Q: D. Eppley, I am contacting you because you are the only surgeon I found that discusses Medpor implants extensively on your blog. I had a rhinoplasty with 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 and the entire tip is bulbous.
I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty. 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). I have what appears to me to be pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball away from my bridge. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose with a ball of tissue 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 rhinoplasty.
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.
A: While I have not examined your nose, the question for your revision rhinoplasty is what is the source of the tip problem and what is the best way to solve it. Between the implant and the scar, it is hard to know the bigger source of the problem but in my opinion but need to go. This is best accomplished with an open rhinoplasty with replacement of the implant with a septal cartilage graft.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a revision rhinoplasty that lengthens my nose. I had a rhinoplasty several years that ended up shortening and lifting my nose too much. This is not a good look for a man. I have read that the best way to do the procedure is with cartilage grafts and the rib may be the best source if substantial lengthening is needed. Does the rib graft make the nose feel any different such as being very rigid?
A: When considering revision rhinoplasty for tip lengthening and derotation, it is important to understand the anatomy of the nasal tip cartilages. The nasal tip cartilages are the only structures in the nose that are ‘free floating’, they are not attached to the underlying septum or upper lateral cartilages by fixed rigid attachments. This is why one can move the tip of the nose around freely and it is compressible, unlike the upper nasal bones or cartilages for example. When any tip lengthening procedure is done, which requires cartilage grafts, by definition more structural support is added and it will become more rigid. It will never be as soft and compressible as when it has less cartilage support. How rigid it may become is a function of the type and amount of cartilage grafts that are needed and how they are placed.
The cartilage grafts needed for significant tip lengthening/derotation must be placed between the fixed structures of the nose and the free floating tip cartilages. This is the way you drive down the tip of the nose. In essence, you are building up the underlying support to push out and down the tip. The grafts can not merely be placed on top of the nasal tip cartilages, that is only effective if you need just a few millimeters of lengthening or derotation effect. To really be effective for tip lengthening, straight pieces of cartilage are needed that are placed in an almost tripod fashion behind the tip cartilages. The use of a rib graft ensures that an adequate amount of cartilage is available.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in revisional rhinoplasty. I have had two reputable doctors turn me down for revision saying that I do not have enough natural cartilage left to build up the nose and that I have too much scar tissue preventing the tip definition and bridge length and height I desire. Please let me me know whether you can revert my current nose to my birth nose – longer, more heightened bridge and defined tip.
A: In revisional rhinoplasty, having adequate building materials (cartilage) is often the key to any degree of success. When it comes to using cartilage for the nose, there are three sources…septum, ear and rib. One is never out of enough natural cartilage because the ribs are an endless source for the amount needed in any nose. The issue may be that your septum and ear from prior surgeries has been used or the cartilage volume demand exceeds what they can supply. While I don’t know your prior rhinoplasty surgery history, most likely they were more reductive procedures so your septal and ear cartilage sources may still be available. But in augmenting your nose throughout its length, the amount of cartilage needed probably exceeds these sources. Thus you do have enough natural cartilage to use but you may not prefer or your other surgeons do not do rib cartilage harvests. But to get nice straight pieces of cartilage that are needed for this type of augmentation rhinoplasty, rib graft cartilage would be best.
While your nose undoubtably has scar tissue, that would not be a limiting factor in increasing dorsal height and bridge length. It can very well be a limiting factor in improving tip definition however.
One important realization is that you at never going back completely to your original nose. You may get close but it will never be able to return exactly to what it was before surgery. That well may be exactly what your two doctors were really saying…they may have felt that what you wanted to achieve is not possible and for what can be achieved may leave you wanting and disappointed.
Dr. Barry Eppley
Q: Dr. Eppley, I am seeking a revisional rhinoplasty. I have had three nose surgeries, the last two years ago. Five years ago I had a rhinoplasty and revision by one surgeon but I was left with a bone spur on the bridge and a long nose with a heavy tip. I then had a revisional rhinoplasty by another surgeon who removed the bone spur and shortened my tip. But my nose tip is still much fuller than I like and my nose overall still does not have quite the shape I would want. Do you think a third revsional rhinoplasty (fourth surgery) would be helpful at this point? I just want to get it finally fixed.
