Your Questions
Your Questions
Q: Dr. Eppley, I am interested in rhinoplasty surgery.There are two main things I would like to change about my nose, that you will see from these photos. I have a small bump on the bridge as my nose, but I also really want to change the tip of my nose. My nose isn’t too wide or anything, but the tip and the bump are my two biggest concerns. The tip is the part I am most worried about and have been hesitant about rhinoplasty in general for fear that it won’t look natural after surgery.
A: Here is some imaging for your rhinoplasty. Your rhinoplasty is not quite as simple as ‘just take away the bump and lift the tip’. One of the reasons you have a bump on the bridge of your nose is because you have a very low radix or frontonasal junction. (the area above your bridge) This is part of your overall more recessed mid facial development. The bump is actually a pseudohump. It appears to be a hump because the bone above it is deficient. Just taking down the bump will make your nose look too low in this area. While some hump reduction is needed, the area above the hump must be augmented with carriage grafts as well. (radix augmentation) Your nose is also long with a hanging columella. The end of the nasal septum must be shortened to allow for any tip rotation upward as well as retraction of the hanging columella. With the hump reduction the tip absolutely must be shortened and rotated upward otherwise your nose will look even longer.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin and jaw enhancement. I am reaching out to you after doing thorough research in hopes that you could bring some clarity to my concerns and harmony to my face. I am attaching pictures of me in different angles as well as pictures that I have edited with photoshop which reflect a look I would like to achieve. Whether that is possible or not, that is something I trust you with.
I am a female model currently living in Los Angeles. In this industry strong, defined bone structure such as jaw line and cheek bones are critical to a models success and highly sought after. As it stands I have a receding chin that I would like to correct and perhaps dramatize the look of my jaw. In your opinion, what does my face need in order to achieve a more defined look, like presented in the pictures? What are my options? As an out of town patient, planning a surgery requires more resources and time. I am looking forward to hearing your thoughts on improving my face as well as to get a general idea of the cost break down per procedure. Thank you in advance for taking the time to read my email, I greatly appreciate it.
A: Thank you for your inquiry regarding jaw enhancement and sending your pictures. What separates your face from that of the model pictures you have shown are three facial features. The jawline (chin and jaw angles) and nose are the most strikingly different. Besides the shorter chin you have mentioned, your jaw angles are more rounded and indistinct. (unlike the models which are more square and defined) Such a more deficient jawline looks more so because of the size of your nose. (and vice versa)This can be treated by separate chin and jaw angles implants or a sliding genioplasty and jaw angle implants. Coming jawline augmentation with a rhinoplasty would make the most dramatic facial change that would enhance its overall features and bring them into better balance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I am seeking a facial profile enhancement. I am not happy with the way my profile looks. I would like your recommendation. I have a deviated septum so a rhinoplasty at the same time might be possible? I also have an overbite and I was wondering what you would recommend for receding chin… orthodontics or cosmetic surgery.
A: It is very common to do a septoplasty and rhinoplasty at the same time, known as a septorhinoplasty. You do have a short chin and treating its deficiency combined with neck liposuction would provide the best result. With an existing overbite the question is how significant it is and whether you are prepared for the commitment of a combined orthodontic-jaw advancement surgery treatment program. (orthognathic surgery) If not then a chin implant or sliding genioplasty would be the cosmetic treatment options. A rhinoplasty, chin augmentation and neck liposuction could all be done at the same time for a significant facial profile change. (facial profile enhancement)
A combination of nose, chin and neck changes can make for the most powerful and significant change in one’s facial profile that is possible. It usually takes at least two changes in one’;s face to create the optimal facial profile enhancement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about rhinoplasty and how it it planned and performed. How do cosmetic surgeons measure the profile of the face? From where to where? Is there a ratio that is considered perfect? Was it derived from the great medieval sculptors?
