Will Nano Fat Grafting Help With Scar Contracture?

Q: Dr. Eppley, i am interested in nano fat grafting.  I have heard that fat is beneficial to scar contracture but also I am aware that fat won’t survive in a scar bed and I could wind up with lumps. That is why I thought that the nanofat probably won’t do any harm and may even help. The side of my nose that has a depression or drop off angle is the area with the scar tissue build up. The tissue is parchment thin there. I would like to fill this area with an autologous material. I had surgery  3 years ago to revise a rib graft  done nearly 6 years ago which left me with unatural harsh drop offs on either side of my bridge. I already had restylane done last year and it lumped up on me and caused too much pressure in my nose. I have also been considering trying belotero filler, Would you have any suggestions?

A: While I think nano fat grafting would not hurt, I don’t think it will produce any positive benefits in terms of filling in skin depressions or rib graft step off areas. This all would be better served to be filled with alloderm (allogeneic) dermal grafts.

There is a difference between scar tissue build-up (contracture) and trying to make the skin thicker or fill in contour depression areas. If the rib graft not has sharp edges or visible stepoffs,, adding a layer of alloderm or been temporalis fascia would be the more assured way of improving the soft tissue cover.

 

Dr. Barry Eppley

Indianapolis, Indiana

Will A Rhinoplasty Revision Give Me A Small Cute Nose?

Q: Dr. Eppley, I am interested in a rhinoplasty revision.I had my nose done twenty years ago. I have a boxy tip and I would like to shorten my nose . My nostrils are big and long. I want them short and round. I want a cute small shorter nose. I’m wondering if there is hope for me. Thank you.

A: When it comes to a rhinoplasty revision, there is always hope. The key to achieving a shorter or smaller nose, in just about any patient, is the thickness of the overlying skin. When the cartilaginous portion of the nose is reduced, particularly the tip, the overlying tip skin must shrink down to reveal the reduced length of the tip cartilages and the greater narrowness of the dome cartilages that has been created. In a thin-skinned patient, such as yourself, this is most likely to occur. In thicker-skinned noses the thickness of the skin often does not reveal the new cartilage shape very well as it may actually become thicker as it contracts, failing to show the details of what was done underneath it.

When the nasal tip length shortens, the shape of the nostrils will change somewhat. Instead of oblong vertically oriented nostrils, they will be shorter in length and somewhat rounder in shape.

Whether any of these rhinoplasty revision changes will create your ideal shorter nose is a matter of personal opinion, but it is fair to say that it will be closer to your nose shape goals that before. You do have the best nasal skin to make that possible.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Breathing Difficulties From My Rhinoplasty Be Improved?

Q: Dr. Eppley, I had a minor rhinoplasty (for instance family and friends did not notice) three years ago.  I am happy with the result, but I cannot breathe at all out of the left nostril.  I believe it is nasal alar valve collapse.  I have to wear breathe right strips at night, and I have a product called Breathe With Eez – a small nasal expander that is a tiny stainless steel thing that I insert.  I have to use this constantly – needless to say, this is uncomfortable and inconvenient.  I cannot breathe well out of the right side either, but the left is much worse.  I do not want to alter the shape of my nose at all because I am very happy with the outcome aesthetically, but I need to be able to breathe.  When I told my surgeon, he told me that he could not believe I would complain because most people would just be happy to have such a nice looking result.  When I complained that he is an ENT and I can no longer breathe out of my nose correctly, he told me he could try and fix it but it would leave scars on my face (he would go through the undereye area)…he treated me like I was crazy to expect to be able to breathe right again, and I did not trust him, so I did not go back for this operation – he explained it in a manner that made it sound terrifying. I would like to discuss possibilities on how to remedy my poor breathing problem.

A: Nasal breathing difficulties after rhinoplasty are not historically rare, particularly when significant tip narrowing modifications are done. If not enough support is left to the lower alar cartilages, they can become weak and bow inward causing internal nasal valve collapse. This problem can be modified if there is also middle vault collapse from a profile reduction as well. While an examination would have to be done to be certain as to the exact reason for your breathing difficulty, there are some standard manuevers for secondary rhinoplasty improvement. These include alar batten grafts to stiffen up the bowed lower alar cartilage on the affected side as well as spreader grafts to the middle vault. These cartilage grafts may have some slight effect on your current aesthetic result but should be relatively minor.

Dr. Barry Eppley

Indianapolis, Indiana

 

Can My Thick Nose Be Made Into A Thinner European Nose?

Q: Dr. Eppley, I am seeking revisional rhinoplasty. I have had two prior procedures in 2001 and 2007. I am seeking to make the following changes to my nose. First I want to eliminate the ethnicity of my Middle Eastern nose. I am seeking a more European looking nasal appearance with significant improvement in the nasal tip and narrowing of the nostrils with less nostril show. Second, my septum as a result of my last rhinoplasty is slightly off midline with a deviation to the left. This will need correction. Cartilage from the right ear was used to support my tip in the past. My left ear is intact and can be uaed for further reconstruction. Lastly, my columella requires shortening without flattening my nose. Thank you for your kind assistance.