A: When it comes to any nose that has been operated more than two times, it is no longer an issue of ‘fixing it’ as scar tissues and other issues make the quest for an ideal result no longer possible. The multiply operated nose can only be potentially improved in some areas and other areas not at all. Thus it it important to clearly identify the exact nasal concerns one has, make a priority list of what is most important and then have me (or other plastic surgeon) decide which on that list has the potential for improvement and which concerns can not be improved. Whether further rhinoplasty efforts are worth it, no matter how unhappy one may be with their nose and what they have spent in the past, depends on whether the most important concern at the top of the list is one in which has the greatest chance of improvement with further revisional rhinoplasty. At your point in time with your nose, this is how you determine whether any further surgery justify the efforts. There are no simple or quaranteed fixes (as defined by one more surgery or tweak here and all will be better) in the tertiary or quaternary rhinoplasty patient.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in a sliding genioplasty revision. Four weeks ago I had a sliding geniplasty but I now think it was moved too far forward. It is easier to change the chin bone now or wait until it heals. Will the chin bone become harder to correct with time? I was not aware as I thought the soft tissues should be healed as to not disrupt muscles etc (this apparently takes 12 weeks), and I still have numb areas on the right side of my chin. Weighing up the pros and cons overall, when is the best time to perform the operation to achieve a better chin result?
Also, I had a rhinoplasty two years ago but have never been happy with my tip. It is still bulbous, maybe even bigger than it was before. Should the revision be done open or closed?
A: A revision of a sliding genioplasty can really be done at any time whether the bone is completely healed or not. The time to do revisional surgery on your chin is based on two considerations, when you are certain that the result you have is aesthetically unacceptable and the state of the bony union of the osteotomy. On the one hand, you would ideally like to change the chin before the bone has completely healed. (6 to 8 weeks) On the other hand, you never want to do a revision before the final result is seen so the patient has time to both adjust to the new look and is certain that a change is needed. You can see how both of these concepts must mesh to pick the ideal time for a revision. The state of the soft tissues (muscles) has really nothing to do with it.
In regards to the nose, the best chance for an improved outcome is an open approach where the needed and desired tip changes can be done under direct vision.
Dr. Barry Eppley
Q: Dr. Eppley, I may need a revisional rhinoplasty? I did not have breathing problems before I had a rhinoplasty? When I went back for a six month follow up I was told I had a deviated septum and needed more surgery. I was told I did not have one before surgery but that it has grown back that way now. Could the rhinoplasty have caused the deviated septum? Or was the deviated septum there before and it was just missed during the initial rhinoplasty?
A: One of the most common reasons for revisional rhinoplasty surgery is nasal airway obstruction. A recent published study of revisional rhinoplasty reported that up to 70% of patients had some degree of airway obstruction and was a main motivating factor for the surgery. There are many potential causes of breathing problems after rhinoplasty of which a deviated septum is but one. Usually, however, a deviated septum is diagnosed before or during the initial rhinoplasty and only ‘recurs’ because it was inadequately corrected. If there were no breathing problems before surgery, it would be unlikely that a deviated septum has developed now. With cartilage graft harvest, presuming that was done, septal deviation is less likely to occur.
One of the most common causes from the initial rhinoplasty is if osteotomies or breaking of the nasal bones was done, particularly if a low-to-low or even a low-to-high osteotomy pattern was done. A low initial starting point for the osteotomy can partially close down the airway. Another common reason is collapse or pinching of the middle vault which narrows the internal nasal valve, a critical point for airway passage in the nose. Both of these sources of nasal airway obstruction come from the common aesthetic manuever of taking down a hump or bump in the nose particularly if it is large. This can cause collapse of nasal structures which have to be recognized during the initial procedure to enable preventitive manuevers to be done.
The short answer to your question is that there may be other causes of airway obstruction besides a deviated septum that must be taken into consideration.
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 some type of revisional rhinoplasty. I had a major depression on the tip of my nose for which I got fat grafted to the tip. But now I feel I have a bigger nose than before and the tip doesn’t really have any definition. What should I do now?
A: With fat grafting to the nose that kind of result would be expected given that a ‘blob of tissue (fat graft) was done. Fat grafts fill space and provide no definition as it is an amorphous graft filler. Why was this method chosen as opposed to fixing the tip depression by cartilage reshaping methods which can fix the depression and give the tip more definition?
