Your Questions
Your Questions
Q: Dr. Eppley, I am interested in revision rhinoplasty. With rhinoplasty surgery my surgeon shortened my nostrils, cut my hump on my bridge, and my nose tip didn’t cut at all, just is rotated upward. I need to know how to reduce with revision rhinoplasty that distance between upper lip and nose and the fat philtrum and how to narrow nose like it was before. Can nose be longer like it was before and narrow with all size. I’ve heard that by lengthening nose with cartilage graft, nose can get wider. I must say again, that I don’t won’t to go with a lip lift, just thinking about revision rhinoplasty.
A: No revision rhinoplasty can reduce the distance between the base of your nose and your lip. Only a lip lift can make that change. There is no procedure of the lip that can reduce or thin out a ‘fat’ philtrum. The only way to narrow the nostrils is by lengthening the nasal tip and this will require a cartilage graft to do so. But this will make the tip longer which may be an undesired aesthetic change. You may instead consider shortening the tip and use alar rim grafts to help wide the nostrils.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had my primary rhinoplasty done six months ago. The method used was diced ear cartilage wrapped in fascia to increase bridge and tip height. What I’ve noticed in my bridge is that it slightly decreased in height possibly due to swelling going away. With the swelling gone, the bridge height isn’t as augmented as I had wanted. For a revision,I wanted to know if Dr. Eppley would consider using the diced cartilage injection technique.Looking for very slight increase in bridge height.I feel that cartilage injection best suits my case.That minor change can make a huge difference. As I have read in some of your articles concerning revision rhinoplasty, many patients desire a revision rhinoplasty because they may be seeking the optimal look for themselves and may not be a result of aesthetic unhappiness with what their previous surgeon performed. In my case, I feel as if my surgeon did an excellent job with my rhinoplasty. My only issue now is that I was extremely gratified in the first three to four weeks with my nose but failed to realize that the swelling played a role in that. Now that the swelling has almost subsided completely, I am looking to add enough bridge height to replicate what it looked like in the first month post surgery. I can’t stress to you enough how little of an increase in bridge height I am desiring, but it’s enough of a change to make a huge difference for me.
A: Thank you for our detailed rhinoplasty history. For a modest increase in dorsal height, I would agree that an injection of diced cartilage, done through an intercartlaginous incision, should be appropriate.While the concept of an injection always sound simple, it is important to note that cartilage must be harvested, prepared and then injected. The question is where that cartilage should come from…the contralateral ear or the septum? Either way this usually requires more than a local anesthetic in most cases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve been diagnosed with lupus and ITP. However, my platelet count was always low (lowest was 12) back in 2013 when I went for my blood work to have a rhinoplasty. I was prescribed steroids to take to increase the count and undergo surgery. So I think I had lupus back then and it affected my platelet count. Every time I wanted to have surgery, I would just take the steroids for about a week prior to surgery. I’ve had 2 rhinoplasty, breast augmentation, upper and lower eyelid surgery, and mid-face lift. But now I am now taking plaquenil and prednisone (50mg) for the past 6 months. I am interested in revision rhinoplasty, zygoma reduction, and jawbone reduction. I am little afraid since this time I am taking medications for my lupus. If my platelet count is above 100. Is it safe for me to have those surgeries?
A: I think you have to recognize that at least two of these surgeries (zygoma and jawbone reduction) are major bone surgeries that can cause a lot of bleeding and require better healing potential that any of your prior aesthetic procedures. Since they are elective I would be very cautious about undergoing them. Plaquenil and prednisone are major anti-inflammatory drugs that can have negative impacts on healing, particularly at the doses you are taking.
If your platelet count is acceptable, I would only undergo a revision rhinoplasty first to see how the surgery goes. That would he a good test before ever proceeding with the more major facial bone surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in another revision rhinoplasty. Are some noses by virtue of skin thickness or other unfavourable pre existing qualities simply not amenable to improvement? I have had 5 rhinoplasties already (the last procedure was done using autologous rib cartilage for the tip and silicone for the bridge. This was in march last year) and have seen little (if any) improvement in the size of my nose (which has always been my chief complaint). After the last procedure, ironically, I seemed to have ended up with an even bigger nose than what I had to begin with. The tip is now also drooping and the nose is long and heavy looking. Is there any hope at all for a smaller and more refined nose? My ethnicity is Asian but I do not think my skin is thicker than what would be considered typical for my demographic. I am willing to treat my nose as aggressively as is required so I can obtain the best outcome. I understand this may include taping the nose every night for the first 3 months and also kenalog injections for swelling / scar tissue resolution. In your practice, how beneficial have you found these adjunct therapies to be? Will/can laser help in thinning the skin to obtain a better rhinoplasty outcome?