A: Thank you for sending your pictures. Based on your two prior surgeries (which appear to have been done via closed rhinoplasty ??) and the thickness of your nasal skin, any tertiary rhinoplasty is challenging in terms of achieving your goals. Your skin thickness makes it impossible to truly have a classic European nose which is more thin-skinned. As you experienced, removing cartilaginous structure underneath is not a guarantee that it will be well reflected on the outside. While you have room for some improvement, I am not optimistic that it can ever achieve the degree of tip narrowing and refinement that you desire. The purpose of your ear cartilage graft used in the past is mysterious to me as such tip grafting will only cause it to become thicker not thinner. Columellar shortening is not possible without causing a downward tip pull and is almost never done anyway except in cases of large projecting nose reductions.

While I think certain features of your nose can be improved (septal straightening, some limited tip narrowing) I have concerns about achieving your goals in a nose that is already scarred and grafted.

Dr. Barry Eppley

Indianapolis, Indiana

 

How Soon After A Rhinoplasty Revision With A Rib Graft Can I Have The Graft Removed or Modified?

Q: Dr. Eppley, I am a revision rhinoplasty patient.I had a rhinoplasty rib surgery done 4 weeks ago. My bridge is too high. I did not know I would have a graft go up so far between my eyes. My tip is pointy. My nose was botched by the primary surgeon who did not listen to my minor adjustments requests. I had a straight bridge, and a normal round tip. He made my bridge crooked zig zag and my tip turned up and triangle shaped.I went a year looking like that. I do not want to look like this for a year. Is there anything that can be done. I want the tip collumella part just taken out. It is too long and pointed.It is rib cartilage, it will not change with time.The bridge all the way up makes me look terrible, and my eyes look different. I spent so much money on all of this, what is your suggestion?

A: I am sorry to hear of your current concerns. While swelling undoubtably still exists at this early time after your rhinoplasty revision, your concerns about being too high in the radix area of the bridge and too long and pointy in the tip may well not change appreciably given those locations and dimensional concerns. The first step is to revisit your plastic surgeon and get their take on it. Of course, you are going to be told that swelling is still there and to wait. But if you don’t want to then I would express that clearly and see what you can work out. They either will agree to do it or they won’t. If they won’t despite your insistence, I would give it  up to three months after surgery and see if your feelings about it have changed. If not, they revisit the surgeon and if you can’t come to an agreeable plan then it is time to seek out another surgeon. There are some benefits to waiting even when a revision is known to give some swelling and inflammation time to settle down.

While the rib graft may have been perfectly appropriate, like all implants, it is easy to get a result that looks oversized or is ‘too much of a good thing’. There is a fine line in a rhinoplasty sometimes between a good augmented result and one that is too big.

Dr. Barry Eppley

Indianapolis, Indiana

 

Can My Nose Be Fixed After A Disastrous Closed Rhinoplasty Result?

Q: Dr. Eppley, I am very unhappy with the result of a rhinoplasty that I had done two years ago. It was a closed rhinoplasty and I wanted to have a more refined and pretty nasal tip. It has ended up, however, being just a balled up fat tip with nostrils that now look bigger. What type of rhinoplasty do I need now to fix it? And can it be fixed?

A: Thank you for sending your pictures. What appears to have happened is that you have lost cartilaginous support of the tip due to overresection of the lower alar cartilages and the caudal end of the septum. The thick overlying tip skin has now just contracted inward without adequate support, resulting in a ball-like tip with excessive nostril show. Your nasal problem most definitely can not be fixed by any closed rhinoplasty method. It will need a rhinoplasty revision using an open approach and cartilage grafting to restore support for the tip to create a more natural shape and decrease nostril show. You will need a columellar strut graft and alar rim grafts to help correct the retraction as well as tip reshaping. These type grafts are best placed through an open rhinoplasty, particularly in the face of a nose that has scar from prior surgery. Presumably these cartilages grafts can be harvested from the septum and the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Can The Tip Of My Nose Be Revised Through A Closed Rhinoplasty?

Q:  Dr. Eppley, I have a problem from a previous closed rhinoplasty. I am very unhappy with the tip of my nose. It has been lifted too high and this has exposed my nostrils unfavorably. It also makes my face look flat. What I want is correction through a closed rhinoplasty. Will that work for me and my nose problem?

A: When the nasal tip becomes too shortened after a rhinoplasty,  it will produce a set of classic aesthetic issues including an obstuse nasolabial angle with excessive nostril exposure. It can be corrected through tip lengthening/de-rotation through cartilage grafting. This is not best done through a closed rhinoplasty. The grafts would be hard to place and secure through such limited visualization. An open rhinoplasty would provide much better exposure to accurate place tip grafts and/or septal extension grafts to create a de-rotation effect. The one exception to this approach is if the amount of tip lengthening needed is small. Then the placement of limited tip grafting could be done through a closed approach. I would need to see photos of your nose to determine which rhinoplasty approach may work for your revisional surgery. The only question I would ask is what is the basis for your deference to an open rhinoplasty? The scar is inconsequential and the results are more consistent and superior.

