this an unviable option.

Q-tip swabs for empty nose syndrome

Here's video showing the  taping together of a few half cut Q-tips which may help with empty nose syndrome for a short period of time.  Disclaimer: see video description.

Nasal Cycle, Turbinates & Sleep

"The nasal cycle is the often unnoticed[1][2] alternating partial congestion and decongestion of the nasal cavities in humans and other animals. It is a physiological congestion of the nasal concha, also called the nasal turbinate, due to selective activation of one half of the autonomic nervous system by the hypothalamus. It should not be confused with pathological nasal congestion. The nasal cycle was studied and discussed in the ancient yoga literature.[3] In the modern western literature, it was first described by the German physician Richard Kayser in 1895.

 In 1927 Heetderks[5] spoke about the alternating turgescence of the inferior turbinates in 80% of a normal population. The cycle is the result of alternating congestion and decongestion of the nasal conchae or turbinates, predominantly the inferior turbinates, which are by far the largest of the turbinates in each nasal fossa. Turbinates consist of bony projections covered by erectile tissue, much like the tissues of the penis and clitoris. The turbinates in one fossa filled up with blood while the opposite turbinates decongested by shunting blood away. This cycle, which is controlled by the autonomic nervous system as described above, had a mean duration of two and a half hours. He further observed and documented that the turbinates in the dependent nasal fossa filled when the patient was in the lateral decubitus (lying down on your side) position. Some[who?] postulate that this alternating positional obstruction has the purpose of causing a person to turn from one side to the other while sleeping. Others note that the asymmetric airflow may have some benefit to overall olfactory sensitivity.[6] The nasal cycle is an alternating one, with the total resistance in the nose remaining constant. In patients with a fixed septal deviation and intermittent nasal obstruction, the interplay of the nasal cycle becomes evident; the sensation of obstruction frequently mirrors the congestion phase.[6] It is possible that the nasal cycle may exacerbate the nasal congestion caused by the common cold, as the lack of motility of the cilia in one half of the nose may lead to an uncomfortable sensation of not being able to shift mucus by blowing the nose."

 https://en.wikipedia.org/wiki/Nasal_cycle

From my experience as a side sleeper indications are that when you first turn on to one side (lets say the left side for example) I notice my right congested side nostril (side furthest from my pillow) starting to open up somewhat or decongest. Since I practically have very little remaining of my Left Inferior Turbinate this is harder for me to gauge when lying on my right side but I still to smaller degree feel this same phenomena. On my right side I can somewhat notice my right nasal cavity (side nearest my pillow) start to swell or close up to some degree. I have my full middle turbinates so perhaps that's why I can still to very small degree detect changes in nasal cycle even with my left nostril when lying on my right side. However this sensation may also be accentuated & related to other reasons such as draining of sinuses &/or squishing of side cheek & nostril up against the pillow.  According to studies "In healthy individuals, the lateral decubitus (lying down) increases congestion in the ipsilateral (same side) nasal cavity and reduces airflow resistance in the contralateral (opposite side) nasal cavity. This does not occur due to a hydrostatic effect, but rather as a reflex response caused by asymmetric pressure on the body [11, 12]. Studies also show that nasal cycle duration during sleep is longer then in wakefulness.  Another interesting conclusion from one study states, "changes in laterality of nasal cycle frequently coincide with switches in posture, tend to occur in REM sleep, never occur in slow-wave sleep, and may be absent in subjects with severe nasal septal deviations".  Atanasov and coworkers [6] showed that the switch from left to right nostril’s domination airflow (and reverse) occurs only during REM phases of the night sleep. Ten years later Kimuraet al.[7] received similar result".  From my personal experience I do not have to even be asleep, never mind being in a REM sleep phase to affect change in my nasal cycle.  At times I have noticed  approx. within 5 to 7 minutes of turning on my left side my right blocked up nasal cavity open up.  I would be interested in hearing from you the readers of this blog about your personal experience on this subject. So feel free to leave a comment.

My main concern would be how one's sleep could be negatively impacted if they have had major removal of their middle &/or inferior turbinates from one nostril or worse both nostrils. I would postulate that losing your 'normal' cycling of the nasal cycle could potentially affect not just regular sleep patterns but also REM sleep (associated with deep dream sleep). However if it's true that 20% of the population does not experience this nasal cycle it would be interesting to compare their sleeping patterns to the 80% of those that do experience the nasal cycle & to those who have had major removal of both middle/inferior turbinates as i describe above. As far as I know there hasn't been any related studies to comment on this further. As far as how my sleeping pattern goes, it has been negatively impacted from the rhinoplasty's I've had. This is not just due to near complete removal of  my left inferior turbinate but also due to hypertrophy of  remaining right  I.T., nerve pain, & nasal valve collapse. I noticed particularly after my last revision rhinoplasty where my Left inferior turbinate was practically fully removed & Right I.T. further reduced that when I awoke it was much more difficult for me to remember my dreams then prior to the surgery.  I notice that I feel more of an instant awakening now then prior which was more gradual.  However I still do get REM sleep & force myself to try & recall my dreams upon awakening.

More Info:
https://www.realself.com/question/Septoplasty-and-turbinate-reduction

https://www.ncbi.nlm.nih.gov/pubmed/23576311

http://file.scirp.org/pdf/OJBIPHY_2014071716523330.pdf

http://ihatecpap.blogspot.ca/2010/03/is-my-sleep-apnea-caused-by-nasal.html

https://www.hindawi.com/journals/ijoto/2014/717419/

Vascularity of the nose and it's significance in revision rhinoplasty

  Blood supply and drainage

 

Like the face, the human nose is well vascularized with arteries and veins, and thus supplied with abundant blood. The principal arterial blood-vessel supply to the nose is two-fold: (i) branches from the internal carotid artery, the branch of the anterior ethmoid artery, the branch of the posterior ethmoid artery, which derive from the ophthalmic artery; (ii) branches from the external carotid artery, the sphenopalatine artery, the greater palatine artery, the superior labial artery, and the angular artery.

The external nose is supplied with blood by the facial artery, which becomes the angular artery that courses over the superomedial aspect of the nose. The sellar region (sella turcica, “Turkish chair”) and the dorsal region of the nose are supplied with blood by branches of the internal maxillary artery (infraorbital) and the ophthalmic arteries that derive from the internal common carotid artery system.