A: Due to skin thickness, there are some noses where the ability to truly make it smaller or more refined is very limited. I would think after five rhinoplasties (four revision rhinoplasty surgeries) that has probably become true for your nose..even though I have never seen it. Regardless of what your nose’s original skin retraction capabilities were, that skin shrinkage capability is now probably lost. I do not know what the objective of your last rhinoplasty surgery was, but by adding rib cartilage and a silicone implant I can not see how it could have ever gotten smaller. By adding volume your nose would have predictably gotten bigger.
At this point I would not think that any amount of taping or steroids after a revision rhinoplasty is going to make your nose any thinner. That would be hard to imagine after so many revision rhinoplasty procedures. Laser is not a treatment for thinning the skin of the nose. There is no such procedure for doing so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. I had a rib graft placed last year and now it is quite deviated. I want to straighten my nose and it should be a bit higher. What I don’t understand is why the rib graft was ok in the beginning and now it has deviated so much. Can you morselize the deviated part and put it back in. Will the morselized parts be healed like bone does? Will the nose be deviated again? If I go with a nasal implant instead of the rib graft, will it have any chance to deviate again? And will you have to harvest ear cartilage for the nose tip or you can utilize the cartilage that they used in the previous surgery?
A: It is not rare that a rib graft to the nose will eventually develop some deviation. This is a function of its natural curved shape and the memory of its cartilage shape. No matter how the rib graft is harvested it is rare to ever get a perfectly straight piece. As a result it must be carved to be straight. Depending upon how it is carved and where it was harvested along the subcostal margin, deviation can develop. Usually it appears quite soon after placement (a few months) but can be delayed in its appearance much later.
If the goal is a straight nose that is higher, then the rib graft should be replaced with a nasal implant in your revision rhinoplasty. A nasal implant will have more assured straightness since it is made straight. The tip of the nose and the columella, however, should remain cartilaginous, most likely using the rib graft which was removed.
If the goal is simply a straight nose with the same height then the rib graft should be configured into a diced cartilage graft for your revision rhinoplasty. This will eliminate ant risk of subsequent graft warping.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. I have a problem with my deviated nose. This is the result of the rib cartilage placed in my nose which has become deviated. I had a nose job done in 2011 in Korea. It was fine at that time but now the deviation of the nose is very visible. My nose was originally not deviated like it is now
1. My question is whether it is possible to also have a nose surgery to remove that rib cartilage and replace with a good and straight implant. I just want a straight nose, the nose tip and wings are ok.
2. How much of the cartilage can you reuse and how much ear cartilage you need to harvest for the tip?
A: Unfortunately rib cartilage does have a tendency to warp in some patients creating a subsequent deviated nose. You have several revision rhinoplasty options considering that it is just the bridge part of the rib graft that is the issue. (and not the tip) These include the following:
- Remove the dorsal part of the rib graft only and replace with an implant
- Remove the deviated part of the rib graft, morselize it into small pieces and replace it as a diced cartilage graft without using an implant.
The decision between these two revision rhinoplasty choices depends on whether you just want to straighten the nose only or straighten it with further augmentation along the line of the bridge.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. My ENT performed a septoplasty in March of this year. He added cartilage from my septum to make my nose shorter and wider for breathing purposes. While my breathing has never been better, my appearance has changed, and I’m not a big fan of how my nose looks now. I would love to see if this is something that could be corrected.
A: By your description, you likely had spreader grafts placed in the middle vault and perhaps even alar batten grafts. These do successfully open up the internal valves and improve nasal breathing but can make the nose in some patients potentially wider.
The question is now how make your nose look better without recreating your breathing issues. This is most likely an augmentation approach for your revision rhinoplasty but I would need to see some pictures of your nose now to see what potentially could be done if anything. Given your improvement in breathing I would not recommend removing your spreading or batten grafts. Rather I would look at building up the bridge and tip of the nose somewhat to overcome the shorter and wider nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cheeckbone reduction and maybe jaw reduction to make my face smaller and oval shape. My question is, do I need a jaw reduction or the cheeckbone reduction is enough to slimmer my face? Also, I had a rhinoplasty done about ten years ago. The tip is very visible. It looks like a small pimple on my nose, probably because my skin was thin. I’d like to have a revision. Please let me know what you recommend.
A: When it come to narrowing the wide Asian face, one procedure or changing one facial area is rarely enough to have a significant effect. Combining cheekbone reduction with jawline reduction (jaw angle, masseter muscle and chin elongation) is the most effective approach. Of course each patient must be individually assessed to determine if one of these facial changes would be the most dominant and, in your case, there most certainly is. The width of your cheek bones is by far the widest part of your face and would be the one procedure (cheekbone reduction) you would absolutely do if there was only one procedure you wanted to do.
