Q: Dr. Eppley, I am looking for a doctor that has done brow bone augmentation. I came across Dr. Eppley and am considering both rhinoplasty and brow bone augmentation to improve my profile view. I want my forehead to come out further, as of right now my eyes are flush with my forehead and it’s very flat. I want more dimension in my face. I wanted to know what you would recommend and how confident yo are with Asian rhinoplasty. Thanks!
A: Thank you for your inquiry and sending your pictures. I have done many Asian forehead and brow augmentation and rhinoplasty procedures. The key question for both procedures are the materials to do them. In the forehead you have the option of either bone cement application through a near complete coronal incision or a custom forehead/brow bone implant placed through a smaller scalp incision. For the rhinoplasty, one of its key elements is the augmentation of the nasal bridge. This can be done using either a cartilage rib graft or a silicone nasal implant.
The use of these various materials for both forehead and brow bone augmentation and rhinoplasty affects numerous aspects of the procedures including cost and recovery. I would need further input from you on these choices.
Dr. Barry Eppley
Q: Dr. Eppley, I am seeking an Asian rhinoplasty. I want the maximal amount of nasal tip projection and thinning that can be achieved. What can be done to give the nose these tip changes and want can I realistically expect if I do them?
A: In every single case of an Asian rhinoplasty that I have ever done, improved tip projection and shape is always a primary aesthetic goal. There is a limit, however, as to how much nasal tip definition can be achieved based on the thickness of one’s skin. The most nasal tip definition can only be achieved by the combination of a columellar strut, lower alar cartilage dome narrowing and stacked shield grafts on top of it. (if using rib it would be an L-shaped construct) In every case of an Asian rhinoplasty that I have done this i always the objective and the maximum tip lengthening procedures are done to achieve it. The only caveat I would add is that the amount of tip projection created can not cause some much pressure on the tip skin that it blanches it on closure. This will set up the potential tip skin necrosis.
Whether this approach can achieve what you are expecting is a bit of an unknown as you can not simply make ay Asian nose as long or as thin as some patients would like.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I am a 32 year-old Asian woman that has a bad nose problem now. I had a silicone implant rhinoplasty done severn years ago. It looked good and was fine until about six months ago when my nose got really red and the implant got infected for no apparent reason. It had to be removed.:( Now my nose is sunken in and the tip is really short, it looks worse now than beforeI had the implant put in. Based on what I have read, it appears that a cartilage graft from the rib would be needed to get my nose back to the way I want it to look.
A: A rib graft rhinoplasty is the best choice for you now without question. The short nose of Asians can pose a real challenge when complications have occurred from a prior rhinoplasty. Unlike Caucasians rhinoplasty problems which are often the result of too much supportive cartilage removal, revisional Asian rhinoplasty problems result from augmentation problems from implants or grafts. When nasal implants get removed due to either infection or skin thinning, scar contracture will cause the tip to rotate upward as well as lower the height of the bridge due to the implant removal. This accentuates the naturally short nose of most Asians not to mention the scar tissue that has been created.
How effectively the Asian nose can be effectively built back up and lengthened is the result the result of the cartilage donor source. (an implant is obviously not a good choice when a prior implant has had to be removed) The amount of cartilage then controls what type of structural support and lengthening manuevers can be done. Rib grafts provide the most amount of cartilage one can use allows long straight grafts to be made for septal extension, columellar strut and extended spreader grafts as well as dorsal onlay grafts. No amount of tip or dorsal grafting from the ear or septum can produce the effects of what a rib graft can provide.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in Asian rhinoplasty. May I know what charges and how much time will be spend on it. And what is best option for Asian rhinoplasty, cartilage graft or something else.
A: Thank you for your inquiry. The first place to start is to see some pictures of you and see what your goals are. Even though I likely know what they are, I would like to hear your nasal goals. Secondly, since almost every Asian rhinoplasty involves either dorsal or dorso-columelar augmentation, one has to decide whether one wants it done by cartilage grafting or a synthetic implant. There are advantages and disadvantages with both approaches and that choice significantly affects the time of surgery, cost and recovery. Although an implant rhinoplasty is relatively easy to go, has a lower cost and a very short recovery, the use of an implant in the nose has a significant incidence of long-term complications including infection, thinning of the overlying skin and implant extrusion. A rib graft in the nose requires more skill to perform, involves a donor site, costs more and has a longer recovery. But once healed, rib grafts become a permanent and natural part of the nose. From my perspective a rib cartilage graft rhinoplasty is always better in the long run but it is involves a bigger commitment up front.