Internally, the lateral nasal wall is supplied with blood by the sphenopalatine artery (from behind and below) and by the anterior ethmoid artery and the posterior ethmoid artery (from above and behind). The nasal septum also is supplied with blood by the sphenopalatine artery, and by the anterior and posterior ethmoid arteries, with the additional circulatory contributions of the superior labial artery and of the greater palatine artery. These three (3) vascular supplies to the internal nose converge in the Kiesselbach plexus (the Little area), which is a region in the anteroinferior-third of the nasal septum, (in front and below).

Furthermore, the nasal vein vascularisation of the nose generally follows the arterial pattern of nasal vascularisation. The nasal veins are biologically significant, because they have no vessel-valves, and because of their direct, circulatory communication to the sinus caverns, which makes possible the potential intracranial spreading of a bacterial infection of the nose. Hence, because of such an abundant nasal blood supply, tobacco smoking does therapeutically compromise post-operative healing.

Lymphatic drainage

The pertinent nasal lymphatic system arises from the superficial mucosa, and drains posteriorly to the retropharyngeal nodes (in back), and anteriorly (in front), either to the upper deep cervical nodes (in the neck), or to the submandibular glands (in the lower jaw), or into both the nodes and the glands of the neck and the jaw.

 http://en.wikipedia.org/wiki/Anatomy_of_the_human_nose#Blood_supply_and_drainage

Epistaxis (Nosebleeds)

Jeffrey D Suh MD, Rohit Garg MD, MBA

 

The nasal cavity is extremely vascular, meaning it has a large blood supply. Blood is supplied via both the internal and external carotid systems. The major blood arteries in the nasal cavity include the anterior and posterior ethmoid arteries and the sphenopalatine arteries. Over 90% of nose bleeds occur in the anteroinferior (front bottom) nasal septum (wall that divides your nose between left and right sides) in an area known as Kiesselbach’s plexus, named after Wilhelm Kiesselbach, a German otolaryngologist. Keisselbach's plexus is located over the anterior nasal septum and is formed by anastomoses (coming together) of 5 arteries:

• Anterior ethmoidal artery (from the ophthalmic artery) (Figure 1)
• Posterior ethmoidal artery (from the ophthalmic artery)
• Sphenopalatine artery (terminal branch of the maxillary artery) (Figure 2)
• Greater palatine artery (from the maxillary artery)
• Septal branch of the superior labial artery (from the facial artery)

Approximately 5% to 10% of epistaxis is estimated to arise from the posterior nasal cavity, in an area known as Woodruff’s plexus. Woodruff's plexus is located over the posterior middle turbinate and is primarily made up of connection of branches of the internal maxillary artery, namely, the posterior nasal, sphenopalatine, and ascending pharyngeal arteries. Posterior bleeds usually originate from the lateral wall and more rarely from the nasal septum.

http://care.american-rhinologic.org/epistaxis?print

  Blood supply and viability of nasal grafts

By Dr. Richard Davis
Rebuilding a damaged outer nose has similarities to rebuilding an A-frame house. Both structures have an architectural framework that provides structural support and determines the overall, length, width and shape of the structure. In order to modify the structure's shape, the framework must be exposed and then physically reconfigured. In the nose, the structural framework is the nasal skeleton, consisting of cartilage and bone, whereas the house is typically wood and concrete. However, unlike a house, the nasal framework is composed entirely of living tissue – tissues that must have a constant flow of blood to remain viable. In the nose, nutrients such as oxygen, glucose, minerals, etc, are delivered to the skeletal framework through a network of tiny blood vessels found within the overlying skin and underlying mucous membranes. By necessity, any type of nasal surgery (or nasal injury) causes varying degrees of damage to this circulatory network. While the human body has an incredible capacity to heal from such damage, recovery is never fully complete and some blood vessels are permanently lost.

Fortunately, the nasal circulation has excess capacity, so the overall circulatory impact of a well-executed surgical intervention is usually negligible. However, repeated surgeries, especially when combined with poor surgical technique, can eventually impair circulatory function. Moreover, the surgery itself causes additional temporary circulatory impairment as a consequence of swelling and inflammation. When the total circulatory impairment exceeds the threshold for minimal tissue perfusion, tissues become oxygen-deprived, or ischemic, and complications such as cell death, infection and tissue resorption soon develop.

Because revision rhinoplasty relies almost entirely upon the transplantation of cartilage into the nose, a healthy recipient blood supply is a key element in ensuring survival of grafted tissues. A robust circulation not only ensures prompt re-vascularization of the transplanted cartilage grafts, it also lowers the risk of infection and graft resorption. Gentle surgical technique, avoidance of tobacco or nicotine, and good supportive care can help to optimize circulatory support to the vulnerable grafted tissues. 

However, in noses with severely damaged circulation, such as those subjected to multiple previous rhinoplasty procedures, the likelihood of graft resorption, infection, and even skin necrosis (death) are increased, especially when coupled with smoking, infection, cocaine abuse, excessive swelling, diabetes or other conditions, medications or supplements that impair circulation. In this patient population, good surgical technique is often negated by poor circulation and the results of surgery are usually disappointing.

Vascular Anatomy of the Nose and the External Rhinoplasty Approach

Dean M. Toriumi, MD; Royce A. Mueller, MD; Thomas Grosch, MD; Tapan K. Bhattacharyya, PhD; Wayne F. Larrabee Jr, MD

Arch Otolaryngol Head Neck Surg. 1996;122(1):24-34. doi:10.1001/archotol.1996.01890130020003. 

 Conclusions:  The major arterial, venous, and lymphatic vasculature courses in or above the musculoaponeurotic layer of the nose. In the external rhinoplasty approach, dissection in the areolar tissue plane below the musculoaponeurotic layer will minimize tip edema and protect against skin necrosis by preserving the major vascular supply to the nasal tip.(Arch Otolaryngol Head Neck Surg. 1996;122:24-34)
 http://archotol.jamanetwork.com/article.aspx?articleid=623221
 
Nasal tip blood supply: an anatomic study validating the safety of the transcolumellar incision in rhinoplasty.

 Rohrich RJ, Gunter JP, Friedman RM.