From a visible nasal tip standpoint, which I assume may be from prior tip graft or implant,the tip can be either modified (tip point reduced) or over grafted. (cartlage graft on top of the tip) It would be helpful to know what exactly was done from your rhinoplasty now 10 years ago.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am in search of a very skilled revision rhinoplasty surgeon and am impressed by your work.
I had my first septorhinoplasty with right inferior turbinectomy around 18 years ago. My nose looked wide and had bulbous tip and pinched nostrils on birth and I had breathing problems. During first surgery the doctor took too much of my bridge away. My breathing problems got a bit better but my nose looked totally deformed. I am of course very depressed due to that and am very much judged by people in life when they see me before I even open my mouth due to my appearance.
I long to have a normal nose, I would like to have my bridge built up. These pictures were taken in 2012 just before tip plasty. I am sending the same pics to you for evaluation as the doctor did not even touch the bridge, only the nasal tip (hook) noted on left profile was made smooth, but everything is the same no difference at all. I did not want my bridge touched at that time as I thought things will get worst but am prepared now to take the plunge with the right surgeon.
I was told that I did not have any septal cartilage left for grating but never had ear or other cartilage or implant used so far. What do you think could be done to improve my nose? I do not want any synthetic implants in my nose, thus the only option is my ear or rib cartilage?
I want to have an elegant nasal bridge, and have the pinched nostrils look better and start to live life better. I would be ever so grateful for your feedback.
A: In looking at your pictures, you do need a dorsal augmentation by a cartilage graft and a rib donor source would be the best and really only good choice in your revision rhinoplasty. This provides an adequate amount and shape of the dorsal augmentation that you need. You would also benefit by alar rim grafts to provide improved support to your nostril rims so they do not collapse downward. Slivers of rib cartilage graft would be an excellent source of the straight thin grafts that are needed here.
Dorsal augmentation would bring the upper two thirds of your nose in better balance/proportion to the tip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I’ve had a bad experience with a primary rhinoplasty making my nose too thin, specially in the upper area where my eyes are (T shaped). I believe the cause of this is overly aggressive osteotomies. I have morphed a picture where I make the upper third of the nose wider (Y shaped). Would you mind telling me if this is possible with a revision? Thank you for your time. Looking forward to hearing from you.
A: The nasal bones can not be recut and expanded to create that shape in the upper nose. A revision rhinoplasty using outward osteotomies is not stable and will not hold even if they could be cut to make that shape. Widening the nasal bones is hard enough but to make the nose have a T-shape (or return to it) would be impossible by just moving the nasal bones. The only way to create that shape would be by adding a material or graft to the outside of the nasal bone. That could most easily and assuredly be done by making a small custom implant to fit over the radix to create that exact shape using a 3D CT scan. This is a perfectly safe place for a small nasal implant. It could also be done using graft materials such as cartilage, bone or acelluar dermis but there are shaping/contour concerns with this type of revisional approach and issues of symmetry and smoothness would be a concern.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need help in determining what type of revision rhinoplasty I need. I had a tip rotation/refinement using Medpor in my columella topped with ear cartilage. I was healing well; the nose seemed narrowed/slightly more projected. But I was injured and the nose seems to have swollen, derotated, and healed unnaturally. It is more swollen on the left (especially in the tip) than on the right side; the entire tip is bulbous.
I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft/overlay graft in the dorsum. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty (referred to it as a septorhinoplasty). He said he could reset the “wings” of the implant that is intended to pinch the sides of my nose closed, remove excess cartilage, and remove “soft tissue”.
I’m seeking a revision because after the injury the nose changed shape. The tip/dorsum is higher, rounder, and tilts leftward due to prolonged swelling and possible shifting of ear cartilage (not excess). I have what appears to me to be a pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball someplace away from my bridge, underneath where the tip used to be before it “dropped” filled out due to injury or naturally, like a tube. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose, with a ball of tissue where the nose used to simply droop down flat. That “ball” is projected by the implant in my columella.
The tissue is soft but fibrous and based on everything that happened I feel I am looking at scar due to prolonged swelling, not curving ear cartilage. The skin on the “injured” parts of the nose is whiter and oiler than the “healed part of the nose which went through no trauma. I make this comparison because there isn’t a surgeon I’ve consulted that sees scar tissue, but I know how the nose was shaped and oriented before injury and don’t know that scar can be removed in a closed septorhinoplasty.
Any advice on whether a closed rhinoplasty is really likely to help would genuinely be appreciated. I am caught between the appeal of not going through another open rhinoplasty and the thought that I will pay a hefty price for something that will not actually help much at all, will have a period at least as stressful, and will cause the same problems in the tip.
