Q: Dr. Eppley, I definitely want to remove my acne scars, but other than that, I’ve been given so many different suggestions, I’m not even sure anymore. For the acne scar laser resurfacing, I was told my skin type has a high chance of pigmentation. What are safe options? I do want a rhinoplasty, but I want it to be very subtle, and I’m mainly interested in fixing the tip that sort of goes down like a beak. How is this usually corrected? Also, you mentioned that it appears my buccal lobe was removed. Does this mean the maximum amount was taken out? I am now 2.5 weeks post op. Do you think my final results will give me the skeletonized appearance I desire? I still feel 2 grape sized bumps, hard as rock, when I push down on my cheeks.
A: What would structurally benefit your face is not a mystery and is very straightforward…it lies with your nose and chin. Your chin is very deficient, by at least 9mms, and is one feature that will keep your face from ever having a very defined and angular appearance., By using a sliding genioplasty to bring it forward it will improve your facial profile and help create a more defined appearance in the front view.
You have a very classic ethnic nose with a broad flat tip that has little support and no projection, hence a rounded tip that droops down. An open tip rhinoplasty will reshape the tip and give it a better profile and a more narrow appearance in the frontal view. You would also need some upper dorsal/radix augmentation.
Fractional laser resurfacing is the only type of acne laser resurfacing that you should have as this has a very low risk of any hypopigmentation problems. It will take more than one treatment and the best result you can hope for is about a 50% improvement in the appearance of your facial acne scarring.
It takes a full 3 months for the buccal space where the fat pads were removed to become soft and not feel as hard lumps, this is perfectly normal to feel what you are feeling at just 3 weeks after surgery.
Dr. Barry Eppley
Q: Dr. Eppley, I was told in a consultation with a local plastic surgeon that I needed cheek implants, chin reduction (just shaving the bone down and removing some fat/skin), and a little off the hump in my nose. That is the basis for my inquiry. Even though those were his suggestions, I still wanted to keep looking because I didn’t see that he had a very extensive client base where he had performed all of those at once…or more than one procedure at the same time.
I normally pose differently and make myself look better in pictures, but my profile is very flat in the cheek area and prominent in the chin. I’d like to get this corrected somehow, but I think with so many things to address at once, I get concerned that the surgery would be very noticeable and I would look like a different person all together…
A: In reviewing your pictures, I could make the following comments:
Your vertically long but non-projecting chin would be best treated by an extra oral vertical reduction ostectomy. (submental chin reduction) A burring technique would not remove nearly enough. You need at least 8mms or more off to really make a difference.
Your flat mid facial profile is ideally treated by a combination of paranasal and malar shell cheek implants. This will help pull out the entire midface. (both the nasal base and the cheeks)
You do have some significant facial asymmetry that actually affects the whole left side of the face. (which is shorter) The chin reduction will help with the lower facial asymmetry. The eye asymmetry, however, will not be improved.
One realization is that these changes will make a facial difference with much better balance…but it will likely be noticeable as your face gets vertically shorter and more horizontally projected.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in rhinoplasty surgery. As you can see from my attached pictures, I have a bulbous tip and a deviated septum. I hope to reduce the bulbous tip as well as straighten my nose. Can you please notify me if this can be done? Also from the pictures can you tell me whether or not I have thick nose skin? If I do have thick skin, will I still be able to reduce my bulbous tip and gain a more straighter profile on my nose?
A: I think you are an excellent candidate for rhinoplasty. You have a wide bulbous tip with played domes of the lower alar cartilages with intervening fat. But it should shape up nicely with an open rhinoplasty where the cartilages can be reshaped and brought together to create a much more narrow tip with more refined definition. I do not see that the thickness of your skin as being a limiting problem for getting a good rhinoplasty result. You have intermediate skin thickness which will shrink nicely when the underlying cartilages are reshaped.
Dr. Barry Eppley
Q: Dr. Eppley, I would like to know if the following facial surgery results are possible.
1) With a custom cheek/orbital implant can I augment all of the inferior, lateral, and superior orbital rims along with a small portion of the malar bone?
2) Can off-the-shelf jaw angle implants guarantee that my jaw angles will look more squared/pointed rather than U shaped and heavy?
3) With a rhinoplasty do you believe you can achieve an aesthetically pleasing nose job that keeps a lot of masculinity to my nose. (i.e., keeping a majority of the nasal bone projection and width while still projecting the tip out a slight bit and straightening the nasal bone and cartilage from a frontal view?