A: Contrary to popular perception, plastic surgeons do not use specific anthropometric measurements in planning and subsequently performing rhinoplasty surgery. While there are many known angle and measurements of the nose, and plastic surgeons are well aware of them, they are only roughly applied in performing the procedure. Surgeons use a gestalt about these anthropometric values and measurements rather than a precise application of them. Plastic surgeon may learn these measurements in their training or through experience but they do not use such precise measurements in surgery. This is because actual surgery does not translate well to afew millimeters or degrees of angulation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I originally sought rhinoplasty due to great discomfort concerning the projection of my nose. The tip feels enlarged and out of proportion to the rest of my face as well as deviating to one side. However, after speaking with a surgeon, I have come to learn that my jaw is retrusive which makes my nose look larger. I would like to know whether or not you think I would benefit from both jaw and rhinoplasty surgery, or whether you think one or the other would be enough to balance my face. I have attached some photographs in this email.
A: Thank you for sending your pictures. I think it is quite clear that in looking at them that the short chin/jaw is a far greater contributor to your profile concerns than that of the nose. Like many profile concerns, it is really a ratio of the nose:chin in looking at the deficiency and where the greatest improvement may come from what procedure. In your case I would put it at 80:20, jaw:chin. While chin augmentation will make a major difference, a rhinoplasty where the tip is thinned and a bit shortened will make for an even better result.
In many cases of rhinoplasty, the chin augmentation that may be done with it is complementary to the nose changes. But in your case it is the reverse…the rhinoplasty would be complementary to the chin augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Two years ago, I had a septoplasty procedure with turbinate reduction due to a diagnosis of moderate sleep apnea. It turns out my septum was severely deviated, essentially blocking air at the back of one nostril. Shortly after surgery, I could breathe and smell things much better. Soon thereafter, everything has returned to pre-operative functionality, if not even worse. The surgeon I went to is an ENT physician, and refused to do rhinoplasty. I was advised by physicians later that a rhinoplasty procedure likely would have improved my nasal function significantly, simply by lifting the tip slightly. Would I be a candidate? I am concerned, because others have told me it’s a jaw issue and I would need orthognathic surgery.
A: The rhinoplasty procedure that you refer is two-fold and relates to the only two external (outer) nasal procedures that are known to improve nasal airway flow, spreader grafts of the middle vault and tip rotation. While both may be able to improve nasal airflow I would have no confidence that they would substantially improve sleep apnea. The only facial procedure that can reliably improve sleep apnea are jaw procedures that pull the face forward, particularly the lower jaw with the attachment of the base of the tongue, to open the posterior airway. But given the magnitude of orthognathic surgery it is understandable why other effort (nasal surgery) may be on interest to explore first.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have two questions about rhinoplasty. First, is there any leeway in the 7 day recovery time? And the second one is I have seen that if you have trouble breathing, insurance may pay for some of the procedure. Is that true? I ask because my nose is a little crooked to the right and I feel like there is a big difference between the left and right side as far as breathing goes.Thanks.
A: Depending upon how one chooses to define recovery, only the first phase of a rhinoplasty is done at one week after surgery. That is when the nasal tapes and splints are removed. But that is far from when one has a full recovery from the procedure. But that is certainly the most obvious appearance part of it due to the external nasal dressing.
If one has breathing problems in which deranged anatomy is evident in a CT scan, then a predetermination with your insurance can be filed to see if they will pay for the functional or breathing part of the surgery. An insurance predetermination can not be filed without a recent CT scan report. The purpose of a predetermination letter is to provide your health insurance carrier with the information so they can determine if you qualify. But insurance does not cover any part of a rhinoplasty that changes the external shape of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a rhinoplasty. I’m looking for mostly tip narrowing and some nostril narrowing for when I smile, and also don’t like how close the bottom of the nose is to my lip when I smile. I’m wondering what you suggest.
A: It is important to recognize that rhinoplasty, like almost every other facial plastic surgery operation, is a static and not a dynamic procedure. The rhinoplasty operation is designed to fix anatomic problems in the shape and function of the nose that exist when one’s face is at rest and not smiling. Thus your nasal tip can be significantly narrowed and shortened and the nostrils narrowed, and that will have some positive impact on the appearance of the nose when smiling, but not to the degree that you may ideally like. The distance between the base of your nose and upper lip when smiling is a dynamic one that rhinoplasty will not really improve per se. Lifting the nasal tip may provide some illusion that it is improved but not by actual measurements between the nose and lip. That area of improvement is not an achievable or expected outcome from any rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a nasal hump reduction rhinoplasty. I have been looking into various options to achieve a straight nose in profile. As you’ll note from my photos this really is VERY minor – I’m under no illusion that this is not the case. Despite that I’m still very apprehensive about any work on the nose due to the complexity of it all and high revision rate. In particular I’m most concerned about affecting the nasofrontal angle negatively, and building up the bridge and radix too high whereby the eyes look closer together. The latter in particular is concerning as I’ll be having a midfacial operation that will widen the area even more. As such even a slight narrowing effect on the eyes could be exasperated later on with this next operation (infraorbital rim advancement).