A: The short answer to your revision rhinoplasty dilemma is…have an open rhinoplasty and get the Medpor implant out and replaced with your own cartilage if it is still needed. This is the only to ensure that you can get the best result long-term. A synthetic implant in the tip of the nose may or may not be part of the problem…but I doubt it will be part of the cure. With scar tissue in a revisional nasal tip surgery, visualization and removal of all scar tissue with cartilage reconstruction is the only way to successfully reshape the bulbous and overprojected nasal tip consistently.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a few questions after my rib graft rhinoplasty surgery. I’ve noticed that the very top of my nose bridge has started to warp to the right. It’s at the very top and it’s kind of hard to notice in person, it’s more apparent to me and then in pictures. Also a bump/hump has developed on the upper nasal bridge. I just didn’t know what possible things could be done about this if this indeed is a problem. Also, I know I’m jumping to conclusions, but if there had to be a revision surgery, how long would I have to wait? I’ve done research on revisional rhinoplasties and some doctors suggest waiting 6 to 12 months. But I saw that this was more for patients who thought their nose tip was too bulbous or the nose was too big, so the doctors suggested to wait for the swelling to go down. Another doctor suggested that he’s performed surgery as soon as two months on patients who’s revisions would be easier to fix sooner rather than later. How long would I have to wait to do a revisional rhinoplasty?
A: The timing of revisional surgery for any procedure fundamentally comes down to knowing that one has a stable target. This translates into three issues to consider: all swelling has resolved, the tissues have shrunken down and adapted to the new underlying framework and one has had enough time to accommodate to the new look. When all of these factors are considered, the timing of revisional surgery will vary based on the exact rhinoplasty procedure that was done. In general, most plastic surgeons would say that six to 12 months is when any type of revisional rhinoplasty can be done. This is, of course, a general statement and each nose and the concerns must be considered separately.
The key concept is that you don’t want to chase a ‘moving target’ when it comes to revisional surgery. Patience can be difficult but critical with secondary surgery. You don’t want to play ‘wack a mole’ with revisional surgery by jumping in too soon.
It is true that nasal dorsal issues are different then nasal tip issues because of the quicker resolution of swelling and tissue adaptation. Since your specific concern appears to be at the upper end of the rib graft in the radix, this type of revision might be considered sooner than other post rhinoplasty concerns. Some slight deviation and/or step-off of the upper end of the rib graft is not uncommon and can often be felt. How visibly significant that is will determine whether any revision is worth the effort.
The key concept is that you don’t want to chase a ‘moving target’ when it comes to revisional surgery. This is particularly true when one has had multiple procedures as one would like only undergo one revisional procedure. You don’t want to play ‘wack a mole’ with revisional surgery but jumping in too soon.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am suffering from an excessive buildup of scar tissue underneath the skin after my rhinoplasty. Multiple Kenolog shots did not help. my nose looks about 30% bigger and more bulbous then it was a few months right after the surgery. (my rhinoplasty was three years ago) I am convinced that 5-fu is the right approach for me now. I know that you are one of the best and most experienced surgeons known for using this post surgery corrective method. Can you please help me?
A: I would not think that 5-FU injections would be helpful for established scar tissue years after the original rhinoplasty surgery. The biology of 5-FU effects is to inhibit the creation or development of scar tissue, not causing it to break down. Steroids, specifically Kenalog, actually work through a dual effect of inhibition and breakdown of scar tissue. In short, while 5-FU injections can certainly be done, I would not be optimistic that it would achieve the desired effect of nasal size reduction that you desire. It would be better, in my opinion, to have a revisional rhinoplasty for scar removal and then lay in on dissolveable collagen sponges (carrier) a mixture of steroids and 5-FU. This could then be followed by an early and aggressive use of 5-FU injection therapy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am of African descent and I want to improve the shape of my nose and make my lips smaller. Sadly in my attempt to reduce the size of my upper lip and nose I ended up with a crooked nose and lips. The worst part being that my lips remained just about the same size.
A: My assumption, based on your pictures, is that an implant was placed in your nose since that is about the only thing that can make the nose deviate like that after a rhinoplasty. When trying to improve a nose shape like yours (originally), the fundamental principle is one of a strong columellar strut to support the tip and a good dorsal augmentation. While an implant can be used for the dorsal augmentation, it should never be used for the tip-columellar support as it has a high propensity to deviate…just like yours has done. (not to mention placing the skin over the tip of the nose at jeopardy for vascular compromise) You need a good cartilage graft for support for your revision rhinoplasty and this almost always requires a piece of rib to do so. The implant may be able to be salvaged and used, but once you need a rib graft for the columella you might as well abandon the implant and go with a completely natural graft approach. There are other additive techniques that can be done, such as nostril narrowing, but the dorso-columellar buildup (augmentation) is the key.
