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Inverted-V deformity

An inverted-V is a visible shadow across the middle of the nose, shaped like an upside-down V, where the lower edge of the nasal bones stands proud of the cartilage that should have been supported under it. It is what a middle vault does months after a hump is removed and the roof is not rebuilt, and the operation that exists to prevent it is the spreader graft.

What repeats

Four findings that hold across the literature.

It is a late sign of an unsupported middle vault

Removing an osseocartilaginous hump separates the upper lateral cartilages from the septum and leaves an open roof. Unsupported, those cartilages fall inward over months as swelling resolves, and the step at the end of the nasal bones becomes visible. The review of over-resection sequelae lists it beside saddle nose, polly-beak, alar retraction and the pinched tip as a standing consequence of taking too much.

Rests on: Moritz et al., when reductive rhinoplasty goes wrong · Rohrich et al., component dorsal hump reduction.

The spreader graft exists because of it

Sheen's 1984 paper is titled for the problem: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. A strip of septal cartilage, roughly 1 to 2 mm wide and 3 to 4 mm high, is set between the septum and the upper lateral cartilage on each side to hold the angle open and the width even. Forty years on it is still the reference operation.

Rests on: Sheen, the spreader graft · and the dorsum and the hump.

Prevention is the whole argument

The component technique is built around not creating the problem: separate the upper lateral cartilages from the septum deliberately, reduce cartilage and bone independently, and rebuild the roof before closing. Placed prophylactically in cosmetic primaries, autospreader flaps, the upper lateral cartilage folded inward instead of a separate graft, held nasal width at one year, a 1 mm increase that was not significant, while preserving breathing scores.

Rests on: Rohrich et al. · Jabbour et al., prophylactic autospreader flaps.

Not opening the roof avoids it entirely

Dorsal preservation lowers the intact roof from underneath, so the keystone stays joined and there is no open roof to close. Avoiding the inverted-V is named as one of its attractions in the comparative work; what preservation trades for it is its own failure mode, the hump returning.

Rests on: McCleary et al., preservation against open structural · and preservation rhinoplasty.

By what it takes to fix it

The correction depends on what is left under the skin.

Cartilage still there, just unsupported

The straightforward case: spreader grafts placed at a second operation restore the roof and the dorsal aesthetic lines. Septal cartilage if any remains, ear or rib if not.

Rests on: Sheen · and rib cartilage grafts.

Cartilage collapsed and scarred

Where the upper laterals have folded and healed inward, they are released and held out, and the gap is filled, extended spreader grafts, or a graft plus camouflage under thin skin.

Rests on: Moritz et al. · and revision rhinoplasty.

Soft-tissue collapse with a breathing complaint

Where the problem is the sidewall falling in rather than the framework, an absorbable lateral nasal wall implant has been used in revision functional cases, with patient-reported obstruction scores as the endpoint. It is a small, single-centre series.

Rests on: Seyidova et al., nasal wall implant in revision · and the septum and the airway.

Thin skin over any of it

Thin skin shows a graft edge, so the same construction that works under thick skin needs camouflage (perichondrium, fascia or diced cartilage) over it.

Rests on: rib cartilage grafts.

What to ask about an inverted-V

Questions the evidence supports asking.

Is this the bone edge or collapsed cartilage?

They look similar in a photograph and need different operations: narrowing or rasping the bony edge, against rebuilding the cartilage roof under it. The examination and the palpation decide it.

Was the middle vault rebuilt at my first operation?

If spreader grafts or autospreaders were placed and it still happened, the second operation is different from one where the roof was never closed. Ask for the operative note.

Rests on: Rohrich et al..

How long after surgery does it appear?

It is a late sign: the cartilages settle inward as swelling resolves, which is why it shows up months out rather than in the first weeks. That timing is also why nothing is done about it early.

Rests on: recovery.

Will fixing it change my breathing?

The middle vault is the roof over the internal valve, the narrowest part of the airway. Rebuilding it is a functional operation as much as an aesthetic one, and the prophylactic-autospreader data are reported on breathing scores as well as width.

Rests on: Jabbour et al. · and the septum and the airway.

The terms, defined

The words used about this deformity.

  • Inverted-V deformity: the V-shaped shadow where the caudal edge of the nasal bones stands proud of collapsed upper lateral cartilages. [40199493]
  • Middle vault (midvault): the upper lateral cartilages and the septum between them; the roof over the internal valve. [15457053]
  • Open-roof deformity: the flat gap left between the nasal bones after a hump is removed and not closed; the inverted-V is what it becomes once the cartilage falls in. [15457053]
  • Spreader graft: a strip of cartilage set between septum and upper lateral cartilage to hold the middle vault open. [6695022]
  • Autospreader (spreader flap): the upper lateral cartilage folded inward and fixed, instead of a separate graft. [42415377]
  • Keystone area: where nasal bone, upper lateral cartilage and septum meet; preservation keeps it joined and so never opens the roof. [40331571]
  • Dorsal aesthetic lines: the paired highlight lines from brow to tip; what the inverted-V interrupts. [15457053]

Where else this is documented

Sources outside the journals, each one free to read.

The national guideline

The American Academy of Otolaryngology publishes a clinical practice guideline on nasal form and function after rhinoplasty, with a plain language summary written for patients. The middle vault is the roof over the internal valve, so the guideline covers both halves of this problem, the profile and the airway.

Rests on: the clinical practice guideline · the plain language summary.

The surgeons' own textbook chapters

Rhinoplasty Archive, the free online rhinoplasty textbook edited by Daniel G. Becker, carries chapters on the middle vault, on spreader grafts placed through an endonasal approach, and on the hump reduction that creates the open roof. They are written for surgeons.

The reference summary

Rhinoplasty in StatPearls, on the National Library of Medicine's Bookshelf, gives the anatomy of the middle vault and the complication list in full text at no charge.

The regulator

The absorbable lateral nasal wall implant is a manufactured device, so its clearance and its labelling sit with the US Food and Drug Administration rather than in the journals. Clearances are searchable by device name and by maker.

What is not settled

  • No trial tests whether prophylactic autospreaders prevent the deformity they are placed to prevent. The cohort that reports them measures width and function, not incidence. [42415377]
  • The incidence itself is unreported. Every source describes the deformity as common after unsupported hump reduction; nobody has counted it prospectively.
  • Whether preservation's avoidance of the open roof translates into fewer inverted-V deformities at five years is untested, the comparative literature stops at twelve months. [40331571]
  • The nasal wall implant for soft-tissue collapse rests on one small revision series with patient-reported outcomes only. [32766052]

Written by rhinoplasty.cc from the sources linked above, 2026-09-09.

Who publishes on revision and secondary rhinoplasty

Ranked surgeons with papers under this topic in the archive, most first.

Rod J. Rohrich (8) · Dean M. Toriumi (7) · Samuel Lin (5) · Richard E. Davis (4) · Sam P. Most (4) · Michael Lee (3) · Paul Nassif (2) · Angela Sturm (1) · Anil Shah (1) · Anita Patel (1)

The literature: Revision and secondary rhinoplasty, 181 papers. Video: Revision and secondary, 322 videos. Every technique.