The nasal tip blood supply was studied through anatomic dissections and microangiography in 31 fresh cadaver specimens. The lateral nasal artery was present in all specimens, bilaterally in 30 (97 percent) and unilaterally in one (3 percent) and was located in the subdermal plexus 2 to 3 mm superior to the alar groove. The columellar branch of the superior labial artery was visualized bilaterally in 3 specimens (9 percent) and unilaterally in 21 (68 percent), and was absent in 7 (23 percent). Transcolumellar (external rhinoplasty) incisions were performed in 11 of these cadavers prior to dye injection. A consistent crossover flow (100 percent) was seen from the lateral nasal artery arcades to the distal aspect of the transected columellar branches. We conclude that nasal tip blood supply is derived primarily from the lateral nasal arteries, with a variable contribution from the columellar arteries. Collateral flow to the nasal tip may be provided by branches of the ophthalmic artery. The external rhinoplasty transcolumellar incision does not compromise nasal tip blood supply unless extensive tip defatting or extended alar base resections (above the alar groove) are performed.
 http://www.ncbi.nlm.nih.gov/pubmed/7708862

Blogger N.B.  It is my personal belief that repetitive reopening of the same external incision can increase the possibility of developing necrosis &/or serious cutaneous nerve damage ie.Neuroma's.  Of course there are other factors to consider as mentioned above and consideration as to the location of where the original external incision was made is of utmost importance.

The question of  "How many times can a nose take an open rhinoplasty w/o damaging the skin" was posed on the realself website. There's differing opinions from rhinoplasty surgeons.
 http://www.realself.com/question/times-nose-open-rhinoplasty-damaging-the-skin

Good vascularity is not only important in viability of bone/cartilage, synthetic implant grafts but equally important in viability of skin grafts and flaps. Injectable fillers can cause vascular occlusion. I would speculate that over cauterization of a specific area may also be a concern as to compromising vascularity.

New(er) Treatments for Empty Nose Syndrome

Empty Nose Syndrome (ENS) has unfortunately been a controversial diagnose amongst Otolaryngologists (ENT physicians).  Many ENT physicians in the past refused to seriously acknowledge the patients moderate to debilitating and paradoxical symptoms which developed after re-sectioning of the inferior turbinates (I.T's) in particular the anterior portion or whole I.T. and/or part of the middle turbinates. Victims of ENS had suffered double victimization because their  surgeons would defensively and reflexively write them off simply as unhappy patients who must of coincidentally developed a latent mental health problem after their turbinectomies.  There are still some obstinate ENT physicians that still reject the diagnoses outright but many are finally waking up largely due to the ease of information available on internet where publications have scientifically explained the victims host of complaints.
http://archotol.jamanetwork.com/article.aspx?articleid=484831

The person most responsible for shedding light on this topic was retired surgeon Dr. Eugene Kerns of Mayo Clinic in Rochester Minnesota. He is credited for coining the term Empty Nose Syndrome.
It was after two of his ENS patients committed suicide that he decided to devote more time to this unknown misunderstood condition. Both patients led normal active lives prior to their turbinate surgeries with no history of mental illness. In 2000 Dr. Kerns gave a taped lecture on Empty Nose Syndrome to fellow rhinologists, Dr. Kern tells his audience that the nasal mucosa “is the organ of the nose.” He outlines the four main function of this organ: “Olfaction, defense, respiration, and cosmesis.” ‘Please think of it as an organ system, just as you think of the lungs, the liver…the kidneys, as organ systems.” He points out that his Empty Nose Syndrome patients lack cilia, lack functioning mucosa. “When we remove functioning tissue what happens?” he asks. “When we destroy mucosa…these respiratory functions and defensive functions can be significantly compromised. When we convert a nose to a mouth….it’s not aerodynamically efficient…wide open noses do not function…” “How much tissue can you remove and still have normal function? We know you can remove probably eighty to ninety percent of a liver and still have normal liver function. You can remove a kidney…and have the second kidney and still have normal function. How much nose can be removed? I don’t think we know that.”
He says it took about six years, on average, following surgery, for the residual tissue of the nose to fail, in his Empty Nose Syndrome patients.
https://ens3.wordpress.com/2010/02/17/dr-eugene-kern%E2%80%99s-empty-nose-syndrome-lecture/

In past decade Dr. Steven Houser has been recognized as a pioneer in the field offering surgical acellular dermal implant (alloderm)  and injectable liquid alloderm (cymetra) for ENS. Alloderm implants have already been implanted successfully for a few years now in a small but growing number of ENS patients. At four years follow-up, results seem stable and encouraging. It seems that Alloderm implants can't fully cure ENS but can help alleviate the symptoms with various degrees of success, depending on the individual condition of each patient. It is difficult or virtually impossible to use Cymetra on its own to achieve a large volume implant, but it can be used successfully to further augment prior Alloderm implants, thus perfecting the initial result achieved with regular Alloderm.
http://en.wikipedia.org/wiki/User:WatchAndObserve/ENS#Treatments

Does the Method of Inferior Turbinate Surgery Affect the

Development of Empty Nose Syndrome?

Steven M. Houser

Pub date:Feb 10, 2014

ENS, fortunately, is extremely rare. The degree of mucosal damage

relates more directly to the development of ENS than the volume of

excised tissue. Most surgical patients will never develop ENS.

Turbinate surgery should only be considered if medical management

(e.g., allergy medications in the face of allergic rhinitis) has failed.

Using the least invasive process to effect airway improvement in the

face of turbinate enlargement is then wise. Turbinate outfracture

appears safe, as do conservative submucosal reduction procedures.