From a lip reduction standpoint, if the tissue removal amount and location is not just right, a minimal result is seen and scar contracture can result in the lip. Since you already have a linear contracted lip scar, that would serve as the posterior (inner) incision location with a more aggressive excision done out on the anterior (outer) vermilion. It is the vermilion which needs to be reduced if any size reduction is to be obtained.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in revision rhinoplasty. I have had two previous rhinoplasty surgeries and have thick skin on the tip of my nose. Is it possible to reduce and sharpen my nasal tip? Can my nasal profile be reduced? I have attached some pictures of where my nose is now.
A: Reducing the profile of your nose, of which I assume the biggest need for that is up high at the bridge, seems like it could most certainly be done. In looking at your pictures, I am assuming it is the high radix of the bridge and perhaps the overall bridge itself that is the aesthetic concern. When it comes to the nasal tip area, particularly in men, the challenge as you know is what your thicker nasal skin will allow to happen. Whether such a change is realistic would partially depend on what was done to this area in your prior rhinoplasty surgeries. I assume that efforts were made in that regard to do so but did not work. To the best of your knowledge can you tell me what was done in those procedures and how long ago was the surgeries?
There is always the old adage that past history predicts future behavior. Thus, if considerable effort was made for tip narrowing (times 2) and this is the result, I would not be optimistic that a third effort would be more successful. But the key question is what exactly was done to your nose in the prior two surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had an open rhinoplasty about five years ago and I am unhappy with the results. It was a very conservative rhinoplasty little to no changes were noticed. Even my friends and family see no difference. I would love to have the tip refined (made thinner and lifted, if possible), a possible reduction of nostrils and even some bony adjustments.
A: In regards to a revision rhinoplasty, the first question is always what was done in the original procedure. That is not something you would ever know but if you could get a copy of your original operative note from your surgeon that information is always helpful. It is instructive to know from where you started and what was done to know what may be more beneficial in the next procedure. A revision rhinoplasty usually has to do things differently than the first time if a different result is to be expected.
Otherwise, although not uncommon, one just has to await what surprises one may find in there during the revision. (where grafts done?, where was the cartilage harvested? etc) But in just looking at your photographs, I see room for improvement from the tip standpoint and in nostril narrowing. It is always easier to make a thinner tip when it is being lifted as opposed to being deprojected in thicker male nose skin.
Dr. Barry Eppley
Indianaolis, Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty, sliding genioplasty and a lip lift. I was born with a unilateral cleft lip and I want my face to be more symmetric. What procedures do you think should be done?I have had one rhinoplasty and I have an L shaped implant. I would like for my nose to be more narrow and symmetrical. With the lip lift I want my lip to be about 15mm or shorter. I have a chin implant, but I think with the genioplasty it will make my chin balance out with the rest of my face.
A: I have done some computer imaging done on your chin, jaw angles, lip and nose. I think it is fairly clear that your chin is fairly short even with the implant in place. This shows that the jaw is rotated up and back (short) and is why the jaw angles are high. A sliding genioplasty (possibly leaving the chin implant in place and moving it with the bone) may be needed to get the 12 to 15mms forward movement you need. Moderate jaw angle implants in the back will help fill give them some more definition. You don’t need your upper lip lifted by 15mms, that would be too much. Something like 5 to 7mms would be more appropriate. The question here is whether it should be done by a subnasal lip lift (lift only the central portion) or a vermilion advancement which moves the whole lip up. (probably better) The nose is challenging because of your very thick skin and the naturally thicker tip skin that many cleft patients have. To make a real difference, the implant ideally needs to be replaced by an L-shaped rib graft so you can get more of a push/lift on the skin and a sharper tip point. The implant just makes it rounder and still short.
The imaging done is to just figure out of these procedures are beneficial. The fine details of it and the degree of changes is an issue up for discussion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had plastic surgery done nearly 4 years ago that has left me what I consider deformed. I don’t resemble myself and there were so many mistakes the doctor made to my face. I am deeply saddened and depressed over this not only because of the cost but that I’m left disfigured and violated. I had my nose done where the doctor inserted a silicone implant promising that he would be able to correct my slight deviation with it. That was not achieved and my nose appears even more deviated, my nose looks short, and my nostrils more visible. I have thin skin so I feel you can almost make out the implant when looking at me. I would very much like to correct the mentioned issues. Also he performed an extraoral jaw reduction on me that left me further disfigured. He overcorrected and now my face has the appearance of a horse. I would like to restore the lost volume and give my face back it’s natural contour. Not to mention the incisional scar is very unsightly. It’s almost two inches long and is hypertrophic and red. I would like to revise the scar to make it less noticeable. I also had a silicone chin implant placed but it does not fit my face. It’s too big and wide and I would just like it removed and possibly have fat grafting to that area instead. I would possibly like other areas to be fat grafted as well such as my nasolabial fold and the hollows of my eyes.
