Your Questions

Q: I am interested in getting a rhinoplasty done. I want a more streamlined look to my nose. It needs to be straighter with less of a downward slope or dip in the bridge area. I think the dip is the result of a barbell bar that I dropped on my nose when I was about 12 yrs old. I have attached some pictures of my nose for you to see. What are your rhinoplasty recommendations?

A:  Your pictures and your history show a classic saddle nose deformity. Your nasal bones and middle vault (upper and middle third of your nose) are collapsed and your internal septum is underdeveloped. This also results in a low and broad nasal tip, short columella and flared nostrils. The key to a successful result in the saddle nose deformity is building up of the entire dorsal line from the bridge down to the nasal tip. Without question the best material for this is your own cartilage. Your septum, however, would not provide adequate donor material. Ideally a rib graft should be used. This provides the best amount and shape that this buildup requires. One could use a synthetic implant, which is easier, but there is a definite risk of long-term problems with foreign materials in the nose. Otherwise, your rhinoplasty would be done through an open approach with dorsal graft and columellar grafting, nasal tip refinement and nostril narrowing. This would provide a more streamlined and straighter look to your nose as the attached computer imaging illustrates.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I was wondering what kind of doctors perform septoplasty?  Are plastic surgeons the only types of doctors that can perform septoplasty?  I was reading that some health insurance can cover a septoplasty but you have to prove to them that your deviated septum is causing you breathing problems.  Is it safe to get a septoplasty/rhinoplasty together?  Can you get a septoplasty first.. and a rhinoplasty later or will that be considered a revision?  Thank you very much for your time Dr Eppley.

A: Septoplasty can be performed alone (if the only objective is to correct breathing problems) or it can be done in conjunction with rhinoplasty. (known as a septorhinoplasty if both breathing and the shape of the nose are concerns) Most major rhinoplasties always include a septoplasty as the septum provides a source for cartilage grafting which is necessary for many nasal reshaping surgeries. Septoplasty and rhinoplasty are never separated into two stages if one’s intent is to address both function and aesthetics of the nose. Septoplasty may be covered by insurance if there is evidence of significant septal deviation and/or inferior turbinate hypertrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty six months ago. My main goal was to make my nose larger in the middle. I have breathing problems and when I use nasal strips it makes me  breathe better. I didn’t want to change my nose very much but just add support and width to the middle part. My rhinoplasty surgeon said he would put in spreader grafts and a columellar strut. After surgery when the splint was removed, he said he had also put in an onlay dorsal graft to make my nose look more balanced and masculine. My problem is that I didn’t want the dorsal graft. Now that I have more support in the middle vault, the dorsal graft makes my nose higher which I do not like. Can this dorsal graft be removed?

A: Dorsal grafts are onlay materials, usually cartilage, that is simply put on top of the bridge of the nose. How long it is and its size is largely irrelevant when it comes to removing it. The graft should be fairly easy to remove through a closed endonasal rhinoplasty approach. Unlike a bone graft, a cartilage graft never really becomes part of or truly incorporated into the underlying cartilage and bone but simply sits there with a surrounding capsule. This makes its secondary removal fairly easy. Since you are six months out, it is fair to say that you have a good idea of what your nose looks like and are certain that the dorsal graft does not fit into the desired aesthetic shape of your nose.

Dr. Barry Eppley

Indianapolis Indiana

Q: I don’t like the appearance of my nose and want to get a rhinoplasty to fix it. The problem is that the upper part of my nose is not straight or symmetric. There is also a small bump that I want to get rid of as well. Is there any way to really just straighten out the top bone of my nose? The upper part of my nose is diagonal. That is what I believe makes the one side look bigger. Is there any way to shave just a bit off the tip of the nose as well without  tampering with the nostrils or performing open surgery? What happens if the surgery does not heal correctly? Will I need to pay to fix it again? By that I mean deformed nostrils of something of that nature. Thank you so much! Sorry for my abundance of questions.

A:  You are talking about a closed rhinoplasty versus doing an open rhinoplasty. Through a closed rhinoplasty approach, the hump can be taken down, the nasal bones straightened by osteotomies and the tip narrowed by plication with sutures . With a closed rhinoplasty, there would be limited risk of nostril asymmetry. The more major issue and the real concern is how straight and symmetric the nasal bone area (pyramid) can be made. It is also important to realize that the tip changes through a closed approach would be less significant than that of using an open approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: I had a rhinoplasty last year of which I am not too happy about. The bridge was shaved too low and I do not like the tip. It looks fat and pinched to me. I have attached a front and side view of your nose so you can see the problems. I would love to see what kind of improvements you think should be made! Thank You.

A:  I have looked at your nose and my thoughts are that you have a fundamentally over-resected nose that was done too aggressively. While it may have looked good initially, the nose is now collapsed and contracted inward at the bridge and upward at the tip. In short, you have excessive hump reduction, an inverted v deformity due to nasal bone collapse, an over-rotated and pinched tip and excessive nostril show. In days of old, this type of problem was more commonly seen. Today it is more uncommon as the emphasis on rhinoplasty has been on conservation of structures and not simply removal.

To improve this nasal deformity, the nose needs to be done through an open approach with the nasal tip de-rotated, the bridge and middle vault built back up and the nostril rims grafted. This requires cartilage grafts which, most likely, can come from the septum and ear but may require rib cartilage to get the best amount of graft material. I have attached some computer predictions which demonstrates the objectives. This is a difficult recondary rhinoplasty problem but good improvement can almost always be obtained.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I had a rhinoplasty several years ago. One of my reasons for having the operation was to get a large hump on my nose removed. Since the surgery I have had trouble breathing through my nose. What can be done to correct the breathing problem resulting after hump removal? Is the cause of these breathing difficulties the enlarged inferior turbinates?

