Rhinoplasty

Q: Dr. Eppley, I am interested in rhinoplasty surgery.There are two main things I would like to change about my nose, that you will see from these photos. I have a small bump on the bridge as my nose, but I also really want to change the tip of my nose. My nose isn’t too wide or anything, but the tip and the bump are my two biggest concerns. The tip is the part I am most worried about and have been hesitant about rhinoplasty in general for fear that it won’t look natural after surgery.

A: Here is some imaging for your rhinoplasty. Your rhinoplasty is not quite as simple as ‘just take away the bump and lift the tip’. One of the reasons you have a bump on the bridge of your nose is because you have a very low radix or frontonasal junction. (the area above your bridge) This is part of your overall more recessed mid facial development. The bump is actually a pseudohump. It appears to be a hump because the bone above it is deficient. Just taking down the bump will make your nose look too low in this area. While some hump reduction is needed, the area above the hump must be augmented with carriage grafts as well. (radix augmentation) Your nose is also long with a hanging columella. The end of the nasal septum must be shortened to allow for any tip rotation upward as well as retraction of the hanging columella. With the hump reduction the tip absolutely must be shortened and rotated upward otherwise your nose will look even longer.

Dr. Barry Eppley
Indianapolis, Indiana

Jaw Enhancement

Q: Dr. Eppley, I am interested in chin and jaw enhancement. I am reaching out to you after doing thorough research in hopes that you could bring some clarity to my concerns and harmony to my face. I am attaching pictures of me in different angles as well as pictures that I have edited with photoshop which reflect a look I would like to achieve. Whether that is possible or not, that is something I trust you with.

I am a female model currently living in Los Angeles. In this industry strong, defined bone structure such as jaw line and cheek bones are critical to a models success and highly sought after. As it stands I have a receding chin that I would like to correct and perhaps dramatize the look of my jaw. In your opinion, what does my face need in order to achieve a more defined look, like presented in the pictures? What are my options? As an out of town patient, planning a surgery requires more resources and time. I am looking forward to hearing your thoughts on improving my face as well as to get a general idea of the cost break down per procedure. Thank you in advance for taking the time to read my email, I greatly appreciate it. 

A: Thank you for your inquiry regarding jaw enhancement and sending your pictures. What separates your face from that of the model pictures you have shown are three facial features. The jawline (chin and jaw angles) and nose are the most strikingly different. Besides the shorter chin you have mentioned, your jaw angles are more rounded and indistinct. (unlike the models which are more square and defined) Such a more deficient jawline looks more so because of the size of your nose. (and vice versa)This can be treated by separate chin and jaw angles implants or a sliding genioplasty and jaw angle implants. Coming jawline augmentation with a rhinoplasty would make the most dramatic facial change that would enhance its overall features and bring them into better balance.

Dr. Barry Eppley

Indianapolis, Indiana

Facial Profile Enhancement

Q: Dr. Eppley,I am seeking a facial profile enhancement. I am not happy with the way my profile looks. I would like your recommendation. I have a deviated septum so a rhinoplasty at the same time might be possible? I also have an overbite and I was wondering what you would recommend for receding chin… orthodontics or cosmetic surgery.

A: It is very common to do a septoplasty and rhinoplasty at the same time, known as a septorhinoplasty. You do have a short chin and treating its deficiency combined with neck liposuction would provide the best result. With an existing overbite the question is how significant it is and whether you are prepared for the commitment of a combined orthodontic-jaw advancement surgery treatment program. (orthognathic surgery) If not then a chin implant or sliding genioplasty would be the cosmetic treatment options. A rhinoplasty, chin augmentation and neck liposuction could all be done at the same time for a significant facial profile change. (facial profile enhancement)

A combination of nose, chin and neck changes can make for the most powerful and significant change in one’s facial profile that is possible. It usually takes at least two changes in one’;s face to create the optimal facial profile enhancement.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty Planning