A: From a nose standpoint, if you had an initial nasal deviation overlaying silicone implant on a nose that is deviated will actually make the nasal deviation look worse not better. So your outcome is not a surprise since you have to lay the implant on the existing nasal base. With thin skin and implant encapsulation, implant visibility often appears years later. From a short nose and nostril visibility standpoint, I am not sure how an implant would have caused that per se with the exception of a high bridge and dorsal line may make the amount of tip projection/rotation perceptibly look shorter and more rotated. From a secondary rhinoplasty correction standpoint, it appears that the implant would need to be removed and cartilage grafting done to augment and lengthen the nose with tip derogation as well as correction of the underlying nasal deviation which almost certainly has a septal deviation as a core root of the problem. The question is where the cartilage needs to be harvested from and that would depend on how much is needed. The debate is always whether it would be a combined septal/ear donor site or whether more is needed which requires rib cartilage. I would need to see some side view pictures to have a better idea in that regard.
From your prior jaw reduction procedure, I am assuming that the incisions and now red scars are at the back of the jaw behind the angles. (a side view picture would show that better) When you say you have lost volume and has changed you facial appearance (I don’t know if I would go so far as calling it horse-like), that likely implies that it looks too long because of the lost jaw angle volume and a steeper mandibular plane angle. (high in back and steeply slopes downward towards the chin) Restoring lost volume from prior jaw reduction in my experience is done by adding a jawline implant closer to the lost angle area to add some vertical length and a little bit of width.
Revisions of the jaw angle reduction scars can certainly be done and would likely result in a better outcome since they would not have the original traction. (pulling and stretching the skin to cut the bone) The interesting question about your scars is whether that access should be used for the placement of the implants since you have them already. That would make your recovery much easier than from gong inside the mouth. Whether the implants can be used forms standard stock sizes or should be custom made from a 3D CT scan is another issue to debate.
One of the may problems with chin implants done in women is that they are are often too wide as extended anatomic styles are often used. The question here is whether it should be replaced with a smaller central button style chin implant (which is far more appropriate for female faces) or replace with a fat graft with its unknown survival rate.
Lastly, fat grafting can be done for the nasolabial folds and eye hollows with the only real issue bend their survival is the risk of some unevenness or lumpiness in the eye hollow area due to the thin skin. This can usually be minimized by using a micronized fat grafting technique where the fat particles are made very small before injecting.
I hope these comments are helpful and if you can send some side view pictures that would be useful for further analysis.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I may be interested in a revision rhinoplasty. I had excessive swelling after nose tip rhinoplasty; nose tip looks great, but my formerly thin nose is much wider and uglier above the tip; and very damaging to me psychologically. I have had two Kenalog (diluted) injections within 15 to 18 months post-op, with limited results. I am completely aware of the risks of revision rhinoplasty. Please advise on whether further kenalog might help, or would recommend a revision.
A: At over one year after a rhinoplasty, there is not going to be much of a change from any form of steriod injections. Steroids or even 5FU work by either preventing or helping to break down early scar tissue formation. This can occur when the collagen bonds are relatively newly formed. But when the scar is mature, as it would be at one year after the initial rhinoplasty, the collagen bonds are too stable to be pharmacologically broken down. Whether a revision rhinoplasty will help thin out a nose above the tip in the middle vault area or higher, however, is suspect. It is not like in the tip where scar tissue can be easily removed and additional reshaping of the cartilages can be done. There is also the distinct possibility that with a more narrow tip, the rest of the nose above it may merely look bigger by comparison. That may not be a major component to the existing nasal issue, but it may be part of it.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in a revision rhinoplasty. Do yout have experience in removing medpor L shaped implants? This nose has become tight and hard.
A: Revision rhinoplasty often involves removal of synthetic implanted materials. I have removed more than my fair share of Medpor implants all over the face. I am assuming when you say an L-shaped Medpor implant you are referring to its use in the nose for dorso-columellar augmentation. Contrary to common perception, medpor implants can be removed without undue difficult even though they get fibrous tissue ingrowth into them and can be quite adherent. Their removal from the nose is the ‘trickiest’ area to do it because of the naturally thinner tissues of the overlying skin. The tissues may be very carefully lifted off of the implant so as not to damage the blood supply to the overlying skin. I have removed such nasal implants numerous times over the years but the key questions is…what do you want to do to replace it? Depending upon its size, the tissues can contract and become distorted after its removal. In other words, your nasal skin and its shape is not going to return to what it was before the initial implant surgery. This is the more important concept to consider in your revisional rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a revision rhinoplasty several weeks ago. My first rhinoplasty left me with an obvious silicone nose with a dropping tip and big flare nostrils since I am Asian. At that time I was concerned about the bridge only. After the revision (they used rib), it looks natural and even a bit slimmer since they did fracture it as well. But somehow I feel it was shorter than my silicone nose. I asked my surgeon about this and he told me that my skin is so thin that it would look fake if they put something in to increase the height of the bridge. He even said he had to dice the rib bcause of this. I just wanna know is there still any hope to make it higher without being unnatural because of this thin skin. Thank you.
