nasal stenosis is a rare phenomenon that can occur secondary to a variety of etiologic factors . in classical classification , these factors are divided by their congenital or acquired basis . the causes of acquired nasal stenosis are mainly infections ; trauma or iatrogenic while congenital causes are rare . iatrogenic trauma includes injury from intubation , nasal examination traumas and traumas from the management of epistaxis , or various nasal surgeries . the treatment of stenosis can be challenging . pre - operative analysis and meticulous surgical planning are necessary for success . stenosis of the nasal vestibule can be a vexing deformity for the facial reconstructive surgeon to successfully repair . like other human body orifices ( e.g. , lacrimal ducts , urethra and ear canals ) , the damaged vestibule has a tendency to contract despite seemingly well - designed surgical manoeuvres to excise the offending cicatrix and create a new vestibular lining . from a patho - physiologic standpoint , stenosis of the anterior nares can be caused by direct injury to the delicate lobule - ala - columella complex , loss of healthy vestibular lining or both . a 27-year - old female patient was referred to a plastic surgeon , complaining about nasal obstruction and severe nasal deformity . past medical history showed three rhinoplasty operations when the patient was 18 , 20 and 25-year - old . in the clinical examination , there was no shortening of columella and its projection was sufficient [ figure 1 ] . patient 's pre - operation photograph : ( a ) basal view , ( b ) frontal view , ( c and d ) left and right oblique view , ( e and f ) left and right lateral view in order to reconstruct the nostrils , composite grafts were harvested from each ear lobe bilaterally ( size : 10 mm  5 mm  4 mm ) and its central fat was removed partially . a 25 mm  3 mm  1 mm graft from ear concha was harvested with post auricular incision as an alar strut graft to reconstruct the right alar notching [ figure 2 ] . after harvesting grafts , bilateral alar base incisions were done and adhesions released and the obstructing cicatrix was excised , then a tunnel was created under the remaining alar cartilage for insertion of 2.5 cm long alar strut cartilage graft in order to correct the right alar notching . alar strut grafts were sandwiched through this tunnel and continued to piriform aperture in the alar base . schematic presentation of strut graft 25  3 mm ( black dots on nose ) harvested from ear concha with post - auricular incision . earlobe composite graft ( red triangle ) was harvested from the ear . by an alar base incision in cheek - alar junction ( red line on nose ) , the adhesions were released , then strut graft and ear lobe composite graft were transferred and fixed it should be noticed that we did not use a columellar incision ( the common approach ) because of severe fibrosis and adhesion and weak blood supply in collumela due to previous operations [ diagram 1 ] . in this diagram the steps of diagnosis and management of a female with severe iatrogenic nostril stenosis due to multiple previous rhinoplasty has shown a prefabricated nostril retainer was applied to preserve the anatomy of reconstructed areas and prevent post - operative contraction . photographs was taken 6 months post operation with good nasal valve and no difficulty in breathing [ figure 3 ] . post - operation photography : ( a ) 1 week after surgery , ( b ) 1 month after surgery , ( c ) frontal view 6 months after surgery , ( d ) basal view 6 months after surgery , ( e and f ) left and right lateral view 6 months after surgery partial stenosis with limited tissue loss can be reconstructed with vestibular z- or w - plasties , split and full thickness skin grafts , a composite chondro cutaneous graft . for example , mavili and akyrek reported a unilateral nostril stenosis that was repaired with the use of an upper lip flap . however , these interventions may not be effective , if a severe stenosis is present . the common approach is excising the obstructing cicatrix ; replace the damaged tissue with a new lining , and using a stent device postoperatively to prevent re - stenosis . this method is useful for isolated stenosis within the vestibule owing to scar tissue , but they do not compensate the alar collapse . copcu reports using a gingiva buccal mucosal flap in addition to a cartilage graft to strengthen the ala . describe the theoretical use of cartilage grafts in conjunction with other techniques for relining the injured vestibule , but they did not use cartilage grafts in their series . the simplest approach for this reconstruction is to excise the stenotic and replace the lining with a split - thickness skin graft . this process involves excision of scar tissue from within the nostril to create multiple flaps ; the integration of these flaps makes an efficient cover . the use of acrylic stents for 5 months post - operatively is advocated after w - plasty to prevent re - stenosis . naasan and page , suggest the double - cross plasty which involves making meticulous superficial and deep incisions in the damaged tissue in the shape of a cross , excising the scar tissue , then interdigitating the resulting flaps , leading to a w - plasty that encircles the nostril . we recommended earlobe composite graft for severe nostril stenosis combined with an alar strut graft from ear concha for the stability of external valve . nostril retainer is very important and patients must begin 1 week post - operation with smaller sizes and gradually change it to larger sizes for at least 3 months post operation . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed . the authors certify that they have obtained all appropriate patient consent forms . in the form the patient(s ) has / have given his / her / their consent for his / her / their images and other clinical information to be reported in the journal . the patients understand that their names and initials will not be published and due efforts will be made to conceal their identity , but anonymity can not be guaranteed .
nostril stenosis ( narrowing of the nasal inlet ) is an uncommon deformity which results in aesthetic and breathing discomfort in patients . 
 the literature review shows that trauma , infection , iatrogenic insults and congenital lesions are major causes of stenosis . 
 nowadays , rhinoplasty is one of most popular aesthetic surgeries which may have complications such as bleeding , swelling , bruising , asymmetry , obstruction of nasal airways . 
 we present a 30-year - old female patient , who complained about breathing and aesthetic difficulties due to external nasal valve obstruction and nasal deformity . past medical history showed that the patient had undergone three unsuccessful rhinoplasty surgeries with aesthetic goals .