How Can My Midfacial Profile Be Improved?

Q: Dr. Eppley, Let me say right off the bat that I've had rhinoplasty 3 times. The first one, done in 1999, was kind of silly because the change was so minute that I felt I wasted my time and money. My complaint was that I wanted my bridge to be higher. The doctor took a bone off my hip, and placed it on top my nose. Basically it looked the same. Yet, I dealt with it and moved on but the feeling that the surgery was a failure never went away. I did a second rhinoplasty in 2005. The doctor placed Gortex on top my nose towards the bridge, which made my nose look a little dented in at the middle part of the nose. For a few years, I tried to convince myself of a positive change, but to no avail. Lastly, the third surgery was done in 2009 to address the dent. The surgery was successful in removing the slight dent but it didn't remove how I felt about my profile. All the doctors made conservative changes to my nose which I am fine with since my intention was not to change the racial characteristics of my nose. Again, I did it with the hope that it would improve my facial profile.

None of these surgeries addressed my main concern which is to make my profile at the midface less pushed in looking when I am expressive with my face. When I do this my profile looks ape-like, so I try not to make expressive facial profile which is really hard to do. It is not easy to walk around stoned face. I also had Invisilign work done last year. This was not done to correct crooked or misaligned teeth, as I have relatively straight teeth. It was to hopefully undo the imperfection I see in my profile while at the same time maintaining my facial identity. My teeth still flares out. The results were not a major difference from what I started with. So basically my teeth is the same way. The orthodontic treatment was done by filing in between the teeth to create space for the teeth to move back. I did this because I absolutely didn't want to loose four teeth to create space. I didn't see any noticeable change.

All the above doctors I visited were never aware of my underlining concern which is that I am not please with my profile because it make me look ape-like, due to how the mid part of my face is position with respect to the lower part, especially when I make facial expressions. This is not an easy issue for me to talk about so I kept it to myself instead of disclosing my feelings to the doctors. The orthodontist I visited last year told me that I have a large lower jaw and a smaller upper jaw which is the reason he was having trouble getting my teeth in the position he wanted, which was more vertical. Hence, the teeth moved backed, but not much. The change was so imperceptible (honestly I don't think It made any difference what so ever to my face) that no one ever commented to me of any change.

That is pretty much my situation in a nutshell. I am not happy with my profile, and as you would expect it is hurting my ability to live a happy, social life because of the way I feel about myself. I've attached pictures for you to look at. Pictures are of me after all procedures.

A: Thank you for sharing your surgical history, concerns and pictures. Your fundamental underlying problem is maxillary alveolar prognathism, which is common with your ethnicity. I am not surprised that orthodontics alone, of any form, did not improve that problem., It never had a chance to, its movements are too small for your problem. Ultimately you would have to have upper teeth extracted and the entire cant of the maxillary incisors brought back in to make a visible difference. Your rhinoplasty using a bone graft was a poor choice because that type of nasal augmentation will end up just resorbing, even if you get enough dorsal augmentation. A cartilage rib graft would have been much better. You had had three inadequate dorsal augmentation approaches because the materials and their volumes used were insufficient. You need a combined dorsal onlay with a columellar strut approach to get a much higher dorsal profile.

There are other midfacial procedures that can be used to help change your profile at rest or in expression but their effectiveness is uncertain. These include augmentations of the paranasal and cheek bones. And perhaps a good nasal augmentation with paranasal implant enhancement may be beneficial. I have attached a computer imaging prediction of that potential outcome.

Dr. Barry Eppley