Dr.  Barry Eppley

Indianapolis, Indiana

Can The Changes Done In My Rhinoplasty Be Reversed?

Q: Dr. Eppley, I had a septorhinoplasty done late last year and I just don’t like the way it looks now. I didn’t know that my bridge would be built up to be higher and more prominent. I went in to just have a septoplasty to try and help me breathe better. The doctor suggested that my bridge be changed and the tip narrowed a bit, both changes which I now regret. I used to have a nice slope to my nose before and it looks so different that the bridge is so high. Do you think this could be just swelling? Is there any way to reverse these nose changes?

A: It is extremely common for the outer appearance of the nose to be changed at the same time that the internal breathing function (septoplasty and turbinates) is being improved. While plastic surgeons may suggest these changes in the patient who just appears for breathing problems, such recommendations are often welcomed very enthusiastically. The convenience of having both nose issues addressed simultaneously is obviously appealing…provided that one does have some real concerns about their nose appearance and they are very clear on what is going to be done. It appears you now have some early ‘buyer’s remorse’. This could be premature regret since it has only been a few months from surgery and swelling is most certainly present. It may also be that you did not have a clear understanding of what the objectives of the rhinoplasty were. This could have been avoided by computer imaging analysis before surgery. While you may have a rhinoplasty revision to try and reverse some of these changes,it is too early to consider that now. You should give your nose up to a full year after surgery for all swelling to go away and you to adapt to the new look. It could very be how you feel now may change at this time next year.

Dr. Barry Eppley

Indianapolis, Indiana

 

Can A Hanging Columella Be Corrected?

Q: Dr. Eppley, I had a combined rhinoplasty and sinus surgery nearly three years ago. The rhinoplasty result turned out to not be so good as the middle part of my nose was too pinched inward. I then underwent a revision about a year ago where cartilage was taken from ear to build up the middle part of my nose. I am still left with one problem that has not been corrected. I have a hanging columella with a slight outward rotation of the cartilage. Is it repairable? What is the cost and since my previous surgery was covered by insurance would the revision be as well?

 A: A hanging columella deformity can occur for two reasons. The underlying caudal end of the septal cartilage may have been adequately reduced or overresected, leaving excess mucosa and skin ‘hanging’ off the cartilage. This usually leaves an outward curve of soft tissue from below the tip down to the base of the nose. The other type of hanging columella, which is not a true columella deformity but may initially appear so, is when the infratip lobular cartilage is too prominent and pushes outward on the columellar skin. This creates more of a ‘hard’ hanging columella because it is composed of cartilage.

Either way, both types of hanging columellas can be corrected fairly easily a minor revisional rhinoplasty procedure.. This type of nasal problem would not be covered by insurance as it is a cosmetic problem, regardless if the original nose procedure was covered by insurance. The cost would be influenced as to whether it is done in the office under local anesthesia or in the operating room under some form of anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

What Is The Best Way To Revise A Medpor Nasal Implant?

Q: Dr. Eppley, I had a revision rhinoplasty about ten years ago. I had a Medpor nasal shell put in. It was a thicker shell which augmented my nose too much in width, but I’ve always liked the right side and the profile is good. However, the left side is too bulbous and makes my nose look too big. I have talked to two rhinoplasty surgeons who have given different opinions although both are very confident about working with Medpor. One suggests removing the shell and replacing it with a smaller implant or a rib graft. The other said to leave the implant in and just carve into it on the left side and make it smaller. What’s your opinion? What do you think will yield the best results, but also be the safest in preventing infection and is less intrusive?

A: The concept of narrowing your existing implant rather than replacing it with a new implant or a rib graft is a sound one to me. If you like most of what you have in place and just need a little tweaking of it, then you should just modify the existing implant. Doing so also has the advantage that it is really what I call an ‘autoimplant’ at this point. It is part implant and part autogenous since you have tissue ingrowth into it. I would also contend that using the existing implant has less of an infection risk than placing a new one, since the ability to get it inoculated with bacteria into its porous structure is less due to the existing tissue ingrowth.

Whether you carve it in place or take it out to reshape the existing implant is matter of nuances. Either way you have to do a complete dissection over the top and both sides of the implant. Even for in situ carving, you need the space to work. The only difference is that in removal you have to release it underneath from the  cartilage-bony framework. Based on my experience, I could not tell you until I was in there which way I would do it. If I had good access with it in place, I would carve it down without removing it. If I could not get a space to work and was concerned about the overlying skin, then I would remove it, carve it down and re-insert. I don’t think any surgeon can tell you which exact method is best until they are in there. What matters is which way will give the best rhinoplasty revision result and not injure the overlying skin cover.

I have never found Medpor implants hard to remove. Surgeons say it is hard because they have never done it or are comparing it to silicone implants which slide out quite easily. Medpor implants require more care and finesse in their removal to not injure surrounding tissues but they can be removed even though they are more adherent to the tissues.

Dr. Barry Eppley

Indianapolis, Indiana