Turbinate excision should be restricted to disease processes that

prohibit lesser approaches (e.g., cerebrospinal fluid leak repair may

necessitate middle turbinate sacrifice). Turbinate reduction

approached via mucosal damaging procedures (i.e., surface cautery

and laser reduction) should be abandoned in favor of safer techniques.
 http://scitechnol.com/does-the-method-inferior-turbinate-surgery-affect-development-empty-nose-syndrome-QZPm.pdf
Poster nose1 on ENS forums has stated even a smaller amount of tissue being removed in such a way that leaves the mucosa damaged can lead to severe ENS symptoms. For example, turbinates that have been cauterized can result in quite severe ENS symptoms.
http://guest.fr.yuku.com/reply/33518/Questions-about-PRP#reply-33518

The term Empty Nose Syndrome fits descriptively well with those who have a structural turbinate deficit. But for those with nasal mucosa dysfunction and little to no structural deficit perhaps a more fitting term would be Nasal Mucosa Dysfunctional Syndrome (NMDS), if I may be so bold to coin a condition. Some who have had their turbinates excised will more likely have a combination of the two. The degree of how much mucosa is damaged/removed will likely coincide with the severity of one's symptoms. In regards to the Inferior Turbinate there's another factor at play. In partial resectioning of the I.T.  resectioning of the anterior portion is much more likely to result in ENS  then resectioning of the posterior portion of the I.T.  I myself can testify to this because my first turbinate surgery consisted of lateral and posterior excision of the I.T's. This did not cause me any ENS. However after my anterior portion was removed in another surgery years later i started to develop some of the symptoms associated with ENS. However I should point out a caveat here is that almost all my left I.T. is now missing. I don't have all the symptoms likely b/c my anterior portion was excised submucosally.  However inbetween those two surgeries I had underwent a cauterization procedure.  Note: I also did not experience ENS symptoms after my cautery of the I.T's where I then had partial lateral anterior I.T's and medial flap of the mucosa which was rolled up to form a smaller medial turbinate performed by the surgeon who performed my first turbinectomy.

Another treatment option now being explored for reducing ENS symptoms is PRP or PRL injections into the nasal cavity. 
PRP (Platelet-Rich Plasma)

Blood is taken from your body and put in a centrifuge. In the centrifuge the blood platelets will be separated. These platelets have great healing abilities which also work in natural wound healing. The out-coming concentrate can be injected to the damaged tissue.  The platelets collected in PRP are activated by the addition of thrombin and calcium chloride, which induces the release of these factors from alpha granules.. The growth factors and other cytokines present in PRP include:^[1][2]

• platelet-derived growth factor
• transforming growth factor beta
• fibroblast growth factor
• insulin-like growth factor 1
• insulin-like growth factor 2
• vascular endothelial growth factor
• epidermal growth factor
• Interleukin 8
• keratinocyte growth factor
• connective tissue growth factor

PRP has been applied for a some time in different applications (for e.g. nerve injury, bone repair and oral surgery), but only for a relatively short time for the nose.

The PRP might bring the nasal mucosa to a healthier level.
http://en.wikipedia.org/wiki/Platelet-rich_plasma

PRL (Platelet-Rich Lipotransfer)

PRL is combining PRP with a lipotransfer.
A lipotransfer is taking your own fat and placing it to another part of your body. The fat contains adult stem cells, which showed good regenerative effects. The stem cells in the fat can be enriched.
Lipotransfers are used for example in breast augmentation/ reconstruction, smoothening wrinkes and other tissue defects.

The therapy consists in the matching between platelet growth factors  and mesenchymal stem cells from adipose tissue taken from the abdomen / buttocks / hip of the patient, through a small liposuction under local anesthesia.

The adipose tissue is centrifuged and purified and subsequently combined with PRP: is thus obtained a compound called PRL (Platelet Rich Lipotransfer), which will be injected in the nasal mucosa in order to stimulate the regeneration of the turbinates and of other atrophic areas in nasal cavity.

http://www.rhinoplastysurgery.eu/ens-cure-prp-prl.html 

http://www.hindawi.com/journals/bmri/2013/434191/ 

 Doctors, who treat ENS with PRP/ PRL

Prof. Valerio Cervelli, Italy

http://www.valeriocervelli.it/

Dr. Enrico Donde, Italy

http://www.rhinoplastysurgery.eu/

Dr. Lino di Rienzo Businco, Italy

http://www.businco.net/

Dr. Robert Bodlaj, Germany

http://www.schlafmedizin-praxis.de/

PRP & ACell Implants now available at US Institute for Advanced Sinus Care & Research
 The newly created US Institute for Advanced Sinus Care & Research is now offering platelet-rich plasma injections combined with acellular dermis implants for patients with Empty Nose Syndrome. The Institute is physically located in Columbus Ohio.  Dr. Subinoy Das, former Director of Sinus Surgery at The Ohio State University, Audit Chair and Fellow of the American Rhinologic Society, and winner of the 2013 Fowler Award for the Top Basic Science Research Project in Otolaryngology is the new Medical Director.  The Institute collaborates with leading otolaryngologists throughout the
world in an effort to provide patients with advanced and rare sinus diseases with cutting edge therapies.
http://guest.fr.yuku.com/topic/5533/PRP-ACell-Implants-available-Institute-Advanced-Sinus#.VKm1KXugTO8

Hyaluronic acid gel in the treatment of empty nose syndrome. 
Marek Modrzyński

Because of its simplicity, safety, and fairly good, but impermanent clinical effects, HA injections appear to be worth considering in less severe forms of ENS. http://www.ncbi.nlm.nih.gov/pubmed/21679513 

 

Acellular dermal (alloderm) grafts versus silastic sheets implants for management of empty nose syndrome.

 The objective of the study is to conduct a prospective randomized blind clinical study comparing the efficacy and safety of use of acellular dermal (alloderm) grafts versus silastic sheets submucosal implants for management of empty nose syndrome (ENS). . Both graft materials are well suited to this procedure with no statistical evidence for a significant difference between them. The silastic implant is inert and yet incorporated into the surrounding tissue because of the fashioned macropores. It is available and inexpensive. Acellular dermis graft is reliable, predictable, and readily shaped. Patients of both groups showed marked subjective and objective improvements. The surgical procedure is safe and relatively simple to perform. 

http://www.unboundmedicine.com/medline/citation/22526572/Acellular_dermal__alloderm__grafts_versus_silastic_sheets_implants_for_management_of_empty_nose_syndrome_ 

Study of inferior turbinate reconstruction with Medpor for the treatment of empty nose syndrome.

CONCLUSION: The reconstruction of inferior turbinate with Medpor is a new promising approach to treat patients with empty nose syndrome.

http://www.ncbi.nlm.nih.gov/pubmed/23208803 

N.B. My understanding is that medpor is difficult to remove if need be since it incorporates itself with other surrounding tissue's. Therefore one should be skeptical to this approach using medpor, silastic sheets (silicone) or any unnatural products inside the nose.