A: In answer to your questions:
- While any design can be made for custom cheek and orbital implants, there are limitations to the surgical access to place them. Through a lower eyelid incision, a custom implant can be placed to cover the inferior and lower lateral orbital rim and cheek, but not the upper lateral orbital rim or superior orbital rim. (those require a coronal scalp incision for placement)
- A preformed off-the-shelf jaw angle implant that I commonly use has a more flared and square jaw angle point to it that does not usually cause a rounded jaw angle look. (that patient undoubtably has the traditional rounded style of silicone jaw angle implant that is what is available to most surgeons)
- I believe your thinoplasty goals are achieveable as you have defined them and as we have looked at them with computer imaging in the past.
With that being said, let me make some general statements based on a lot of experience with male facial structural surgery. (of which all your procedures would qualify) It is important to understand that there are no guarantees in surgery. No surgeon can guarantee that any specific outcome will be obtained no matter how much thought goes into it beforehand. Aesthetic surgery involves risk of which the biggest one is less than the desired result. I mention this as you have used the term ‘guaranteed’, this is not an assurance I can give you. In the same vein, it is important to also understand that male facial restructuring is associated with a notoriously high rate of revisional surgery, probably approximating 25% to 33%. This is of paramount note in the young male patient who often is very difficult to please in their search for an optimal result. A good rule of thumb is that the patient will put twice the amount of time assessing their result after surgery than what they spent beforehand…hence leading to such high revisional rates. Slight asymmetries and imperfections are very poorly tolerated in the young male patient.
I mention these issues as you need to factor these considerations also into whether the facial surgeries we have discussed are for you, your expectations and your level of risk tolerance.
Dr. Barry Eppley
Q: Dr. Eppley, I was scheduled for a rhinoplasty but one week before the surgery I broke my leg playing basketball. I had it fixed and will be unable to to bear weight for another four weeks and therefore was unable to make my rhinoplasty surgery. I am still interested in doing the surgery as early as is possible. I have a follow up appointment for my broken leg this week so I should know more about the length of time I will be on crutches. I just wanted your input and opinion on what you think I should do next.
A: There are two schools of thought about any type of surgery while recovering from another surgery/injury. One approach is to wait until one is fully recovered and then do the elective surgery at a more convenient time. The other approach is to have the elective surgery while one is recovering from the first surgery or injury since one is laid up anyway. Which approach is better depends on the nature of the injury and what the elective surgery procedure is. When one is young and healthy, the recovery from one surgery (a broken leg) does not affect the healing of the subsequent surgery. (rhinoplasty)
Dr. Barry Eppley
Q: Dr. Eppley, how soon after having a rhinoplasty can I play basketball. I am having a rhinoplasty in two weeks and would like to be ready to play sports again in a month after surgery. Do you think this is possible or is it too early?
A: Whether one is having a more limited tip rhinoplasty or a more complete one with osteotomies, there are always important recovery issues of which patients are understandably concerned. One of these frequent recovery issues is that of physical activity. When thinking about physical activity after rhinoplasty there are issues of being able to breathe comfortably through the nose (for exercise) and the risk of trauma to the newly reshaped nose. (participating in sports) It would be fair to say that participating in sports will be delayed longer than just non-contact exercise so let’s focus just on that issue.
The bone and cartilage of the nose takes months to heal after a rhinoplasty and that could be anywhere between three and six months after surgery. So yo can see that is a long time and many people simply aren’t going to wait that long. Thus it is all about assessing the risks of being hit in the nose based on the activity being done. If you are just shooting a basketball by itself, then three to four weeks afterwards should be fine. But if you are playing in a team situation where contact my be likely, it is all a gamble for many months after surgery. Getting hit in the nose within three to six months after a rhinoplasty will likely cause undesirable changes so that is a risk you will have to determine if it is worth it.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a rhinoplasty that changes the upper part of my nose. The lower half of my nose is fine but I have a large nasal hump and would like to get it reduced. In playing with some online imaging programs, I have noticed that removing the nasal hump actually looks worse in my opinion of the nasal radix is not also reduced. If the radix is not reduced it makes my nose and forehead appear as one with a sloped straight line, making more forehead looking like ‘volvo windshield’ in a profile view. If I am not given more of an obvious nasofrontal angle, my forehead will look weak Getting a good nasofrontal angle is the most important point of a rhinoplasty to me. How can this be effectively be done?