Generally major depressions on the tip of the nose that have been present since birth are known as a bifid nasal tip. This is where the natural separation of the meeting of the lower alar cartilages (known as the dome of the nose) are too widely separated and this separation extends down into the medial footplates. (over the columella) This creates a groove or visible split down through the tip of the nose. This is repaired by cartilage suture techniques that bring the widely splayed cartilages together.
What can be done for your nose now is to remove the fat graft and repair the depression with either cartilage suture shaping techniques or crushed cartilage grafts for your revisional rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, Let me first give you some background information. About 6 years ago I had several procedures including a rhinoplasty. The dr. that did the rhinoplasty removed something under the base of my nose possibly part of the nasal spine. The result was a change in the angle under my nose. Also my top lip seems to come down lower than it did before. While I know I am not at the point of looking abnormal I would like to look more like myself before the rhinoplasty. When I push up under my nose it looks more like the way it did presurgery. I think this can be achieved with a peri-pyriform implant. I am not sure if silicone or meseline mesh would be the best material. I am attaching photos. the first in each set is with no expression the second ones are of me pushing up under my nose to show the look I want. I look forward to hearing your opinion.
A: Thank you for sending your pictures. What you are demonstrating is not what any type of nasal base/pyriform aperture augmentation will achieve. In fact, it will achieve the opposite effect…pushing out on the nasolabial angle…but it will not push it back up as you have demonstrated nor will it cause the tip to elevate/rotate.
The changes you are demonstrating can only be done by a revisional rhinoplasty in which lower caudal septal resection and suturing the lower ends of the medial footplates of the lower alar cartilages back to the resected caudal septal area is done. That is what needs to be done to drive teh base of the nasolabial angle in a more superior position.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 25 year old male and I am interested in facial cosmetic surgery. My previous history of cosmetic surgery is otoplasty, rhinoplasty and a chin implant. I would like a more balanced face and more of an oval/square shape.
-Is it possible to augment more on the weaker side (jaw and cheeks) to balance asymmetry?
-On the cheekbone I would like to augment both the temporal process and the zygomatic bone, augmenting both the sides and front of the cheek bone (particular more augmentation on the right side to balance the weakness)
-On the mandible, i would like the Ramus more laterally augmented (a more square jaw) (also particularly more augmentation to balance the weakness on the right side)
-On the nose, a narrower and more defined tip
Left and right profile views:
-augmentation of the cheekbone (both the temporal process and the zygomatic bone)
-more square mandible angle
-slight de-projection of the nasal tip, lower and upper cartilage*
*Tip projection is more pronounced in the photos of the oblique smiling views.
I am sending pictures of anterior view and right oblique smiling view. If you could please send me altered photos with your expected results explaining the procedures you have added and why you feel so.
Thank you for your time and consideration
A: Thank you for your inquiry. Unfortunately the images you have sent me are inadequate for imaging. Only the front view is useful. A NON-SMILING oblique and side views are needed to get a more complete analysis.
1) It is not clear if the images are flipped or not. As I see them, the left side of your face is the smaller or weaker side.
2) The concept of oval and a square face are contradictory. As a male I will assume you mean more of a square facial shape is what you desire.
3) While the temporal hollows can be augmented, the bony zygomatic arch and its temporal process which lies below it can not.
4) Correction of facial asymmetries is difficult even using differently sized implants for each side. Improvement may be obtained but do not expect perfect symmetry as that will not happen.
5) Since you have already have a rhinoplasty, what was done to the tip of the nose initially? What tip changes ere already done and didn’t achieve your goals? It is now a scarred tip and a review of the previous operative note would be helpful to know what now lies underneath and whether cartilage grafts were harvested from your septum. You also have a right middle vault collapse, a step-off at the osteocartilaginous junction, significant nasal deviation and nostril retraction/asymmetry. These and the desire for tip de-projection are going to require cartilage grafts.
All this being said, I have done some imaging based on the one useful frontal view that you have provided with jaw angle, cheek and temporal implants as well as revisional rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, I recently had augmentation rhinoplasty to build up my bridge a and bilateral spreader graft to widen my nose. I am not sure the use of ear cartilage was appropriate for my wants. I wanted my radix to tip slightly augmented and my Dr. used ear cartilage. I never had an over done rhino before either it was a just tip work on my first. I just decided I wanted a more masculine nose. I am looking for some answers about a possible third rhinoplasty yikes. I have never had cartilage taken out of my nose. I am 25 year old caucasian male. I am looking for a surgeon who works well with rib grafts.