More Info on Empty Nose Syndrome:

Innervation of the nasal septum and lateral wall

As I have already mentioned in past blog postings I ended up with severe chronic neuropathic pain after my failed nose revision surgery in 2005 .  What's interesting is that most rhinoplasty surgeons don't educate us lay people (patients) about the risk and complications that can arise from nerve injury during rhinoplasty. In fact not only are some rhinoplasty surgeons "apparently" at a loss about my complication, one reconstructive rhinoplasty surgeon mentioned to me during the consult that there are no nerves in area of where my pain is, which happens to be the lower third of my nose ( tip lobe area including columella). Really? Well a very quick search & scant amount of reading on the internet can easily debunk that tale. However if my memory serves me right he was the first one to suggest my nerve pain may be due to Traumatic Neuroma *1. Perhaps he meant there are no main nerve branches in the tip region where my pain seems to originate from. Anyway lets now turn our attention to the nerves within the human nose.

The upper most yellow region is: Olfactory bulb, & nerves

Surgical Anatomy of the nose by Natalie P Steele and J Regan Thomas (Ch.1 Rhinology and Facial Plastic Surgery Fred J Strucker & assoc. ) 

Nerve supply to the nose is externally derived from branches of the trigeminal nerve. The skin of the nose superiorly at the radix and rhinion is supplied from branches of the supratrochlear termination of the ophthalmic nerve. The anterior ethmoidal nerve, another branch of the ophthalmic, may traverse the dorsum of the nose to supply the tip [12]. In endonasal or in open rhinoplasty, this nerve bundle may be damaged by over-aggressive endonasal incisions violating the fibromuscular layer, or elevation of the S-STE (skin-soft tissue envelope) in the wrong plane, resulting in a numb nasal tip. The infraorbital nerve may also contribute branches to the lateral nasal walls, columella, and vestibule. Knowledge of this external nerve supply is necessary to perform adequate nerve blocks for closed reductions, or for rhinoplasty under local anesthesia with sedation. Intranasal anesthesia is also a prerequisite for these procedures. This may be performed with intranasal cocaine pledgets or other strategically placed topical anesthetics. Perhaps the most important target is the sphenopalatine ganglion located in the posterior portion of the nose just posterior to the middle turbinate. Internal branches of the anterior ethmoid must also be anesthetized in the superior portion of the nose to complete a total nasal block.  

 CUTANEOUS INNERVATION
Nasal skin is innervated by the infratrochlear and external nasal branches of the nasociliary nerve, and by the nasal branch of the infraorbital nerve.

http://www.expertconsultbook.com/expertconsult/ob/book.do?method=display&type=bookPage&decorator=none&eid=4-u1.0-B978-0-443-06684-9..50040-8--cesec41&isbn=978-0-443-06684-9

 Olfactory Nerve (N I)    
The olfactory nerve is a special sensory cranial nerve that is responsible for the sense of smell. The receptors of these neurons are found in the olfactory epithelium and the axons pass through the cribriform plate of the ethmoid bone. These neurons synapse within the olfactory bulb which lies directly above the cribriform plate.
http://droualb.faculty.mjc.edu/Lecture%20Notes/Unit%205/cranial_nerves%20Spring%202007%20with%20figures.htm

Interesting Observation To Note.  
I have been corresponding with someone who also developed nerve related pain and discomfort after revision rhinoplasty a few years ago.  The person also had the open approach technique repeated along same previous surgical incision, as was done with my nose.  This raises suspicion as to whether repeating the open approach technique along same scarred incision increases chances of developing neuropathic pain or neuroma's due to nerve trauma along skin tissue. Another possibility for explaining nerve pain or neuroma's is large removal of scar tissue along the columella /tip region resulting in a lot of new scar tissue development during healing period which may entrap nerve tissue. The open approach has become very popularized to the point that very few rhinoplasty surgeons are performing the more complicated but less invasive closed approach technique which has it's advantages as well as some disadvantages. So with more rhinoplasty surgeons performing primary and revision rhinoplasty with the open approach we may see a rise in unexpected complications due to trauma such as nerve trauma.

*1 Traumatic neuroma follows different forms of nerve injury (often as a result of surgery). They occur at the end of injured nerve fibres as a form of ineffective, unregulated nerve regeneration; it occurs most commonly near a scar, either superficially (skin, subcutaneous fat) or deep (e.g., after a cholecystectomy). They are often very painful. Synonyms include scar neuroma, amputation neuroma, or pseudoneuroma.


http://books.google.ca/books?id=EccLuc0mLWoC&pg=PA5&lpg=PA5&dq=Surgical+anatomy+of+the+nose+natalie+steele&source=bl&ots=qsrQv7eKHq&sig=PlVBbsS-63jA12sYza2Cotlieho&hl=en&sa=X&ei=AhpMU4CnD6ThyQGu3YDQAQ&ved=0CEAQ6AEwAw#v=onepage&q=Surgical%20anatomy%20of%20the%20nose%20natalie%20steele&f=false

http://surgpathcriteria.stanford.edu/peripheral-nerve/traumatic-neuroma/

http://www.wisegeek.com/what-is-traumatic-neuroma.htm
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3052669/#__sec2title
https://www.youtube.com/watch?v=UGj7d1aNhsE

http://www.google.ca/url?sa=t&rct=j&q=&esrc=s&source=web&cd=12&cad=rja&uact=8&ved=0CGQQFjAL&url=http%3A%2F%2Fwww.springer.com%2Fcda%2Fcontent%2Fdocument%2Fcda_downloaddocument%2F9783642280528-c1.pdf%3FSGWID%3D0-0-45-1391308-p174286862&ei=g3dNU4vIIeKMyQG7-4GoDA&usg=AFQjCNHrkjIP-o8nuK0VzRQbtbt-Id63YQ&sig2=Qp43v_yLeNqIssDJhzdCAA&bvm=bv.64764171,d.aWc

Why revision rhinoplasty surgeons should ask to see pictures of future patients unoperated fully developed nose

When a new revision patient visits a rhinoplasty revision surgeon for a consult the surgeon has no idea how much work was done prior in the reduction of the size of the patients original nose unless patient presents them with pictures of their un-operated fully developed nose. The patient may of presented their operative report at time of consult to the revision rhinoplasty surgeon however it still leaves the surgeon guessing & imagining what the nose looked like prior to the previous/original surgery.  I believe this is a critical error that could easily be rectified by new patients presenting the revision surgeon with images of their original [innate] fully developed nose. If you have had multiple surgery's I believe it would be beneficial as well to present the revision surgeon with all the before/after pictures the previous surgeon's took of your nose. The reason I feel so strongly about this is based on my own personal experience. When you have a very large natural nose and end up having a number of revision surgery's by surgeons who 'blindly' and unwisely keep reducing the size of it, this may lead to serious irreversible consequences.

