What causes inverted V deformity after rhinoplasty, and should you return to the original surgeon for revision?
⚠️ Contact your surgeon promptly if you notice breathing problems
Inverted V deformity can be associated with internal nasal valve collapse, which may cause significant difficulty breathing through your nose. If you have worsening nasal obstruction, or if you develop signs of infection such as increasing redness, warmth, swelling, or fever after any nasal surgery, contact your surgeon right away or seek urgent medical care.
Short answer
Inverted V deformity is caused primarily by surgical disruption of the upper lateral cartilages from the nasal septum, combined with wound-healing forces that pull the cartilages inward. It is also worsened by certain risk factors present before surgery. Whether to return to the original surgeon is a personal decision with real tradeoffs, and the research offers some helpful context.
What causes inverted V deformity?
The inverted V deformity is a visible shadow or indentation along the middle of the nose that can appear after rhinoplasty. Research points to two interacting causes: surgical technique and the body's healing process working together.
On the surgical side, the deformity forms when the upper lateral cartilages (the cartilages in the middle third of the nose) are separated from the nasal septum during surgery. A computer modeling study showed that when these cartilages are fully detached, the characteristic inverted V shape reliably appears, with peak depressions of about 0.3 mm along the dorsum. [5]
Wound healing then makes things worse: as the tissue contracts during recovery, it applies a posteroinferior (downward and backward) pulling force along the nasal dorsum, pushing the medial edges of the upper lateral cartilages inward. [5] In other words, the surgical step creates the vulnerability, and healing forces complete the deformity.
Certain patient characteristics also raise the risk before a single cut is made. These include short nasal bones, long or weak upper lateral cartilages, thin skin, previous nasal trauma or surgery, and a "tension nose" shape. When any of these are present, surgeons are advised to take extra protective steps such as spreader grafts or more conservative hump reduction. [4] Similarly, osteotomies (controlled bone cuts) that are not carefully planned can also contribute to an inverted V shape. [7]
Can it be corrected?
Yes. Spreader grafts placed along the middle vault are considered the standard repair, helping to restore both the appearance of the dorsal lines and proper nasal airway function. [4] Functional and aesthetic middle vault problems are among the most common reasons patients seek revision rhinoplasty. [4] The good news is that revision rhinoplasty for deformities like this has a high patient satisfaction rate: one cohort study of 150 revision patients found 97% were happy with their outcomes. [1]
Should you return to the original surgeon?
This is genuinely a personal decision, and the research does not give a definitive answer either way. What the evidence does show is that the most severe revision cases are often the result of prior surgery (meaning the deformity was created, not inherited), and that many patients who seek revision do so because a new deformity developed after their primary procedure. [1]
Some patients do not return to their original surgeon at all. [8] There is no research showing better or worse outcomes based on whether the revising surgeon is the original one or a new one. Factors worth weighing include: how well you trust and communicate with your original surgeon, whether they acknowledge what happened and have a clear plan, and whether they have specific experience correcting middle vault problems. Getting a second opinion from a different qualified surgeon before deciding is a reasonable step. The most important thing is feeling confident in whoever performs the revision.
What to ask your surgeon
- "Was my inverted V deformity caused by cartilage separation, and what will you do differently this time to protect the middle vault?"
- "Do you plan to use spreader grafts, and where will the cartilage come from?"
- "How many revision cases like mine have you corrected, and can I see before-and-after photos?"
- "What are the realistic limits of correction given my skin thickness and cartilage quality?"