PREOPERATIVE DIAGNOSIS:

1. Nasal obstruction secondary to external/internal valve collapse following rhinoplasty.

POSTOPERATIVE DIAGNOSIS: 
Same with open roof deformity.

PROCEDURE:

1. Repair of nasal vestibular stenosis with reconstruction of external valve collapse with placement of bilateral lateral crural strut grafts.
2. Repair of nasal vestibular stenosis with reconstruction of tip support with placement of columellar strut.
3. Repair of nasal vestibular stenosis with reconstruction of internal valve collapse with placement of bilateral spreader grafts.
4. Graft, right and left ear cartilage
5. Right deep temporalis fascia harvest.
6. Repair of nasal vestibular stenosis with reconstruction of external valve collapse secondary to alar retraction with placement of bilateral composite grafts.
7. Repair of nasal vestibular stenosis with reconstruction of nasal inlet obstruction secondary to open roof deformity with bilateral osteotomies.
8. Secondary septorhinoplasty, chin implant, platelet gel application 

FINDINGS: 
Narrow bilateral external valve with right worse than left and over-resected lower lateral cartilages (LLC); left LLC narrower/shorter than right LLC; Left LLC cephalically-oriented with step-offs at supratip break; bone onlay over dorsum removed – open roof deformity; 3+ narrow left middle vault; composite graft size limited to narrow concha cymba; composite grafts (4 mm X 13 mm); open roof deformity; significant alar retraction with  left alar retraction more than right; over-rotated infratip lobule; cartilaginous septum intact with bony septum removed at initial surgery; caudal septum deviated to right.    

COMMENT:
This is a patient who desired to improve the function and appearance of her nose after a previously unsuccessful procedure (different surgeon).  Post-operative photos reveal a much improved nose. In addition, patient's breathing has greatly improved.