 Example: The last revision surgeon i went to  wasn't very experienced or knowledgeable in complicated revision surgery and reduced my already surgically reduced tip. It was angled slightly too far upwards and was over projected. It wasn't in line with the bridge of my nose which was over-resected from previous surgery's. From previous surgery's I had my tip reduced/repositioned twice. I had made him aware of this and brought him my O.R's and my before/after from my previous surgery, but no pictures of my original un-operated fully developed nose. I had a consult with another revision surgeon before this last inexperienced surgeon operated on me, and his opinion in regards to how to correct my disproportionate tip/bridge profile  problem would of been the correct and safer approach. Let's refer to this experienced revision surgeon as Dr. C. and my last inexperienced surgeon as Dr. S. Dr. C.'s approach was to not reduce my tip but to increase the projection of my bridge (known as dorsal augmentation) thereby  bringing it in line with my tip by adding *1 rib cartilage. The estimated time of surgery was between 4 to 6 hours. Dr.S. told me he could prevent me from going through the pain of having rib cartilage and use some ear cartilage (however not in my bridge) but for collapsing nasal valves' which he ended up not doing, and he could 'bring down' my tip and do surgery all within 1and 1/2 hours.  I should of asked Dr. S. what he meant by 'bringing down ' my tip because I was under the impression he would simply rotate it downwards possibly with sutures instead of removing more of my lower lateral/medial cartilages which was already deficient, and remove what he considered heavy scar tissue all along my columella. In the end my tip was reduced and not as out of proportion with my bridge. Small consolation considering the grave consequences I ended up with. Cosmetically my profile looks short/weak for a male; structurally the tip is somewhat collapsed due to the accumulated effect of over re-sectioning of the supporting tip cartilages and physiologically I ended up with permanent painful neuropathy with associated side effects of allodynia/ hyperesthesia. 

Fig.1  Profile: Disproportionate tip to bridge ratio

Now whether presenting Dr.S. with pictures of my original sized un-operated nose would of changed his mind of doing another tip reduction like he did is unfortunately left to hindsight. To be clear Dr.S. just as previous surgeons including Dr.C. never requested or had such a picture of me. Considering Dr.S. had all my operative reports however he would of seen I had two prior tip reductions which should of been a red flag for doing another one especially when a different but more complicated approach would of achieved the desired results.  He also was aware I had two prior inferior turbinectomy's but that didn't stop him in doing another one in both nostrils, which he made a condition for going ahead with the surgery.  So in all probability presenting original pictures of my nose to Dr.S. would not of made the slightest of difference. But not all surgeons think alike. Each one is an individual who has their own beliefs, thoughts, idea's, aside from their education, preferred surgical methods and experience. The more information you can supply your future revision surgeon with the better informed he/she will be, presuming they take the time to study your past history. So I would still recommend strongly for a revision patient to dig up some old photo's of your un-operated fully developed nose and present it to your future revision surgeon making him aware of all the transformations which have already taken place. 

It's important to understand that your original un-operated fully developed nose contains/contained within it a proportionately developed network of nerve endings, vascular system, turbinate bone and tissue. Over re-sectioning of any specific area containing the aforementioned anatomy can lead to a breaking point where one can end up with serious consequences.

This hopefully will make your next revision nose surgeon think twice as to which surgical approach he/she will take with you and deter him/her from doing another reduction or aggressive reduction on your tip (as was done on me) *2 where you end up with similar disastrous results.

*1 The reason rib graft was recommended was because I didn't have sufficient septal cartilage to spare.

 *2 SEE http://noserevisionsurgeryandsurgeons.blogspot.ca/2010/08/neuropathy-caused-by-nose-surgery-it.html

Deviated Septum vs Crooked Nose

All crooked/twisted noses have an underlying septal deformity that requires correction and reconstruction to achieve and maintain a long term straightening of the deviated septum.  It is not uncommon for both septal  and pyramid deviations to be corrected at the same time A deviated septum  is corrected by having a septoplasty to improve breathing. This is normally addressed by  correcting the abnormal curvature of the nasal wall consisting of the septal cartilage (the quadrangular cartilage) and bones at back (vomer and ethmoid bone).  This can be done with a closed (endonasal) approach. A localized deviation or spur is purely a functional problem and has no translation to the external shape of the nose.  A crooked/twisted nose usually involves more then just surgical repair or partial removal of the inner quadrangular septal cartilage . Having a septoplasty alone does not mean you will see a external physical change regarding the asymmetry of your nose. A crooked/twisted nose could involve many or all components of the nose cartilage and bone structures from the top/down (cephalic/caudal) region of the nose this would involve anything from the bony pyramid (upper third of your nose) all the way down to the caudal septum (deviation in this region is known as having a caudal deflection), nasal spine & maxillary crest. From the front/back (anterior/posterior) region of the nose this would involve anything from the side of the bridge (medial section of the bony pyramid) of the nose to the most lateral aspect of the nasal bones, or to where the quadrangular cartilage adjoins to the maxillary crest, nasal spine, vomer and perpendicular plate of the ethmoid bone. Sometimes the aforementioned bones need to be corrected to assist with aligning the nasal wall. . The pair of upper lateral and lower lateral cartilage, and medial cartilage are usually evaluated and those which are found asymmetrical after all other corrections to the septum has been made will be modified in this type of surgery. Technically this is referred to as having a septorhinoplasty because there will be a visible cosmetic change to the external shape of your nose.

Pietro Palma M.D. and Paolo Castelnuovo M.D.Chapter 29 p. 320 Correcting the crooked nose from textbook Advanced therapy in Facial Plastic & Reconstructive surgery edited by T. Regan Thomas M.D

Authors classify crooked noses in three basic variations. However, it is important to realize that any of these three categories may be found in various combinations with each other.

