Flat Nose & Notching Correction: Achieving Natural Harmony Through Closed Rhinoplasty

A flat nasal bridge combined with nostril notching and asymmetry is one of the more nuanced challenges in rhinoplasty. These three concerns — low projection, irregular nostril rim contour, and left-right imbalance — each require precise surgical judgment on their own. When they appear together, the approach must be carefully orchestrated so that every correction reinforces the others rather than creating new imbalances.

At Noselab Plastic Surgery, Dr. Chayoung Kang addresses this combination through closed rhinoplasty — a scarless, endonasal technique that allows for complete structural refinement without a visible columellar incision. This case study walks through the anatomy of the problem, the surgical strategy, and the outcome.

Understanding the Three Concerns

1. Flat Nasal Bridge (Low Dorsal Projection)

A flat or low dorsum is common across East Asian anatomical profiles. The underlying cause is typically a combination of low septal height, underdeveloped nasal bones, and a soft tissue envelope that lacks the structural scaffolding to project forward. The result is a nose that reads as wide and undifferentiated from the midface — lacking the visual definition that creates facial dimensionality.

Augmenting the dorsum must account for skin thickness, existing cartilage support, and the desired final tip position. An implant placed without adequate tip support will simply push the entire nose down over time, resulting in a drooping, unnatural appearance.

2. Nostril Notching

Nostril notching refers to an irregular concavity along the alar rim — the curved edge of the nostril. It appears as a visible dip or scalloping when viewed from the front or base, and can create the impression that the nostril is pinched or retracted. Notching may be congenital or a result of previous surgery where excess alar tissue was removed or alar cartilages were over-rotated.

Correcting a notch requires repositioning or augmenting the alar rim so that its curve becomes smooth and continuous. Depending on severity, this is achieved through alar rim grafts — thin strips of cartilage placed precisely along the rim to restore its natural arc.

3. Nostril Asymmetry

Perfect bilateral symmetry is rare in any facial feature, but when nostril asymmetry is noticeable — one nostril visibly higher, larger, or differently shaped than the other — it draws the eye and can undermine an otherwise successful rhinoplasty result. Asymmetry may originate in the alar cartilages themselves, the septum, or differences in soft tissue volume on each side.

Balancing asymmetry requires independent treatment of each side rather than a mirrored approach. What is done on the right may differ from what is done on the left in terms of graft placement, cartilage scoring, or suture tension.

Why Closed Rhinoplasty for This Combination?

Closed (endonasal) rhinoplasty means all incisions are placed entirely inside the nostrils. There is no external scar on the columella — the strip of skin between the nostrils — that is characteristic of open rhinoplasty. This distinction matters beyond aesthetics.

• Preserved blood supply: Because the columellar skin is not elevated, circulation to the nasal tip remains intact. This reduces swelling duration and lowers the risk of tip skin compromise.
• Faster recovery: Swelling resolves more quickly without the columellar disruption associated with open access. Most patients see 80–90% of their final result within 4–6 weeks.
• Natural movement: The nose moves and feels more natural postoperatively because the soft tissue has not been fully detached from the underlying framework.
• No external scar: In cases where the base of the nose is already being refined, avoiding an additional scar is a meaningful cosmetic benefit.

Closed rhinoplasty demands a higher level of tactile surgical skill — the surgeon works through a limited visual field and must rely on a precise mental model of the anatomy. Dr. Kang has specialized exclusively in closed rhinoplasty, accumulating the case volume and technique refinement that this approach requires.

Surgical Strategy: Layered Correction

Step 1 — Dorsal Augmentation

The foundation of this case is elevating dorsal projection to a height proportionate with the patient’s midface and desired tip position. For most patients, this involves placement of a silicone implant along the nasal bridge, selected and trimmed intraoperatively to match the patient’s anatomy precisely. The implant must sit flush against the nasal bones without rocking, and its distal end must stop short of the tip-defining point to avoid unnatural stiffness at the supratip.

When a patient’s own cartilage is preferred — or when previous surgery has altered the tissue environment — diced cartilage wrapped in fascia (the DCF technique) or a solid septal/rib cartilage dorsal graft may be used instead. Material selection is made on a case-by-case basis during consultation.

Step 2 — Tip Projection and Support

Increasing dorsal height without simultaneously addressing tip support will result in a relative loss of tip projection — the dorsum rises while the tip stays behind, creating a flat or even concave supratip. A columellar strut or septal extension graft is placed to anchor the tip cartilages, project the tip forward, and maintain the nasolabial angle. This structural foundation ensures the dorsal augmentation reads as elegant elevation rather than simple thickening.

Step 3 — Alar Rim Grafts for Notch Correction

Thin strips of septal cartilage — typically 1.5 to 2.5 mm wide and cut to the precise length required — are placed in pockets along the alar rim on the notched side. These grafts restore the smooth, uninterrupted arc of the nostril rim. Placement depth and graft stiffness are calibrated to produce a natural contour: firm enough to hold shape but not so rigid that the rim looks constructed.

Step 4 — Asymmetry Balancing

With the structural corrections in place, the final step is balancing the two sides. This may involve differential suture placement on the alar cartilages, additional small cartilage grafts on one side, or minor soft tissue adjustments. The goal is not mathematical symmetry but visual harmony — a nose that appears balanced and natural when viewed from all angles.

Recovery Timeline

Understanding what to expect during recovery helps patients plan appropriately and avoid unnecessary concern about normal postoperative changes.

Because closed rhinoplasty preserves the columellar skin bridge, swelling in this case series typically resolves faster than the open approach — most patients are comfortable returning to work within 7–10 days.

Result: Before and After

Following surgery, this patient achieved:

• A defined nasal bridge with natural-looking elevation proportionate to facial features
• Smooth, uninterrupted alar rim contours on both sides — the notching fully resolved
• Visually balanced nostrils with improved symmetry from all viewing angles
• A natural tip position that moves expressively and does not appear stiff or implanted
• No visible external scarring

The overall facial impression shifted from a flat midface with undefined features to a face with clear three-dimensional structure — a change that photographs strongly and reads as natural in person.

Is This Approach Right for You?

Candidates who typically benefit from this combined correction include patients who:

• Have low dorsal projection with minimal or moderate skin thickness
• Notice a visible concavity or irregularity along one or both alar rims
• Are bothered by an asymmetry in nostril size, shape, or height
• Prefer a closed technique to avoid external scarring
• Have realistic expectations and understand that final results mature over several months

Patients with very thick nasal skin, severe septal deviation, or significant prior rhinoplasty scarring may require a modified approach, which Dr. Kang will assess during consultation using both clinical examination and photographic analysis.

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