A: My assumption is that based on your description that the ear cartilage graft was used to build up the radix. But that has left you with more of a ‘scooped out ’ dorsum with too high of a radix and the rest of the dorsum too low or that the entire dorsum is now too high and more of a hump? When trying to build up the entire dorsum, I find it difficult to do that with a curved piece of cartilage that simply doesn’t have adequate shape for the complete dorsal line. But it is often used when a septal graft is not available and the concept of a rib graft seems too extreme. In a subsequent revisional rhinoplasty, the ear cartilage graft can be removed and replaced with a rib cartilage graft which offers a straighter piece that can be more assuredly shaped to the desired result.
Dr. Barry Eppley
Q: Dr. Eppley, are you familiar with 2ndary rhinoplasty.? I also need to correct my septum which is crooked. My projection needs to be reduced and I need cartilage grafts placed in my nose because I can’t breath.
A: I am very familiar with secondary or revisional rhinoplasty procedures. Your use of rhinoplasty terminology suggests that you have not only had a primary rhinoplasty but have done some homework as well. What exactly did you have done in your original rhinoplasty and how long ago was it done? I assume your septum has always been crooked and was not corrected during your initial procedure or was it the result of an inadequate straightening from the first surgery? Were any cartilages grafts harvested from the septum in your first rhinoplasty? I will assume that your use of the term ‘projection’ refers to the tip. Is it too high now because of the first surgery or has it always been too high? Are your breathing difficulties a result of the first surgery or have they always been present? I will also assume that you did not have spreader grafts placed during the first surgery.
Please feel free to send me any pictures of your nose with these answers. Secondary rhinoplasty can be a very effective procedure but the surgeon must have a thorough knowledge beforehand of what occurred in the initial rhinoplasty.
Dr. Barry Eppley
Q: Dr. Eppley, I’m 27 years old. I need your help to correct my facial cosmetic problem. I had chubby cheeks and broad nose tip, a saddle bulbous appearance. It did not go well with my body as I’m of medium built. I always wanted to have chiseled face and sharp nose. I finally went to a cosmetic surgeon to get this corrected. The doctor performed a face liposuction, rhinoplasty and he also made a cut in my upper eyelids as I had some fat there as well. This procedure was done in January 2009. After this I developed facial asymmetry. The outcome of this surgery is listed below:
Cheek liposuction :
– The right side of the cheek looks more chubbier than the left one.
– The right corner of the mouth does not move as much as the left one.
– The right side cheek pad is sagging in mid cheek region towards the nose.
– Both cheeks lack toning.
– Face still looks chubby & not chiseled.
– Hardly any difference.
– Nose still looks bulbous.
I went to the same doctor asking for correction but he never agreed to these flaws and in fact tried to ignore. I felt cheated and went to another surgeon. He extracted the buccal fat from my cheeks. However, still my cheeks look chubby. For my nose he has just placed the L-shaped implant through inside of the upper lip without making any other changes to the nose. I like the upper half of my nose as i needed little augmentation there but not in the later half. This has not solved my bulbous nose or wide tip problem. The shape of my nose has not changed. It just looks ” Over Augmented” specially in the lower part. This was done recently in September 2012. The surgeon says he can remove the implant if I don’t like it and give a stitch in the tip to narrow my tip.
I really wish to get this fixed as soon as possible as my life has stopped I really need to move on. Although I belong from a middle class family, I went out of the way to get this done but just ended up wasting my hard earned money. I am a focused person about what I want to achieve in life. I know things have gone wrong but I have not lost hope as I believe nothing is impossible if you are hopeful.
I just need right guidance & skilled specialist who can help me correct this. I have read good reviews about you and seen your picture gallery. I really appreciate your contribution in the field of cosmetic surgery. Please help me with whatever best can be done. I have attached my photographs for your kind reference. Please revert to me and let me how we can take it further.