Type 1: Single Opposing Convexity/Concavity

The C-shaped and inverted C-shaped noses represent the paradigmatic expression of type 1 deformity. The midnose is invariably involved. Tip-definition point and nasion can be correctly located on the midline axis.

Type 2: Double Opposing Convexity/Concavity

Type 2 crooked nose includes S-shaped and inverted S-shaped. The three framework arches (bony vault, cartilaginous dorsum, and inferior nasal third ) are the most frequently involved with variable combinations of convexity/concavity. Interdomal midpoint and midline rhinion are often out of the midsagittal axis.

Type 3: Laterally Deviated Noses

The typical laterally deviated nose appears straight in terms of alignment of the nasal structures but presents different heights of the two halves. The interdomal midpoint is invariably displaced off center of the midline axis. The angulation may start at the nasion or the rhinion. When the angulation is located at the nasion the halves of all three nasal arches present different heights. Angulation starting at the rhinion implies a straight or near-straight bony pyramid.

Some other major findings which the authors point out are:

• The crooked nose should be considered an anatomical 'three-level unit": skin-soft tissue envelope (SSTE),bony- cartilaginous framework, and internal lining. Each of these 3 layers plays a specific role for making the nose appear crooked.

• Total septal reconstruction of the quadrangular cartilage maybe required in severe cases where there is extensive post traumatic or iatrogenic alteration of the cartilage. According to above authors reshaping techniques under those conditions provides poor long term functional and cosmetic results because the original deformities tend to reoccur. 

• Camouflage procedures are used to achieve better symmetry of the nasal contour anatomy  &/or emphasis some crucial surface landmarks (rhinion, tip definition points, pronasale, colemellar break, subnasale). Autogenous softly crushed septal cartilage, remnants of the cephalic alar resections, & mature scar tissue are the authors preferred additive camouflage material. 

• The poor success rate of septum surgery reported by many studies is probably due to the failure to treat concomitant valve derangement & alterations of the lateral nasal wall. In fact, concomitant surgery on the nasal lateral wall is often required for a satisfactory functional outcome.  

•  Precise mini-invasive endoscopic procedures on turbinates and ostiomeatal complex produce excellent functional results.

•  Conventional osteotomy techniques do not always accomplish what was intended. Double and in special cases, triple osteotomies are necessary to mobilize completely the bony pyramid and change excessive broadness, convexity, or bowing of the nasal lateral walls.  

• An often neglected region is the premaxillary area including the inferior nasal spine and the premaxillary wings. 

For further reading on chapter by above mentioned authors

http://books.google.ca/books?id=j0_r6YZIvbYC&pg=PA319&dq=correcting+the+crooked+nose&hl=en&sa=X&ei=gLDuUe_mBpSj8gHXwoC4BA&ved=0CDkQ6AEwAg#v=onepage&q=correcting%20the%20crooked%20nose&f=false

Additional reading sources
http://www.plasticsurgeryassociatesny.com/crooked_nose_article.pdf

http://emedicine.medscape.com/article/840384-overview

http://dwkimmd.com/papers/Mgmt_postraum_deform.pdf

Diagrams
http://eng.idhospital.com/nose/nose03.php

http://lifecaremedi.wordpress.com/2012/07/24/types-of-dns-deviated-nasal-septum/

http://noserevisionsurgeryandsurgeons.blogspot.ca/2010/12/nomenclature-of-nose-this-could-be.html

Video

Identity Loss Syndrome after rhinoplasty

One of the possible unexpected  psychological effects patients may experience after having rhinoplasty can be a sense of loss of identity. This occurs when one experiences a disconnect with their new physical appearance which they either can't accept or takes a long transition period to get accustomed to.One who undergoes a multitude of  initial cosmetic procedures at once or within a short period of time, are more  prone to suffer from this syndrome, versus someone who has a single or few minor cosmetic changes. However the nose is a prominent feature of the face, and therefore a very large proboscis that is dramatically reduced or reshaped after initial rhinoplasty can have dramatic psychological effect creating a self identity crisis. For example pre-rhinoplasty I had a very large hooked crooked nose. After my initial rhinoplasty i ended up with a over shaved bridge, which created a ski sloped nose with a over projected tip. The look (which was very contrasting with my original nose) never fitted in with  my round face, and looked unnaturally long resulting in a Cyranno type appearance. Others who may likely experience this syndrome are those belonging to certain ethnicity, race or have a family physical trait. A middle eastern person or a descendant of, may want to keep a more rounded profile or lowered tip then a 'perfectly' straight septum, or a Colored or Asian individual may want a wider nose then the Caucasian standard ideal nose. Another group who would be susceptible to this identity loss syndrome (I.L.S.) would be those who feel a reduction in their gender defined degree of physical characteristics. A male may feel emasculated if he always had a more rugged 'Roman like' shaped nose , and then after rhinoplasty ended up with more feminine looking nose (more obtuse nasolabial or nasofrontal angle). Same could hold true for women who have petite features and end up with a more masculine nose, due to more acute tip angle, or increase in size/shape of their new nose due to cartilage replacement grafts. Another subgroup are those who feel a disharmony between their physical appearance and their personality type. This  can occur where one ends up with a  nose shape that makes them look rugged/ more aggressive looking or weaker/softer looking  which is in disharmony with their  type of personality.  A person may also associate and develop a strong negative feeling  with their new look not based on gender issue's but because their new look simply resembles a character type they view negatively or very foreign. One other group who may experience  I.L S. are people who have become very accustomed to their facial imperfection (i.e.slight deviated septum, or asymmetric nose), which had become subconsciously a personal identity marker. This is why it is critical for the surgeon and patient to be on the same page, as to what result the patient is seeking. However a patient seeking primary rhinoplasty may not know what they really want.  It may be wise for the surgeon to have a questionnaire that can address these questions, and issue's, just before consult, so the surgeon can further explore these possible issue's that even the patient may not of been cognizant of prior to making the appointment. A follow up appointment may be needed to give time to the patient to be more specific about what cosmetic change their seeking, and to figure out what they like and don't like about their nose. The use of a picture or computer imaging is very useful to experiment with different looks at different angle views to give the patient an idea of how they may appear post rhinoplasty. Young patients may need to realize and be counseled that their favorite celebrities nose(s) may look totally wrong with their facial features.

http://www.dailymail.co.uk/femail/article-2127322/Can-plastic-surgery-change-personality-Excessive-cosmetic-procedures-lead-identity-crisis-warn-psychologists.html

Anatomic reconstruction of the alar cartilages in secondary or revision rhinoplasty

In my October 22, 2012 post i discussed if there is a surgical decision point such as a  50% rule relating to  missing cartilage where some surgeons decide to  rebuild the alar cartilages or other nasal cartilage in general instead of using an assortment of different individual grafts and fillers. While still not knowing the precise answer to that question, the following article which i discovered after writing that article sheds some light on the issue, and it seems a bit more complicated then that. It emphasizes the advantage of anatomic reconstruction of the nasal tip cartilages instead of using nonanatomic cartilage tip grafts.