A: In removing a large nasal hump, several structures are taken down. While most people think a hump is made up of bone, it is really as much cartilage as it is bone. This cartilage includes the upper half of the septum and portions of the upper lateral cartilages. The merging of the upper lateral cartilages and the septum make up what is known as the internal nasal valve. This internal nasal valve is an important area that has great influence on how easily air moves through the nose. With larger hump reductions, the internal nasal valve may become compromised, causing postoperative breathing problems. While the size of the inferior turbinates may have an effect on your breathing, the most likely cause is internal nasal valve collapse.

Reconstruction of a collapsed middle vault (compromised internal nasal valve) is done primarily through cartilage grafts, a procedure known specifically as spreader grafting. This is done through an open rhinoplasty approach. Reduction of the inferior turbinates can be done at the same time to eliminate any other airway obstructive factor.  

Dr. Barry Eppley

Indianapolis, Indiana

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

Indianapolis Indiana

Q: I am interested in having a rhinoplasty for my big nose but don’t want it to make my already large brow bones to look even bigger. I have attached a couple photos (front and side) of myself to give you a better idea and possibly even hear any other suggestions you may have to maybe give my face a better balance.  I did have a rhinoplasty when I was younger but it didn’t make much of a difference. I was going to have a second rhinoplasty, but I didn’t want a smaller, well-proportioned nose to create my brow bone to appear larger than it already is.  In other words I thought my nose being somewhat larger now balances out my brow bone.

A: Thank you for sending your pictures. I have done some computer imaging to demonstrate several points. Your first rhinoplasty result is not very impressive and probably shows little change. I suspect it was done as a closed rhinoplasty by someone with little experience in doing the procedure. But doing your secondary rhinoplasty would actually make little difference in how prominent the brow appears as demonstrated in the attached imaging.  Making your nose bette balanced does not make the brow bone prominence look worse and that is well demonstrated in the computer imaging. The reverse is, however, quite different. Reducing the prominent brow bones would definitely make the nose look even bigger. I have demonstrated the combination of a rhinoplasty and brow bone reduction to see the total change. Therefore, you could feel quite comfortable doing a secondary or revisional rhinoplasty without fear of making any part of the rest of your face look more out of balance.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  I have been left with a dog ear on my face after a nose reconstruction due to skin cancer. The nasal ala was reconstructed but the end result looked like a further growth. (like a pin cushion of skin stuck on to the side of my nose) It underwent a revision about two months later. I am still not totally satisfied as I now have a further deep scar on the side of my nose and an awful obvious dog ear that looks very unsightly. I went for a follow-up and they suggested giving it a year before considering any further surgery. I am desperate to have something done but if we did operate on the dog ear, I fear it might end up worse!! How can this be and why should I live with my face like it is? What can be done now?

A: Reconstruction of the nose after cancer is one of the biggest challenges in plastic surgery. This is particularly true of the nasal ala which is a small but delicate area. Having had two surgeries and now some degree of scar contraction or dogear, it is very important to let the tissues heal and settle down. The healing must progress to the point that it is not only complete but the scar tissues have relaxed. Operating on tissues that are not soft and supple will only lead to further scar contracture problems. It is certainly frustrating to have to wait a whole year with less than an optimal result sitting on your face, but the best result from an effort at scar revision depends on good quality of tissues to manipulate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I have hated my nose for a long time and I have finally decided to get a nose job. I am African-American and I don’t like the lower third of my nose. My nose is too wide and big when I smile. My nostrils flare really wide. I just want to get rid of some of the wideness but don’t want to change the whole nose. Is that possible?

A: One of the many distinguishing features of the African-American nose can be its unique tip and nostril shape. The tip is often more flat and less well-defined and the nasal base is wide, often with nostrils that have a larger size that also flare. Many African-American rhinoplasties involves reduction of the wide and flaring nostrils. This can be done by removing skin from the inside of the nostrils for some minor reduction or by repositioning the entire nostril base for a more major change. Nostril and nasal base reduction can be done by itself but it is important to see how this may change the overall look to the nose. This is where computer imaging is absolutely essential. Most likely changing the size of the nostrils will affect how the tip of the nose looks and will make it look even more flat and shorter. Some tip changes through columellar strut grafting may be needed with nostril reduction to keep the lower third of the nose in balance. Dr. Barry Eppley Indianapolis, Indiana

Q: I had a septorhinoplasty about six weeks ago. As a male, I was told that my thick oily skin will cause a lot of swelling in the tip of the nose that will take longer to settle down and go away. My concern is not the swelling in the tip of the nose but that it is drooping and the columella seems to be hanging too low. These were two key issues that I really wanted improved but right now it does not look like this has been achieved. Is it possible that my concerns are just do to swelling? Should I be considering early revisional  surgery?

A: While it is still early in the rhinoplasty healing process, some improvement in the major focus of the nose should be evident at this point. There is no doubt that swelling is still present at this point and it may be considerable. So all hope is not lost that the final result may still turn out satisfactory. Whether revisional surgery may or may not be needed can not be foretoold at this early sfter surgery point. What you don’t want to do in consideration of revisional surgery, however, is chase a ‘moving target’. Give the nose a full six months after surgery and then go back and get a more useful after surgery evaluation from your plastic surgeon. What matters most at thaty point is how is how much change has occurred from now until then. If improvemenmt has been seen, then more time may be adviseable. However, if there has been no visible significant change between 6 weeks and 6 months after surgery, then revisional surgery is going to be needed.

Dr. Barry Eppley

Indianapolis Indiana

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

Indianapolis Indiana