Q: Dr. Eppley, I have some questions about rhinoplasty and how it it planned and performed. How do cosmetic surgeons measure the profile of the face? From where to where? Is there a ratio that is considered perfect? Was it derived from the great medieval sculptors?

rhinoplasty measurements dr barry eppley indianapolisA: Contrary to popular perception, plastic surgeons do not use specific anthropometric measurements in planning and subsequently performing rhinoplasty surgery. While there are many known angle and measurements of the nose, and plastic surgeons are well aware of them, they are only roughly applied in performing the procedure. Surgeons use a gestalt about these anthropometric values and measurements rather than a precise application of them. Plastic surgeon may learn these measurements in their training or through experience but they do not use such precise measurements in surgery. This is because actual surgery does not translate well to afew millimeters or degrees of angulation.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, I originally sought rhinoplasty due to great discomfort concerning the projection of my nose.  The tip feels enlarged and out of proportion to the rest of my face as well as deviating to one side.  However, after speaking with a surgeon, I have come to learn that my jaw is retrusive which makes my nose look larger.  I would like to know whether or not you think I would benefit from both jaw and rhinoplasty surgery, or whether you think one or the other would be enough to balance my face.  I have attached some photographs in this email.

A: Thank you for sending your pictures. I think it is quite clear that in looking at them that the short chin/jaw is a far greater contributor to your profile concerns than that of the nose. Like many profile concerns, it is really a ratio of the nose:chin in looking at the deficiency and where the greatest improvement may come from what procedure. In your case I would put it at 80:20, jaw:chin. While chin augmentation will make a major difference, a rhinoplasty where the tip is thinned and a bit shortened will make for an even better result.

In many cases of rhinoplasty, the chin augmentation that may be done with it is complementary to the nose changes. But in your case it is the reverse…the rhinoplasty would be complementary to the chin augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, Two years ago, I had a septoplasty procedure with turbinate reduction due to a diagnosis of moderate sleep apnea. It turns out my septum was severely deviated, essentially blocking air at the back of one nostril. Shortly after surgery, I could breathe and smell things much better. Soon thereafter, everything has returned to pre-operative functionality, if not even worse. The surgeon I went to is an ENT physician, and refused to do rhinoplasty. I was advised by physicians later that a rhinoplasty procedure likely would have improved my nasal function significantly, simply by lifting the tip slightly. Would I be a candidate? I am concerned, because others have told me it’s a jaw issue and I would need orthognathic surgery.

A: The rhinoplasty procedure that you refer is two-fold and relates to the only two external (outer) nasal procedures that are known to improve nasal airway flow, spreader grafts of the middle vault and tip rotation. While both may be able to improve nasal airflow I would have no confidence that they would substantially improve sleep apnea. The only facial procedure that can reliably improve sleep apnea are jaw procedures that pull the face forward, particularly the lower jaw with the attachment of the base of the tongue, to open the posterior airway. But given the magnitude of orthognathic surgery it is understandable why other effort (nasal surgery) may be on interest to explore first.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, I have two questions about rhinoplasty. First, is there any leeway in the 7 day recovery time? And the second one is I have seen that if you have trouble breathing, insurance may pay for some of the procedure. Is that true? I ask because my nose is a little crooked to the right and I feel like there is a big difference between the left and right side as far as breathing goes.Thanks.

A: Depending upon how one chooses to define recovery, only the first phase of a rhinoplasty is done at one week after surgery. That is when the nasal tapes and splints are removed. But that is far from when one has a full recovery from the procedure. But that is certainly the most obvious appearance part of it due to the external nasal dressing.