ANATOMIC RECONSTRUCTION OF THE NASAL TIP CARTILAGES IN SECONDARY AND RECONSTRUCTIVE RHINOPLASTY    Author: Dr. Frederick J. Menick

   Most techniques for secondary rhinoplasty assume that useful residual remnants of the tip cartilages remain but frequently the alar cartilages are missing- unilaterally, bilaterally, completely or incompletely- with loss of the lateral crura, middle crura, and parts of the medial crura. In such severe cases, excision of scar tissue and the residual alar remnants and their replacement with nonanatomic tip grafts have been recommended. Multiple solid, bruised or crushed cartilage fragments are positioned in a closed pocket or solid shield-shaped grafts are fixed with sutures during an open rhinoplasty. These onlay filler grafts only increase tip projection and definition. Associated tip abnormalities (alar rim notching, columella retraction, nostril distortion) are not addressed. Problems with graft visibility, an unnatural appearance or malposition have been noted.

   Fortunately, techniques useful in reconstructive rhinoplasty can be applied to severe cosmetic secondary deformities. Anatomic cartilage replacements similar in shape, bulk, and position to normal alar cartilages can be fashioned from septal, ear and rib cartilage, fixed to the residual medial crura &/or a columellar strut, and bent backward to restore the normal skeletal framework of the tip. During an open rhinoplasty, a fabricated and rigid framework is designed to replace the missing medial, middle, or lateral crus of one or both alar cartilages. The entire alar tripod is recreated. These anatomic alar cartilage reconstructive grafts create tip definition and projection, fill the lobule, and restore the expected lateral convexity, position the columella and establish columellar length, secure and position the alar rim, and brace the external valve against collapse, support the vestibular lining, and restore a nostril shape. The anatomic form and function of the nasal tip is restored. This technique is recommended when alar cartilages are significantly destroyed or absent in secondary or reconstructive rhinoplasty and the alar remnants are insufficient for repair.

   Anatomically designed alar cartilage replacements allow an aesthetically structured skeleton to contour the overlying skin envelope. Problems with displacement are minimized by graft fixation. Graft visibility is used to surgeon's advantage. A rigidly supported framework with a nasal shape, can mold a covering forehead flap ro the scarred tip skin of a secondary rhinoplasty and create a result that may approach normal.

   Anatomic alar cartilage reconstructions were used in 8 reconstructive and 8 secondary rhinoplasties in the last 5 years. Their use in the repair of postrhinoplasty deformities is emphasized. (Plast, Reconstr. Surg. 104: 2187, 1999.)

http://www.drmenick.com/wp-content/uploads/2012/06/PDF%20Anatomic%20Reconstruction%20of%20the%20Nasal%20Tip%20Cartilages%20in%20SecondaryReconstructive%20Rhinoplasty.pdf

My shrinking nostrils: Nasal tip collapse as a result of rhinoplasty

By now  those of you who have been following this site, will be aware of the terms external and internal nasal valve collapse. When thinking of those terms we automatically think of lateral collapsing of the nasal wall towards the septum particularly with inspiration. But when a significant amount of your tip cartilage (the middle and medial crura) are excised during rhinoplasty you will likely notice, as is in my case, that your nostrils are now significantly less projected then they were before your primary nose surgery. In fact the short projection of my nostrils were pointed out to me by a revision rhinoplasty surgeon a few months back. At closer inspection of the base view of my nostrils, I would guesstimate (since i don't have nostril pictures of my original adult pre-operated nose) that my nostrils are close to  half the length of what my  nostril projection was prior to my primary surgery. I have had my tip reduced in all of my three revision rhinoplastys, as well as reduced and reshaped in my primary. My nasal spine was also reduced in one of my revisions. The problem of an overly large  nasal tip was a result of my primary nose surgeon being overly aggressive with my bridge (I had a very large hooked shaped nose), so by overcompensating for that, the surgeon ended up giving me a ski sloped nose with a very long protruding tip... the Cyrano effect  A big cosmetic assessment mistake that was made by my last surgeon was not understanding how to safely bring into balance the longer tip with my scooped out bridge. The safe, smarter but more complex procedure which should have been performed, was to add grafts to my bridge building it up to line up better with  my tip. Another possibility which could of been performed alone or in tandem with the former was to reshape the tip cartilages using sutures and rotate it downward, since I already had some excision to my tip cartilages previously. Unfortunately the surgeon wasn't that experienced or skilled so he decided to opt for quick & easy 'fix'  and aggressively excise the tip cartilages further down, not taking into account all the previous excisions i had. So in essence he was able to achieve the cosmetic goal of reducing the length of my tip, but unfortunately not without major consequences. I don't believe I have tip ptosis at least not a very distinguishable form of it because my tip was already positioned fairly high after my first revision surgery. However it's very likely that the major and minor supporting tip structures have been negatively impacted on, as well as the vascularity of my skin and soft tissue envelope. I would assume that in order to correct my flattened "shrunk" nostrils i would probably require tip projection as well as correcting the lateral collapse I have, to achieve a normal and relatively proportional sized nostrils ( proper ratio's) for the base of my nose. It's also important to recognize that anything which decreases the nasal valve cross sectional area can negatively impact the nasal airway, creating further feeling of nasal obstruction. Even though there's a significant amount of information about reducing flared out nostrils for cosmetic reasons, not much exists for increasing or restoring the size of one's flattened out nostrils due to prior nose surgery's. At least not that I have found online. As far as nasal tip ptosis is concerned I will discuss that in greater detail on another post.

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