A: Thank you for your inquiry and sharing your unfortunate cosmetic surgery experiences. Your issues break done into two areas; your nose and your chubby face. It looks like you have had some negative effects of liposuction including asymmetric fat removal and weakness of the buccal branch of the facial nerve on one side. Since you have already had the buccal fat pads removed, ti is not clear how much more improvement, if any, can be gained by further attempts at subcutaneous facial liposuction. I know that you are very unhappy with your fuller cheeks, but I do not think there is any ‘magical surgery’ that can provide the amount of facial slimming that you desire. It may be worth an effort to do some small cannula liposuction to try and get some areas more even but there is no operation that is going to make your face chiseled…it simply does not exist from where you are now.
Conversely, I think your nose does have room for more significant improvement from a further rhinoplasty effort.. What is not clear to me is exactly what has been done. (or even why) It is not clear at all what was done on the first rhinoplasty and the second rhinoplasty appears to merely have been the placement of an L-shaped silicone implant. It does not appear that you have had any real tip work done other than to try and stretch it out with an implant…which may have only pushed the wider tip up higher. I think you would benefit by some tip work for narrowing but the real question is what to do with your L-strut that is in place. There is dorsal augmentation benefit to it being there but it has also now stretched out the tip skin so removing it and not replacing it with something is going to make the tip situation worse. Normally I would opt for a rib cartilage graft replacement but that may further than you want to go.
Dr. Barry Eppley
Q: Dr. Eppley, I had a rhinoplasty in 2010 and I feel that it looks short for my face, nostrils not the same shape or size, alar base too round and wide, nostrils are flared. Nose is upturned and too short for my face. I feel my upper lip has too much space from lip to nose. Would like a softer more feminine appearance.
A: Thank you for sharing your story and photos. I obviously do not know what your nose looked like to start with and exactly what was done to your nose. It would be extremely helpful to see photos and the original operative record from your 2010 rhinoplasty. What types of grafts were harvested (if any), where they may have been placed, and what is left of the original cartilaginous structures will all play a part in what needs to be done. Secondary rhinoplasty surgery is usually much more difficult because of scar, distorted structures and sometimes depletion of easily available cartilage graft harvests.
But that important issue aside, your nose is short with wide nostrils. The tip lacks projection, the columella is short and upturned and the dorsum is low. Such a nasal shape is very characteristic of many ethnic rhinoplasties. (as said by a Caucasian plastic surgeon) In changing your nose to your desired goals, it is a matter of the degree of change. It is an issue of either tip derotation and nostril narrowing or that combined with dorsal augmentation. That aesthetic difference is important as that would determine the type and amount of cartilage grafting that will be needed. But either way cartilage grafts would be needed and most likely that means costal or rib graft harvesting to get the amount of straight pieces of graft needed, particularly if dorsal augmentation is going to be done.
As for the lip lift, I don’t see the benefit in your case. Your upper lip skin is already at a good length with substantial upper lip vermilion show. I think you perceive your upper lips as short, as least partly because of your short and up turned nose. While I doubt its benefits to you, I would at least wait until the nose is done and see what you think about your lip then. An open rhinoplasty and lip lift has to be performed separately anyway due to blood supply concerns of the intervening columellar skin.
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, I had a rhinoplasty done in 2008 which was the worst decision I ever made. The surgeon overresected my dorsum, leaving me with an unsightly saddle nose deformity. I lost many friends and my confidence suffered for years because the nose was simply wrong. I am considering your diced cartilage injection technique because it’s the fastest way for me to regain my dorsum. May we discuss further?
A: What is important in any revisional rhinoplasty procedure is the result not that any one technique is faster or less invasive. When it comes to rebuilding the dorsum, you need cartilage and ac cartilage harvest. Whether this could be done from the septum, ear or rib depends on how much volume you need. Then there is the issue of a scarred dorsum as a result of the first procedure. This makes the skin much harder to raise and more difficult to get a good pocket. Diced cartilage, unless it is wrapped in a carrier (fascia or surgical) can create an uneven contour if it is merely injected in large volumes. It is more appropriate for small defect areas.
In short, the diced cartilage injection technique may not be suitable for a larger augmentation of a low dorsum. I would have to see pictures to be sure. Standard techniques such as cartilage onlays or block rib grafts may be suited for your revisional rhinoplasty. Don’t compound your original problem by seeking a technique that is ‘fastest’ or has the least recovery, have a technique done that offers the best result even if it is not the ‘fastest’.