A: One of the more obscure aspects of rhinoplasty surgery is radix reduction. Radix augmentation is more common in many hump reductions. But in very large hump reduction in which the nasal bones are high and extend into the glabellar region of the forehead, radix reduction may be needed. In looking at your pictures your assessment is correct, a break between the forehead and your nose is needed to avoid a complete connected slope effect of the forehead down through the nose. Significant radix reduction as part of a rhinoplasty can be done by one of two methods; a guarded rotary burr or a percutaneous osteotomy method. Having done both, I find the osteotome method to work well when a really deep notching of the frontonasal angle needs to be done. This is done by using a 2mm osteotomy placed through the skin at the bridge of the nose creating one bone cut into the frontnasal angle, The other osteotome cut is done from inside the nose to complete the 90 degree angle creation.
Dr. Barry Eppley
Q: Dr. Eppley, I am looking for a rhinoplasty that can get my nostril size reduced. I would like to reduce how much of my nostrils you can see from a front profile ( basically bring the front of my nose down). Lastly I don’t like how you can see in my nostrils from the side profile. Does this all seem possible?
A: From a rhinoplasty standpoint, the size of one’s nostril’s is controlled by several anatomic factors. These include the length of the lower alar cartilages, the amount of caudal septal support, the angulation of the lower alar cartilages away from the dome and the width of the nostril base. When looking at your nose, the main reason you have a lot of nostril show is that the length of your nose is short making the tip of your nose rotated upwards. (which is why there is excessive nostril show in the front view) In addition, you have alar rim retraction with a bowed rather than straight alar edge. (which is why these is too much nostril show in the side view)
To increase your nasal length and decrease nostril show, your rhinoplasty must have increased structural support. This is done through cartilage grafts, harvested from the septum or ears, placed to push the tip of the nose down (septal extension graft) as well as along the edge of the lower alar cartilages. (alar rim grafts) You may also benefit from nostril narrowing as well but that can only be determined by a front view picture which you did not provide. I have attached some imaging to show what this type of rhinoplasty can do.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a rhinoplasty to permanently build up my radix. I had some fillers placed in my radix and glabella a few months back, and I really liked the augmentation. Anyway, I’m intending to get a rhinoplasty to augment these areas permanently next year. As such, I was wondering if it were possible to do so and if so, what kind of material will be used? I understand that rib grafts are used for the bridge, but can it also be used for the radix/glabella? Secondly, I’m hoping to get a touch up with some fillers some time in December. Will it be fine for me to do so, or will repeated treatments of dermal fillers complicate the rhinoplasty?
A: A radix augmentation rhinoplasty can use either autogenous or synthetic materials. But, in my opinion, cartilage grafts are the best material to use for radix augmentation. They will hold up for the rest of your life without any risks of complications. The size of the radix defect and the volume needed will determine where the cartilage should come from. (i.e., donor site) While rib cartilage is always ideal in terms of unlimited volume, most radix augmentations can be done with septal or ear cartilage the vast majority of time. There is no problem with getting fillers again next month. It does not complicate placing a radix cartilage graft later.
Dr. Barry Eppley
Q: Dr. Eppley, I’m an Asian American and I’ve been thinking of a few cosmetic procedures to enhance my flat face and that is rhinoplasty and midface augmentation.I’ve decided to go with the midface first. Being that, I’d like to know your inputs on the area of my midface that needs to be augmented for a more chiselled, three-dimensional look. I know that there a few parts to the midface – premaxillary and maxillary area for the anterior cheek ( I may be wrong on that ). So with that being said, what would you say about having both paranasal and malar implants done together? (for the case that I may need both) Would that cause a great incremental change in my facial projection compared to just one procedure done?
A: In looking at your face, which is not atypical for many Asian males, you might consider a somewhat different approach. The best procedures for ‘pulling your face out’ (increasing midfacial projection is a rhinoplasty combinjed with paranasal implants. It is very difficult to give much definition to broad wide cheeks without burying the rest of the midface behind them. (making the nose look even smaller) Look at the imaging I have attached to see what effect is created by initially pulling the nose and its base out. With your specific facial shape, this is where the real value is in any plastic surgery for you. The cheeks can be enhanced by probably not in the ideal chiselled fashion that you seek, I don’t think that is realistic for your face.
Dr. Barry Eppley