A: I believe what you refer to as a ‘shorter nose’ really refers to the height of the dorsum rather than the actual length of your nose. By your description, your silicone implant was bigger than the rib graft that replaced it. This is particularly evident as the rib graft was diced, most likely done because the harvested rib was not straight and dicing it ensured that the risk of warping after surgery was eliminated. Large silicone implants do tend to thin the overlying nasal skin due to pressure and the lack of an underlying vascularized surface doing the outward push. When replacing such an implant one certainly doesn’t want to place a bigger implant or even one that is exactly as big in height. (implant thickness) But in using rib grafts in rhinoplasty, particularly in a diced form, the graft size could have a good height as this more natural material allows blood vessels to grow through it. This rduces the risk of further thinning of the skin or skin compromise.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m looking to get a revision rhinoplasty to fix facial asymmetry and improve appearance. My goals are to straighten my nose and decrease the amount of tip projection. Can you take a look at the attached document which shows some computer imaging and let me know what you think? Thanks!
A: Thank you for your inquiry and sending your goals. One of your nasal goals ia achievable, the other is not. Straightening a nose, particularly after a primary rhinoplasty, is always a challenge but potentially achieveable. Correcting the deviated nose would require a complete septoplasty and grafts to stabilize the realignment from an open rhinoplasty approach by separating the upper lateral cartilages from above for access. Shortening the nasal tip projection by the amount you have shown is not a realistic goal. While the cartilaginous framework can be shortened that much, the overlying skin is not going to contract down that far. And if one tries to reduce the support for the tip skin by that much, the tip skin is likely to end up with a ball-like deformity. It is far safer and more realistic to settle for a 1/3 or perhaps 1/2 that much reduction to avoid intractable tip skin problems.
I make these comments as general statements without knowledge of what was done during your primary rhinoplasty. Knowing those structural changes may change the aforementioned opinions.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in neck liposuction, revision rhinoplasty, and cheek augmentation. I want to get rid of neck fat, define my jaw and neck line, straighten nose-one side of nose is bigger, and add volume in mid- and lower cheeks and under eyes. I have attached pictures for your review and assessment.
A: In looking at your pictures and your areas of interest, I can make the following comments/recommendations:
1) You jawline is ill-defined because your chin is both horizontally and vertically short. This makes your lower face look very deficient and creates a lack of any jawline definition. What you would ideally benefit from is a vertical-lengthening chin osteotomy which adds lower facial height and creates a more obvious jawline. This will also improve the appearance of a fuller/fatter neck although some submental liposuction done with the chin procedure would complement that improvement.
2) Your nose shows numerous secondary rhinoplasty issues. I do not have the benefit of knowing what you looked like before but I see issues relating to lack of upper dorsal height, tip asymmetry/thickness, nostril asymmetry and a deviated columella.
3) The need for volume in your cheeks and lower eyes is a bit perplexing to me. I see no benefit to lower eyelid volume augmentation. Perhaps with the chin lengthening, more volume in the lower cheeks (submalar implants) may be aesthetically beneficial to you. I have left those areas unimaged so you can see the other more important areas of facial change first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a revision of my primary rhinoplasty last summer and don’t like the shape of the nostrils and the tip. I also don’t breathe well from right nostril. Do you think I need grafts from ears or rib??
A: In looking at your frontal picture, I see widely spaced domes on the tip and significant tip asymmetry due to the right alar rim being very low compared to the left side. The profile view from the left side show a big step-off at the mid-columellar incision.
Your nose certainly has room for improvement, particularly given that you have had two rhinoplasty procedures. Why you have ended up with this result is a bit puzzling given that you have had open rhinoplasty approaches. I certainly would be tempted to say that further improvement is certainly possible but whether cartilage grafts are required to do it is a bit premature. It would be helpful to have more information if possible such as the operative notes from the two operations. That issue aside, what is needed always becomes evident in a revision when the tip is degloved and anatomy of the tip cartilages become evident. While swelling and scar tissue can obscure underlying tip cartilage anatomy, most external tip deformities are a direct result of how the underlying cartilages are shaped. You have such a significant tip deformity that I would wager the right lower alar cartilage is twisted and rotated downward, perhaps due to lack of support. In that case, cartilage grafts are needed such as a strong columellar strut from the septum and an alar onlay graft from ear cartilage. I would doubt that rib cartilage is needed. But I would leave that as an option to be determined during your revisional rhinoplasty procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, a month ago I underwent jaw advancement surgery as well as open rhinoplasty. My surgeon harvested bone from my skull and used it for both the nose and the jaw. Immediately after the surgery I realized that I had a hump, which I never had. I had a droopy nose and flared nostrils, but I had a really nice bridge, no hump. As the inflammation subsided, it became more and more apparent that the bone implant was very visible and crooked. I consulted my surgeon and he said it was just swelling. I saw several other surgeons and they all said it was not swelling, that it will not resolve, and that the bone was poorly shaped and implanted. I now must find a doctor to correct this deformity and I would like your professional opinion as to how long I should wait for a revision.