If one has breathing problems in which deranged anatomy is evident in a CT scan, then a predetermination with your insurance can be filed to see if they will pay for the functional or breathing part of the surgery. An insurance predetermination can not be filed without a recent CT scan report. The purpose of a predetermination letter is to provide your health insurance carrier with the information so they can determine if you qualify. But insurance does not cover any part of a rhinoplasty that changes the external shape of the nose.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, I am interested in getting a rhinoplasty. I’m looking for mostly tip narrowing and some nostril narrowing for when I smile, and also don’t like how close the bottom of the nose is to my lip when I smile. I’m wondering what you suggest.

A: It is important to recognize that rhinoplasty, like almost every other facial plastic surgery operation, is a static and not a dynamic procedure. The rhinoplasty operation is designed to fix anatomic problems in the shape and function of the nose that exist when one’s face is at rest and not smiling. Thus your nasal tip can be significantly narrowed and shortened and the nostrils narrowed, and that will have some positive impact on the appearance of the nose when smiling, but not to the degree that you may ideally like. The distance between the base of your nose and upper lip when smiling is a dynamic one that rhinoplasty will not really improve per se. Lifting the nasal tip may provide some illusion that it is improved but not by actual measurements between the nose and lip. That area of improvement is not an achievable or expected outcome from any rhinoplasty surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, I am interested in a nasal hump reduction rhinoplasty. I have been looking into various options to achieve a straight nose in profile. As you’ll note from my photos this really is VERY minor – I’m under no illusion that this is not the case. Despite that I’m still very apprehensive about any work on the nose due to the complexity of it all and high revision rate. In particular I’m most concerned about affecting the nasofrontal angle negatively, and building up the bridge and radix too high whereby the eyes look closer together. The latter in particular is concerning as I’ll be having a midfacial operation that will widen the area even more. As such even a slight narrowing effect on the eyes could be exasperated later on with this next operation (infraorbital rim advancement).

As such, what would you recommend? As far as I can tell the position of my radix and nasofrontal angles are all relatively ideal. Would it be best then to shave down the dorsal hump? Or would building up the radix be ok given how minor it would be?

I look forward to your response.

A: My advice for you is not to have rhinoplasty surgery. The revision rate in rhinoplasty where patients have relatively major nasal shape issues is around 15%. When it comes to minor deformities the revision rate is higher…much higher. Contrary to popular perception, the smaller the nasal problem in many cases the harder it is to get it right. (perfect) The margin of error in minor aesthetic nose concerns is zero. It is just as easy to overcorrect in minor nasal shape issues as it is to get it perfect. By your own admission the position of the radix and nasofrontal angles is ideal and the hump is very minor. Be aware you will be scrutinizing the after surgery result just as carefully (if not more so) as the preoperative deformity. The chances of a successful outcome is no greater than an unsatisfactory one. Unfortunately rhinoplasty surgery is not a precise science and can not be controlled down to the level of a millimeter or two of structural changes.

In addition if you are going to being having infraorbital augmentation in the future, that facial change can potentially impact how you see other facial structures. Since that will be having a more major impact on your face I would defer any consideration of rhinoplasty until after that procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty

Q: Dr. Eppley, Thank you for your rhinoplasty consultation and doing some computer imaging for me. Now that I am moving forward with actual rhinoplasty surgery can you send me the exact prediction images of my nose results? That will help me understand what I can expect after surgery.

A: There is no such thing as ‘exact prediction images’ in rhinoplasty or any other facial surgery. Prediction imaging is done as a communication method between the surgeon and the patient to determine what changes the patient desires and to make sure what may be possible is in line with the location and extent of changes the patient wants. They should not be interpreted as exact replicas that surgery may achieve nor are they guarantees of the result that would be obtained. They are estimates as to what the surgeon believes may happen but can not take into account the exact anatomic changes they would be done nor the effects of healing on these surgical changes. Therefore one should appreciate the term ‘prediction images’ when it comes to this important presurgical step. Fortunately it is usually more accurate than predicting the weather but the accuracy of rhinoplasty prediction imaging depends on the surgeon doing it.

Dr. Barry Eppley

Indianapolis, Indiana