Dr. Barry Eppley
Q: Dr. Eppley, I am looking for a nicer more natural-looking side profile. I saw a before and after picture of a hispanic lady you did and like the result. I’m considering the following surgeries – brow bone augmentation, forehead augmentation and nasal bridge augmentation (higher nose bridge) to go with the newly adjusted brow bone.
I have a few questions…
1) Have you done this procedure on Asians before? If yes, mind sending me some before and after pictures?
2) How often do you do brow bone surgeries? I’ve done some research online and it seem that you’re the only surgeon that specializes in this.
3) How much are the costs to have the above surgeries?
4) What are some of the side effects/worst case scenarios?
5) Would you say I have protrusive eyes? I feel like there’s still some fat/excessive skin after eyelid surgery and my brows are too close to my eyelid.
Would also like to hear your recommendations.
A: In answer to your questions:
1) Augmenting the forehead and nose to improve the profile is most commonly done in the Asian patient in my experience. They make up nearly half of all forehead augmentation patients in my practice. Building up the forehead with PMMA is the typical approach due to the volume of material needed. The end goal is to have a rounder forehead that eliminates any backward slope and flat profile to it. While the material can extend down and build up the brow bones as well, it is not possible to extend the material onto the radix of the nose to build it up as well. It may reach the frontonasal junction but true radix augmentation must be done from below as that area is part of the nasal dorsum not the forehead.
2) Brow bone and forehead augmentations are done by few plastic surgeons and those who do them almost universally have a craniofacial training/experience background as that is how you learn to do any type of skull reshaping surgery.
3) I will have my assistant pass along the costs of forehead augmentation to you by separate e-mail tomorrow.
4) The most common side effects are shape or contour issues. How smooth is the result? Are the edges over the temporal lines visible? Is the amount of augmentation enough? Contour irregularities are the main reason for any revisional surgery which has a risk of about 10% in my experience.
5) In looking at your pictures, I assume you recently had ‘double eyelid’ surgery based on the scar location. I will also assume that they didn’t take ouy any upper eyelid fat which commonly needs to be done in the Asian eyelid. Also, brow bone augmentation may increase the distance between the brows and the upper eyelid lashline.
6) Lastly, radix augmentation needs to be done through the nose and is often part of an overall dorsal augmentation in an Asian rhinoplasty. I know that you stated you recently had a rhinoplasty but I do not know what was done. Did they build up the dorsum and, if so, with what?
I have attached some imaging predictions based on brow/forehead augmentation and a nasal dorsal augmentation.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in eyelid surgery (I'm Asian), nose surgery, jaw surgery and I have a small skull. I want some plate inserted to make my head fuller as I cannot tie back my hair without looking awful with small skull and square jaw. I need help as my self-esteem is very low and just can't accept my aging.When I was younger, I had a long face. Now that I am 43 years old my jaw got wider. I am short and this just makes me look uglier. My skull is small and flat on top for my face. I am okay with the back of my head. I want a fuller top without teasing up my hair to make my face proportional. I would like to be able to tie my hair back and tight without my face looking big and wide. I would like a deeper set of eyes and nicer nose too. I have expression lines across my nose. I wake up early for work and the fleshy eyelids means a lot of space for water retention. I have attached pictures for your review and thoughts.
A: Thank you for sending all of your pictures. Let me start by reviewing your requests based on the pictures that I see.
1) Eyelids – I see that you do have a high eyelid crease that is now overhanging with skin. I suspect given your ethnicity that you have always had a slight overhang with a crease but the skin is now overhanging more. Removal of the overhanging skin would be indicated which could be done to leave a little residual overhang or have no overhang at all, whichever is your preferred aesthetic result.
2) Nose – With your nose shape and ethnicity, the typical aesthetic goals would be a higher bridge and a narrower and more projecting nasal tip with possible nostril narrowing. Computer imaging will be needed to be certain of your exact aesthetic goals.
3) Skull – Based on your description, you desire a higher cranial height at the top located more to the back of the head. (vertex) This could be built up using a PMMA material with an increased height of approximately 10 to 15 mms using my standard skull reshaping techniques.
4) Jaw – Your wider lower jaw is as common ethnic feature that could be improved by either muscle reduction by Botox injections or jaw angle width reduction by lateral ostectomies. Given that these are rather different treatment approaches (noon-surgical vs surgical), it would be very important to have a precise understanding of your exact goals and their importance in this facial area.
