Your Questions
Your Questions
Q: Dr. Eppley, I am interested in implants for a frontonasal augmentation effect. Would it be possible to place a nose bridge implant so that it extends onto the forehead and fans out, so that it kind of gives the effects of a forehead augmentation as well? I am look to create the look of deeper set eyes. Also, how much for each of those procedures? Thanks.
A: I suspect you are referring to augmentation of the glabellar region of the forehead just above the nose. While both areas can be augmented concurrently (frontonasal augmentation), they can not be done using a single implant or through the same incisional approach. While such an implant can be custom designed, one has to consider the logistics of it surgical placement. Such a frontonasal implant would be too big to pass it into the forehead through an open rhinoplasty approach. Conversely an adequate nasal pocket could not be made from any type of superior or scalp incisional approach unless it was an complete corral scalp incision. These are general statements and I would have to know more about the exact forehead and nasal areas you want to augment to determine their applicability to your aesthetic facial needs.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting a nasal implant for my rhinoplasty but I am very leary of necrosis and the aesthetic results and safety of a Shirakabe vs. Dorsal nasal implant. I would like to ask you whether the Shirakabe or Dorsal nasal is best for avoiding necrosis. Which one? or does it not matter? Would a dorsal nasal implant have good results since I have a bulbous tip? Aren’t Shirakabe’s better for Black/Afro American? Could you define my nasal tip more (having a dorsal nasal implant in comparison to a Shirakabe) without necrosis developing? Thanks.
A: I think in general one has to be very leery of having any type of synthetic material under the skin across the nasal tip. A nasal implant that puts any pressure on the nasal tip skin is destined for long-term problems. The issue is not immediate skin necrosis but long-term skin thinning, implant visibility and/or infection. Synthetic implants that cross the nasal tip area have a significant long-term risk of these issues. While implants work well for the nasal dorsum and have a much lower incidence of problems, the same can not be said for the nasal tip. The best ‘implant’ for the nasal tip is your own cartilage, particularly that of rib cartilage. If you were asking me what is the best to use both in terms of results and the lowest risk of potential complications, I would choose cartilage over an implant every time in rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What I don’t like about my nasal implant is that it looks stiff and sits on top of the bone rather than conforming to the natural contours of the bone. The frontal view looks nice but the side view not as good. From the side view I prefer more of a “ski slope” look. Is rib cartilage as stiff and firm as the implant? Can rib cartilage still warp? Is rib placed in the bridge area the same way the implant is? Does the nose have to be cut open to place rib? I was also wondering if tip surgery is generally less expensive without an implant in my nose? Thanks for the info.
A: Rib cartilage is stiffer and more firm than a nasal implant. Unlike a nasal implant, rib grafts do have the risk of warping although that is largely related to the shape of the rib graft harvested and how it has been carved. Like nasal implants rib grafts are put in the same way which is best done through an open rhinoplasty approach. The cost of a tip rhinoplasty would be the same regardless of whether a nasal implant already was present in the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about implant rhinoplasty for my Asian nose. The original surgeon who performed my first rhinoplasty knew that I did not want an implant initially but sold me on the implant because the only thing that he offered that would be equivalent in terms of withstanding the test of time is fascia. He described it as a thin piece of skin from the scalp area that would show little difference. He never mentioned anything about rib grafts or diced cartilage wrapped in fascia. I feel that I was mislead purposely. Is it common for plastic surgeons in the United States to do this to make a buck and is this medically ethical?
A: There are numerous approaches to augmentation of the Asian nose including implants and rib cartilage grafts as you have mentioned. It is certainly true that fascia alone would provide no nasal augmentation at all due to its very thin and pliable tissue characteristics. It is good to encase a diced cartilage graft but is not an augmentation material per se.
Surgeons naturally present and offer to patients for any surgical procedure what they know and are comfortable performing. Presumably what they have to offer for any cosmetic condition is what they feel will work well and is in the best interest of the patient. It is also far easier for surgeons to offer implant rhinoplasty over rib grafts for nasal augmentation because it is simpler, easier to perform and costs the patient less. Even if presented with the rib graft option, many patients initially choose implants for all of those reasons also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a nasal implant question. I would like to have the very tip of my nose lengthened but have been told that my existing implant must be removed due to the fact that it causes the skin of the tip to harden and in future years the implant will cause problems anyway? During my first rhinoplasty a little cartilage was added to the tip. I didn’t feel that it was nearly enough. I have a blue silicone implant in the bridge, “Flowers” is the brand.
A: If you want to lengthen your nasal tip, placing cartilages on top of the nasal implant in the tip area can be done. (if the implant even goes down over the tip) There is no reason to remove the nasal implant to do so.
By the way, if you have a blue colored implant on your nasal bridge, that is not an actual implant. That is the nasal implant sizer used to try in before placing the real implant. Some surgeons unethically place sizers instead of the real implants because they cost only 10% as much as the real implant. That is why the company colors them blue, to try and prevent surgeons from using the sizers as the actual nasal implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am a young African American woman. I have a larger forehead which I can live with. The problem I have is that since my forehead is wide and protrudes and my nose is stubby, it makes my glabella look flat and too wide. I would like a glabella that makes my face look more define. What do you suggest? Thank you.
A: Thank you for your inquiry and sending your pictures. What you really have is a combined glabellar (forehead) and nasal bridge ‘defect’ or recessed area. This glabellar-nasal area lacks the protrusion and dimensions that the rest of your face has so it is disproportionate. (or as you have accurately stated…too flat) Building up this area could be done in multiple ways. The simplest would be fat injections but that carries with it the unpredictability of how well the fat would survive. The best approach is to really have a custom glabellar-nasal bridge implant made as a single piece. A standard preformed nasal implant will not augment the globular region of the forehead. Such a custom nasal implant would be placed through an open rhinoplasty approach (low) with an endoscopic technique from above. Other strategies include a preformed nasal bridge implant combined with bone cement augmentation of the glabella. As you can see there are various augmentative strategies using different materials.
Dr. Barry Eppley
Indianapolis, Indiana