Dr. Barry Eppley
Q: Dr. Eppley, I had a rhinoplasty two years ago of which I am not happy with the result. My nose now looks too feminine. It is upturned rather than long like I wanted it and the bridge of my nose seems too low now. The tip of my nose is still too wide and I see too much nostril now. I know that revisional rhinoplasty is difficult and my option are limited at this point. But what do you recommend as I trust your judgment. I have attached some pictures for your review and comments.
A: While I do not have the advantage of see what your nose looked like before, I can tell that you had a rhinoplasty and I see several improveable problems. First, the tip is overrotated superiorly, making the nose look short and giving it the false impression that the nasal bridge is low. Secondly there is alar rim retraction probably caused by lack of support from the lower alar cartilages from too much cephalic trim and/or as part of the tip overrotation. These conditions could all be improved by a secondary rhinoplasty which will require septal cartilage grafts to support tip derotation/lengthening, batten grafts for lower alar cartrilage support as well as alar rim grafts for nostril rim lowering. With your thick nasal skin, there is a limit as to how much tip narrowing you can achieve and you may have already reached the best that you can do.
Dr. Barry Eppley
Q: Dr. Eppley, I had a rhinoplasty done three years of which I am very unhappy from the results. I am of Middle eastern ethnicity and initially had a big hump on my nose that I wanted to get rid of. I just wanted my nose to look more proportionate and not be so big. Right after ther surgery it did look better but as the swelling went down after a few months it didn’t look as good. While the hump is gone, my nose is now twisted and somewhat deformed. My breathing got worse after surgery too. It seem like it is getting worse with each passing year, is that possible? i have attached some pictures so you can see what I mean. I know I need a redo rhinoplasty but what do you recommend to make it better?
A: Your nose has some of the classic problems from an over-resected or radical reductive rhinoplasty. I suspect this was done through a closed technique and you may have initially had a large dorsal hump. Your nose shows middle vault collapse, indentations at the osseo-cartilaginous junctions, a pollybeak tip deformity and alar rim retraction. The upper nose deformity can happen when a large dorsal hump is taken down and the resultant open roof is closed with osteotomies that get infractured too far. This causes disruption of the upper lateral cartilages from the nasal bones creating an ‘hourglass’ deformity where the hump used to be. The middle vault constriction (pinched middle third of the nose) is the result of too much of the height of the upper lateral cartilages being removed causing collapse and possible breathing difficulties from pinching of the internal nasal valves. The tip deformity is marked by a hump in the supratip area and alar rim retraction with excessive nostril show. This occurs when too much cartilage is taken away and the tip is no longer supported. It then collapses and retracts so that the upper end of caudal end of the septum (septal angle) is now more prominent than the tip.
Your revisional rhinoplasty would be done through an open technique using spreader grafts for the middle vault, rasping of the dorsum, lowering of the lower end of the septal height, and columellar and alar rim grafts to the tip. In essence, cartilage support need to be put back into your nose to improve its appearance as well as your breathing.
Dr. Barry Eppley
Q: I am interested in getting a revisional rhinoplasty but honestly this is a difficult decision. Overall I’m not eager to go through the whole process again. I’m trying to determine if my gain in appearance is worth putting myself through it again. I’m 43 years old now and somewhat concerned about my body healing as quickly or as well. As a side note, I am in good physical condition for my age as I do lots of exercise. I figure if I’m going to do anything more with respect to my appearance, now is the time. I may be having a bit of a mid-life crisis I suspect. I do have an appointment to see about Botox/filler/collagen and/or fraxel laser treatment in attempt to back-off the aging process which is now in full-swing.
A: It is always a difficult decision as to whether to revise a rhinoplasty or not. Having experienced the recovery once gives one pause to really assess the the benefit:risk ratio for round two. Given the fact that your rhinoplasty result may be very reasonable (no major complications or deformity) and you are shooting for a more advanced aesthetic outcome also makes one ponder it carefully. In the end, the appeal of the potential benefits has to outweigh the understandable disdain for the process to get there.
One potential advantage of a revisional rhinoplasty, besides that of the nose, is whether there are any other facial procedures that could be combined with it. These might include fat injections for fillers or any type of laser skin resurfacing. This is what I call an opportunity factor given that being in the operating room under anesthesia is a very rare occurrence.