What I would like you to do is to review these points, give me your thoughts on each and establish a list of the most important to least important changes on this list.
Dr. Barry Eppley
Q: Dr. Eppley, I’m an Asian patient who underwent augmentation rhinoplasty 4 months ago with diced rib cartilage, but the augmentation isn’t enough. When I consulted the surgeon, he said the diced cartilage technique either undercorrects or overcorrects the nose. With bloc rib rhinoplasty, it’s easier to control precision of the augmentation required but subject to warping. Is that true? I’m planning to have another revision to augment the height again using bloc rib cartilage. What do you think? How long more do I have to wait for a revision? I just wish to push for more height. Thanks.
A: In general, diced cartilage for total dorsal augmentation can be a very satisfactory technique if the amount of height required is no more than 3 or 4mms. For most Asian rhinoplasties, sufficient dorsal height is usually closer to 7mms. Thus a diced cartilage dorsal augmentation may be insufficient because the push of the skin at this amount of augmentation is significant and the diced cartilage construct is not strong enough to resist it. So even if the diced cartilage roll was 7mm in height, it would be pushed back down and flattened somewhat. A bloc cartilage graft is much more successful in displacing the dorsal nasal skin upward the required amount for the obvious reason thatit is solid and can not be deformed. While it is true that bloc cartilage has the risk of warping, the key to prevention of that problem lies in the harvest. Rib grafts are absolutely needed and getting a fairly straight cartilage graft of 3.5 to 4cms in length can be difficult but it can be done.
As for the timing of the revision, since you know you desire more now that the initial swelling has gone down you could proceed at any time with a revisional rib graft rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, when using diced cartilage graft for nose augmentation do you overgraft to compensate for potential resorption? Did you use a columellar strut on your nasal augmentations and do you do anything for wide and flared nostrils? In some rib graft rhinoplasty results, the nose looks pinched. I have read that some doctors place two extra grafts on each side of the nose giving the frontal view a very nice look to it. What are these grafts and how are they done? While I love the idea of diced cartilage mainly because there is less chance of warping, I am concerned that there would not be enough build up to achieve the height that I desire with this. In addition, my rib graft rhinoplasties that I see have a tip that is bulbous and not sharp. I would like a much pointier and defined tip. I feel like this is one of the biggest flaws I keep seeing over and over in the before and after results that I have seen on asian ethnicity patients. It seems as if the surgeons augmented the bridge and completely forgot the tip.
A: In answer to your questions:
1) In looking/suspecting the degree of augmentation that you want from your rhinoplasty, I would ‘overgraft’ as much as possible. The limiting factor in any augmentation rhinoplasty is what the skin will accomodate (how much can it be stretched) and how much recoil (deformational elastic limit) the skin will do. The thicker the skin, the greater the elastic recoil will be. (push back) This is what leads to resorption of cartilage more than any other factor.
2) Columellar struts are used in every augmentation rhinoplasty. The length of the columellar strut and its stiffness (thickness) depends on how much nasal tip lengthening is needed. Most non-Caucasian rhinoplasties need and get nostril narrowing as part of their rhinoplasty.
3) There is no question that whole rib grafts are going to give more of a push on the skin and resist recoil than any diced cartilage graft. Given the result you are showing, a whole rib graft would need to be used as that is pushing it to the limits of what the skin can tolerate. What you are referring to as ‘side grafts’ are known as lower alar rim grafts, sometimes called batten grafts. (although this is not technically correct) They are placed obliquely to the rib graft at the nasal tip. This adds expansion/fullness to the lower alar cartilages so that when the tip gets significcantly elevated, it is not like a tent pole sticking out of the top of the tent. (pinched look)
4) What you are seeing in the tip is more often a conservative approach to tip projection/stress, rather than ignoring the refinement of the tip area. You have to remember that when you significantly push the tip up in an open rhinoplasty, the tip skin over the graft has very little blood supply. There is a real risk of tip skin necrosis after surgery, a disastrous event in rhinoplasty. There are well documented cases of it happening and I have seen it with a bone graft many years ago. In your type of nose, the columella is very short. Once you push up the tip area with rib grafting, the open rhinoplasty incision must be closed. If the rib graft is too high, one can not close the columellar incision. Pulling the tip skin down pushes the partially devascularized nasal tip skin tight over the graft. This is where the risk of tip skin death is and the blood supply may get cut off. This is an important issue to recognize during surgery as a sharp point on the end of the rib graft, if the skin is too tight, will cause this problem to occur. It is far better to have a more rounded end of the rib graft and not too tight of columellar skin closure over it to avoid this nightmare of a problem. This is the likely biologic explanation for some of the nasal tip results you are seeing.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 27 year-old Asian female who would like to change the shape of my nose. I have a low nasal bridge and a flat tip of my nose with low projection. I would like to get my nose more Westernized with a higher bridge and more tip projection. I have read that this takes cartilages grafts that either come from my nose or from my rib. I definitely do not want a rib graft done so I am considering implants instead. I know about the implant used to build up the bridge but how does the tip get more projection as well? Is cartilage used to do that or can implants be used for it?