A: I don’t know the other details of your open rhinoplasty, other than you clearly have had a cranial bone graft augmentation. While cranial bone would not be my first choice for dorsal nasal augmentation, the logic of using it if bone was being harvested anyway for your mandibular osteotomy is logical. While you are only one month out from surgery and there still is persistent swelling, I would agree that the bone graft is oversized. While cranial bone will undergo some remodeling and even potential loss of volume, there is no assurance that this will happen in an even and regular fashion. Most certainly, you can not count on it remodeling into the desired amount and shape of dorsal augmentation that is desired. So the question is not whether a revision rhinoplasty will be needed but when and what exactly to do at the revision. There are arguments to be made for early vs delayed revision and, in my mind, it depends on what else was done to the nose and what the end goals were. If everything is fine and headed in the right direction with the rest of the nose and only the bone graft is the problem, then an earlier revision at 2 to 3 months could be done. If other aspects of the nose are undesired or unknown yet due to swelling, then it may be better to let the whole nose settle down and delay a revision until six months after the original procedure so any other adjustments can be done at the same time. One also has to factor in how much this new hump bothers you now, as if it is causing some distress, a revision can be done quite soon using a closed approach to remove, reshape and reinsert the bone graft so it has a better profile.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have an interest in a revision rhinoplasty. I had a prior rhinoplasty to try and make my nose thinner and smaller. But unfortunately that has not been how it has worked out. As you have previously written on your blogs, the more skeletal framework we take away from a thick nose such as mine, the more shapeless it may become. I have finally come to accept that my nose will never be small, but I am hoping that the tip can be a bit more defined. Also, I noticed that my nose exhibits lots of nostril show since the surgery. Would it be possible to make my nose longer, so that the nostrils will be less noticeable along with further nostril size reduction? Maybe you can see that my nose kind of looks like a pig’s snout similar to the “before” picture of the lady’s picture I have attached. I’ve attached a picture of myself along with a before and after picture I found online.
A: What you are talking about is that you have a bit of an overrotated nasal tip from the prior procedure, resulting in excessive nostril show. This can definitely be improved by a revisional rhinoplasty procedure using a derotation manuever with a tip lengthening graft (to push it down and forward) and nostril rim grafts to lower the outer alar rims. This would require a septal cartilage graft, which although some has been taken from the prior procedure, most likely enough may exist to do these extension tip grafts. This is an unknown variable that can only be determined at the time of surgery. As a secondary option, we would have to be prepared to use ear cartilage if necessary. Septal grafts are preferred because they are straight and more stiff.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a primary rhinoplasty over a year ago where my doctor used diced costal cartilage in fascia but I do not feel we had the same aesthetic vision. My nose is still larger and higher than I would like it to be (more masculine than feminine). I would like it to be smaller and more feminine. I am wondering were I to pursue revision rhinoplasty, would the diced cartilage with the fascia be shaved? If so, would new fascia (requiring a second operation site) need to be applied over the shaved sections? I am trying to assess the risks associated with revising a rhinoplasty that was done using diced cartilage and the likelihood that it can be reshaped. I can live with my nose today but don’t like it.
A: When undergoing a rhinoplasty, because it is a facial structural change, it is important to see what the result may be like through computer imaging before surgery. This is an operation that is about changing how you look so there is significant psychological overtones to how the result will impact a person afterwards. While computer imaging is a prediction and not a guarantee of a rhinoplasty outcome, it does shake out whether what the plastic surgeon envisions and what the patient hopes to achieve are closely matched.
Secondary revision of a prior dorsal augmentation with diced cartilage can be done. The augmented cartilage can be shaved down or completely removed depending upon what creates the best aesthetic result. It almost sounds like in your case that the need for an augmented dorsum may not have been desired at all since you now realize that a smaller and lower dorsum is desired. You have correctly pointed out, however, that dependent on how smooth the diced cartilage reduction is done that some graft coverage may be needed. If there are some irregularities that are best covered by a graft, I would choose an allogeneic dermal graft (less than .5mms or less) rather than another fascial harvest.
Dr. Barry Eppley
Indianapolis, Indiana