Dr. Barry Eppley
Q: Dr. Eppley I am interested in revisional surgery. Over a year ago I had a rhinoplasty done. While there have been some improvements, there are numerous features about it of which I am not happy. I would like tip size reduced/refined to reduce the overall size. I might be intereted in some more narrowing of the bridge depending on upon complexity and down-time. I have attached some pictures for you to review of where I am now.
A: Thank you for sending your pictures. I can tell by the appearance of your nose and your description that you have had prior rhinoplasty surgery. Based on your desires, I see an upper third (bridge area) which can be further narrowed by osteotomies, an indentation of the right osteo-cartilaginous junction between the right nasal bone and right upper lateral cartilage, and a tip that is a little too wide and with a slight amount of over-projection. The nose has a fairly good dorsal profile and tip rotation. (nasolabial angle) These are features that you don’t want to change. For a revisional rhinoplasty, I would do low lateral narrowing osteotomies for the bridge small cartilage graft for the right upper middle vault indentation, and tip shortening and narrowing. This would be done through an open rhinoplasty which I assume is how your first rhinoplasty was done. I have attached come projected imaging. Since it has been over a year since your first rhinoplasty it is reasonable to critique the result and consider any revisional rhinoplasty at this time.
Dr. Barry Eppley
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
Q: Dr. Eppley, I would like your opinion on my nose condition. My history is that I have always had a big nose, it being very big and fat particularly at the tip. During my first rhinoplasty, they shortened the bridge between the tip of my nose and the upper lip but the size of my nose remained the same. During a second rhinoplasty, another doctor took out all the cartilages. The nose subsequently increased in size on the top (created like a bump on the ridge). The doctor explained it to me that it was due to the internal scar and the thick texture of my skin. Then I had a third rhinoplasty with the same doctor as the second rhinoplasty. The nose has now increased to an unrecognizable condition. According to the doctor, it is the nature of my thick skin and inner scar. He advised me not to intervene any more, as no improvement is possible with my type of skin. Some time later, I had an injury to my nose and it became bent to the side a little with a hanging tip. The pictures I am sending you shows the nose after the third rhinoplasty and after the injury. After numerous consultations with various doctors, I decided to take a chance with injections of steroids. After 6 injections, my nose has decreased to what you can see in the pictures. But the doctor who has given me injections insists that my nose cannot be any smaller than it is right now. He says that since I need new cartilages to be inserted and the size of the nose will inevitably increase.
So my questions are:questions:
1) Is it indeed possible to make it smaller or at least a little thinner?
2) If new cartilages are inserted, can it still at least become thinner (doctors say that it will be only bigger)
3) Will it be noticeable that I had prior rhinoplasties?
4) How realistic is it to expect a smaller nose with my type of skin and inner scars?
I greatly appreciate you taking the time to look it over.
A: Thank you for sharing your rhinoplasty history and your pictures. While I have no idea what your nose looked like when you started, there is no question now that you have collapse of the lower 2/3s of your nose. Too much cartilage has been removed so the skin has no little support. This explains the nasal appearance after your second rhinoplasty and why it so easily got bent with the trauma. Ironically removing the cartilaginous support underneath the skin, if done excessively, actually makes the skin sleeve look bigger and sag more. A little cartilage tip cartilage removal and reshaping is one thing, a lot removed can turn into a disaster.
The question, of course, is what can you do now? If you are having any breathing problems (and I imagine you might) then rhinoplasty reconstruction with cartilage grafts (probably rib) can be beneficial. That will actually provide some midline nasal support, like a tentpost, and can possibly make the nose look somewhat thinner. When done through an open rhinoplasty, excess skin can be removed from the edges of the incisions which can also be helpful in creating less of a skin sleeve.
As you may have surmised, yours is a very difficult but not an impossible nose problem. All of your prior surgeries and steroids have definitely created scar but that is not a signficant problem in an open rhinoplasty approach. In conclusion, do I think you can be better than where you are right now…yes. You will never have a thin or small nose but it can be better shaped and supported to look less large than it does now.
