One of the most common issues present in patients seeking revision rhinoplasty is the inverted-V deformity. This refers to an upside-down V-shaped indentation between the end of the nasal bones and the start of the upper lateral cartilages, along the top of the bridge. If a patient were to run their fingers along the sides of the bridge, they would feel that this mid-portion of the bridge feels indented on each side and narrower than the width of the nasal bones. This inverted-V deformity interrupts the brow-tip aesthetic line, which is the smooth arched line on each side, running from the middle of the eyebrow down along the side of the nasal bridge and down to the tip.
The inverted-V deformity can result following hump removal in rhinoplasty, if the upper lateral cartilages are allowed to collapse against the septum. Besides the aesthetic impact of this issue, patients may have difficulty breathing. This is due to narrowing of what are called the internal valves of the nose. The internal valves are defined as a narrow point in the nasal airway, bordered by the septum, the upper lateral cartilage, and the inferior turbinate. If the upper lateral cartilage has fallen against the septum, this valve becomes significantly narrowed. In medical terms, this is called nasal vestibular stenosis and insurance coverage may be obtained if patients have tried medical therapies such as nasal steroid sprays (Flonase, Nasonex, Nasacort, Rhinocort, Veramyst, etc.) and antihistamines (Claritin, Zyrtec, Allegra etc.) but failed to notice much improvement in breathing. This insurance coverage can help offset a great deal of the cost of revision rhinoplasty, as Dr. Mehta is in-network with most major companies.
During an examination of the nose, two maneuvers can help determine if the patient’s difficulty breathing through the nose is the result of internal valve collapse. The first is to perform what’s called the Cottle maneuvers. This involves pulling the cheek to the side with a finger. If breathing improves, this may indicate narrowing of the internal valve as a result of upper lateral cartilage collapse. Many patients come in already having tried this at home. The other test during the nasal examination is to lift the upper lateral cartilage out to the side with a Q-tip inserted inside the nose. This is similar to the effect of putting on Breathe-Rite nasal strips, which many patients have tried as well.
The solution to correcting the inverted-V deformity and nasal vestibular stenosis is the placement of cartilage grafts called spreader grafts. These are long thin pieces of cartilage that lift the upper lateral cartilages outward, widening the cross-sectional area of the nasal airway. The analogy commonly used is that these are beams that run along the top of the roof of a house, to prevent the sides from caving in. These grafts are ideally taken from the septum and are generally between 1 and 2 cm in length, 1-3 mm in width, and 3-5 mm in height. If the cartilage in the septum is insufficient or unavailable, rib or ear cartilage can be options as well.
Dr. Mehta places these spreader grafts during a first-time rhinoplasty for >80% of patients, as this helps to prevent the Inverted-V Deformity from occurring in the first place. The decision of whether to place spreader grafts during first-time surgery is based on the strength and width of the upper lateral cartilages, the size of the hump being removed, and the length of the mid-portion of the bridge, called the middle vault. If there is more collapse on one side vs. the other, spreader grafts of different thickness or even two spreader grafts can be placed on the same side. The grafts can be shaved down to around 1 mm in thickness if patients do not need substantial grafts.
If you feel you have an inverted-V deformity and would like to meet with Dr. Mehta to determine if he can improve both the shape and function of your nose, please contact us below for a consultation.