A: In changing the tip and columella of the Asian nose, a septal extension graft as well as a columellar strut graft is used. The septal extension graft is placed along the caudal edge of the septum and out onto the anterior nasal spine. This graft not only helps tip projection but also improves a retracted columella and opens up the nasolabial angle. When combined with a columellar strut, these two tip grafts together give more tip support for the weaker lower alar cartilages and is a standard technique in my practice. It is entirely possible, and very likely, that the septum of the nose may not provide an adequate donor source for the amount of grafts needed. If the septum is inadequate, one can use synthetic implants instead. The best choice of implants would be Medpor or porous polyethylene sheeting from which to fabricate these grafts. Usually a combination can be used, using the septum or the columellar strut and Medpor for the septal extension graft for an Asian rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in changing the look of my nose. I am Asian and my nose looks too much like a button on the end. I would it to be slimmer. I have attached some pictures of my face. What type of rhinoplasty do you think I need or would be helpful to achieve this goal?
A: Your nose has many typical Asian features marked by a short columella and broad tip with thick skin. There is no definition to the tip which I assume is what you mean by a button tip. But the shortness of your columella has also created a nasolabial angle that is less than 90 degrees. This magnifies the ‘button’ appearance of the tip of the nose and certainly make it look flatter. This could be improved by a rhinoplasty that reshapes the tip through a columellar strut graft onto which the lower alar cartilages can be reshaped. This would help open up the nasolabial angle and provide a little bit more length to it. This would produce tip narrowing and elevation, effectively changing the flat and wider tip to a more shapely one. The thickness of your nasal skin will limit how much narrowing can be done but improvement can certainly be obtained. I have attached some rhinoplasty predictive imaging of the front and side views to illustrate these potential changes. These are provided with the understanding that they are predictions and not guarantees of the rhinoplasty outcome.
Dr. Barry Eppley
Q: I’m a 21 year-old female of Chinese descent. I want to narrow and sharp my nose tip and wings and make the nose bridge higher. In the upper eyelids, I want to take out the fat and make them more deep and wide. I also want to open my eyes in the inner canthal area. Lastly, I want to reduce cheek and jaw and augment the chin so that the face looks more narrow and longer. I know some of these are common to the Asian face. I have provided some pictures for you to do computer imaging. Thank you very much!
A: Thank you for sending your pictures. I will do some imaging on them but I am limited as to what I can show because the quality of the picture and the angles from which they are taken are inadequate. The most useful photos for compiuter imaging are front and side views taken on a clean background (solid color wall or door) that are non-smiling.
In reference to your specific procedure requests: I can make the following comments:
1) Your nose reshaping/rhinoplasty requests are fairly standard for your ethnicity. Changing the nose by narrowing the tip and flare of the nostrils and making the bridge higher is common for this type of Asian rhinoplasty.
2) From an upper eyelid standpoint, you are referring to a double eyelid procedure with defatting and creating more of a prominent upper eyelid crease…which will make your eyes more wide or open looking. From an inner eye/canthus standpoint, you can get rid of the skin overhang with an epicanthoplasty but the scar trade-off must be carefully considered.
3) For facial narrowing, cheek and jaw angle reduction can be done from inside of the mouth. Whether this is best done by burring or oteotomy/ostectomy reduction is an issue for discussion.
4) The chin can be augmented with a specific female-type chin implant that makes it longer and comes to more of a point.
Dr. Barry Eppley
Q: I am Vietnamese and want a rhinoplasty. The rhinoplasty I would like to have done is a higher nose base (i think its call dorsal augmentation), have the tip more pointy (is that call narrowing?), as well as nostril reduction. I was also wondering if I need “nasal bone osteotomies”? And for a dorsal augmentation, please can you let me know what is the difference between a cartillage and a synthetic implant. And please if you could let me know the average cost of a rhinoplasty so I could have a better idea. I have attached a fromt picture of me for you to see what my nose looks like. Thanks so much!