Dr. Barry Eppley
Q: I am in need of revisional tip rhinoplasty. But I have been warned strongly about the risks of ear cartilage, since my septal cartilage is quite probably inadequate to serve as a graft source. It would be more than a pity to spoil the present symmetry of my nose tip in the pursuit of a small derotation/lengthening. I was wondering about the possibility of newer advancements with stem cells in plastic surgery. They have received great publicity and already articles are being written on the new potential they offer and the speeding-up of changes for reconstructive medicine. I would be extremely grateful and certainly willing to undergo the surgery at any expense if you would be in a position to predict near-future applications, and incorporate them in your practice at least for volunteers to whom this would mean so much. Lots of grateful thanks, and I hope to hear from you again with some promising news or estimations, or even information some time later.
A: Stem cells in plastic surgery to make new tissues remains a hopeful but unproven surgical technique. Its appeal is great and that makes great print and internet copy but there remains a far leap from the laboratory to that of useful clinical applications. I do not know why anyone would tell you that there is ‘danger’ with ear cartilage in revisional rhinoplasty It is a very reliable, simple, and predictable graft material to use in the nasal tip and has a very long history of successful use in revisional rhinoplasty. Even if stem cells could make cartilage (and someday they will in the near future), they could not make a graft that would be better than actual ear cartilage. .
Dr. Barry Eppley
Q:How difficult would it be to remove a dorsal onlay graft composed of a continuous piece of septal cartilage? The underlying structure of the nose was not changed.
A: Cartilage grafting in rhinoplasty is commonly done for a variety of structural enhancement reasons. Building up the bridge of the nose, widening the middle vault, and supporting and expanding the tip of the nose are common reasons for the use of cartilage grafts in rhinoplasty. Raising up a low dorsum, also known as the bridge of the nose or dorsal augmentation, can be done with cartilage grafts or synthetic materials. When possible, the use of your own natural cartilage is always best as it poses no long-term problems in terms of infection or tissue reaction. The most common problems with cartilage dorsal augmentation is shifting or asymmetry of the graft, underprojection (not enough height) or overprojection. (too much height which is rare)
Cartilage grafts to the nose heal with a surrounding capsule or scar. Inside this envelope sits the cartilage graft. Much like the original mucoperichondrial lining from which it was harvested (septum), this lining can be raised up and the cartilage graft exposed and removed. The cartilage grafts do not heal and become one with the surrounding cartilage like a bone graft would do in other areas of the face. There remains a clear demarcation between graft and the surrounding tissues. It should not be a problem to remove it in one-piece although it is best done through an open rhinoplasty approach.
Because it is a septal graft, it is unlikely that enough volume has been placed to make the graft too big or too high. I would be curious to know what about the graft makes you want to remove it.
Dr. Barry Eppley
Q : I recently had a rhinoplasty approximately 3 months ago. The purpose was to make my nose more symmetrical (nose was crooked due to getting hit in the nose 10+ years ago) and smaller/narrower. I consider the results (as I see the nose today) as somewhat of an improvement, but I believe that better results (potentially much better) are possible. Furthermore, I am not 100% certain, but I believe that the results were better the day I got the cast off than they are today (could be my imagination though).
A: Thank you for sending your photographs. My first general comment is that the details of a rhinoplasty often don’t become revealed for several months after surgery. While all areas can look great right after the splint is removed, asymmetries may appear in the tip or bridge as the swelling subsides over the next few months. As I tell my patients, we will not have a victory parade until 3 to 6 months later when the final results will be seen.
In looking at the pictures and reading your comments, the issue is that of the asymmetry of the upper part of your nose from the position of the nasal bones. There is an asymmetry of the nasal bones after osteotomies, the right is more infractured (and perhaps more thoroughly osteotomized) than that of the left. The asymmetry is probably a combination of positional issues on both sides, the right nasal bone is in too much and the left nasal bone is out a little far.
Correction could consist of further infracture of the left nasal bone and onlay augmentation of the right nasal bone. Outfracture of a nasal bone is unpredictable in stability.Ideally, cartilage is the best onlay material but an adequate piece in size may not be obtainable from the septum. (based on your previous surgery) An alternative onlay option is a thick piece of allogeneic dermal graft.( available in 2 and 3mms thickness)
Since it has been three months, I suspect that what you see now is the way it will be. A revisional rhinoplasty could be done in the next few months, about six months after your initial surgery.
Dr. Barry Eppley