A: Thanks for sending the picture. While its clarity is satisfactory, it is not a good image to judge the effects of a rhinoplasty. At the minimum, two facial views are needed…a front and a side view. A non-smiling front view is needed as smiling distorts the nostrils and makes them even wider. The effects of dorsal augmentation can not be seen at all in a front view and requires a side view to see that part of the result.
There is no question that what you are looking for in your rhinoplasty is dorsal augmentation, tip narrowing amd nostril reduction. These are very typical changes that are requested in rhinoplasties of your ethnicity.
The biggest decisiion to make in your rhinoplasty is that of the augmentation material for the dorsum. This is a classic debate between a synthetic implant and your own cartilage. Cartilage for your dorsal augmentation, due to the volume needed, would have to come from the rib. Your septum is inadequate for your dorsal augmentation needs. While there is no question that a small piece of rib cartilage is much better for you over your lifetime and will not give you any healing, infection or rejection problems, it is not appealing in a primary rhinoplasty to harvest it. This is why many such Asian rhinoplasty patients choose a synthetic implant even though there are higher rates of long-term problems with them.
Nasal osteotomies means cutting the base of the nasal bones to try and narrow the broad width of the upper part of the nose. With an adequate dorsal augmentation, this would not be necessary as when the dorsum is built up it makes the base of the nasal bones look more narrow.
The average cost of a full or more complete rhinoplasty, all fees included, is in the range of $ 6500 to $ 8500.
Dr. Barry Eppley
Q: I have heard of rib graft nose augmentation. Is this method better than using silicone implants? It seems that most people use silicone so why rib? Can a rib graft be carved like silicone with a nice shape ? Can it get warped and twisted? How many people are fixing their nose using rib grafts? How many people need to be redone because of problems with the rib graft? I want to fix my nose but am scared of using a rib graft because of what I have heard about them.
A: Rhinoplasty with dorsal nasal augmentation can be done using either a synthetic implant or an autogenous rib graft. While there are advocates for both approaches, either one can have very successful results. It is not a function that one is better than the other, they just have different advantages and disadvantages. Synthetic implants to the nose are relatively simple to do and require less operative time and surgical skill to do but they have potential long-term problems such as infection and extrusion in some patients. Rib grafts to the nose are harder to do and require greater skill and familiarity in working with this type of graft as well as requiring a donor site but they do not have long-term problems of infection or risk of graft extrusion.
In my experience, diced rib cartilages to the nose eliminate the risk of warping or twisting and mold nicely for dorsal augmentation. Solid rib grafts must be very carefully harvested, shaped and secured to avoid the problems to which you refer. I have done both techniques successfully and decide between the two rib cartilage graft techniques based on the quality and shape of the rib graft harvest.
The vast majority of patients wanting primary dorsal augmentation rhinoplasty for esthetic reasons, such as the Asian patient, is going to choose a silicone implant because of its simplicity and lack of the need for a donor site.
Dr. Barry Eppley
Q: I want to augment my nose from the top down to the tip of my nose. I am of Asian decent. But my question is using cartilage, how can my nose be reshaped?? Since cartilage is kind of like meat can it have a form like silicone implant ? Also I heard that cartilage can shrink or warp?? THEN WHAT HAPPENS TO MY NOSE ???
A: What you are interested is a very common treatment for the Asian type nose, that of dorsal augmentation rhinoplasty. This can be done as either dorsal (alone the bridge) augmentation only or as dorso-columellar (done the bridge and then a 90 degree turn at the tip and then down underneath the columella which is the strip of skin between the nostrils) augmentation. By far, the most common method for this type of nasal augmentation is with the use of preformed silicone implants.
But the procedure can also be done using your own cartilage. This obviously requires a cartilage graft harvest, almost always from the rib. Because of the donor scar and the temporary after surgery discomfort, most patients choose an implant. (even though from a long-term standpoint your own rib cartilage is better) Your concepts about cartilage shape and how it feels, however, is not accurate. It is not like meat but more like the consistency of a carrot stick. (as a matter of fact one is trained on how to carve cartilage using a carrot stick!) The rib (carrot stick) can be carved and then placed into the nose just like an implant. One has to be careful in harvesting the graft so that as a straight a graft as possible is taken and it must also be carved straight so it does not look crooked in the nose after it is placed.
Dr. Barry Eppley