As such, what would you recommend? As far as I can tell the position of my radix and nasofrontal angles are all relatively ideal. Would it be best then to shave down the dorsal hump? Or would building up the radix be ok given how minor it would be?
I look forward to your response.
A: My advice for you is not to have rhinoplasty surgery. The revision rate in rhinoplasty where patients have relatively major nasal shape issues is around 15%. When it comes to minor deformities the revision rate is higher…much higher. Contrary to popular perception, the smaller the nasal problem in many cases the harder it is to get it right. (perfect) The margin of error in minor aesthetic nose concerns is zero. It is just as easy to overcorrect in minor nasal shape issues as it is to get it perfect. By your own admission the position of the radix and nasofrontal angles is ideal and the hump is very minor. Be aware you will be scrutinizing the after surgery result just as carefully (if not more so) as the preoperative deformity. The chances of a successful outcome is no greater than an unsatisfactory one. Unfortunately rhinoplasty surgery is not a precise science and can not be controlled down to the level of a millimeter or two of structural changes.
In addition if you are going to being having infraorbital augmentation in the future, that facial change can potentially impact how you see other facial structures. Since that will be having a more major impact on your face I would defer any consideration of rhinoplasty until after that procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Thank you for your rhinoplasty consultation and doing some computer imaging for me. Now that I am moving forward with actual rhinoplasty surgery can you send me the exact prediction images of my nose results? That will help me understand what I can expect after surgery.
A: There is no such thing as ‘exact prediction images’ in rhinoplasty or any other facial surgery. Prediction imaging is done as a communication method between the surgeon and the patient to determine what changes the patient desires and to make sure what may be possible is in line with the location and extent of changes the patient wants. They should not be interpreted as exact replicas that surgery may achieve nor are they guarantees of the result that would be obtained. They are estimates as to what the surgeon believes may happen but can not take into account the exact anatomic changes they would be done nor the effects of healing on these surgical changes. Therefore one should appreciate the term ‘prediction images’ when it comes to this important presurgical step. Fortunately it is usually more accurate than predicting the weather but the accuracy of rhinoplasty prediction imaging depends on the surgeon doing it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in a rhinoplasty procedure where the nostrils would be thinned out. Not brought closer to the center but actually having each nostril thinned out. However I can’t find any literature or examples on the Internet (I remember reading about it years ago though). Is this a thing and can it be done?
A: You may have trouble finding such a rhinoplasty procedure (nostril thinning) because it is very rarely done. That does not mean it can not be done just that one has to consider the aesthetic tradeoffs very carefully. True nostril thinning (not nostril narrowing or base width reduction) is done by excising skin right along the nostril rims. While this can thin the nostrils it will leave a fine line scar and may also create some increased columellar show in the side view. (alar rim retraction) This used to not be an uncommon procedure in cleft rhinoplasty. Thus a patient has to be selected very carefully for it so one does not simply trade off one nostril problem for a new set of nostril problems that may be worse than what one had initially. Scars along the edge of the nostril rim do not heal as favorably as other nasal locations.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a combination of procedures including:
1. Brow bone implant augmentation using a custom made brow bone implant and possibly forehead augmentation as well. As you can see from the attached pictures this area of my face lacks definition. i would like a more masculine look. I had upper eyelid surgery done some six years ago. Unfortunately that was a botched operation, the surgeon operating on me sliced off too much of my left eyelid which has left the eye about half way to a third open when I close my eyes. The left eye is wider than the right when open. I was wondering, since the brow augmentation is performed around this area, would this type of surgery cause my eyes,particularly the left one to open further, thereby leaving the eye completely open when shut or when i am asleep? I guess implanting around this area is bound to pull the upper eyelid area upwards and pressure on the tissue surrounding that area.. I would not consider going ahead with brow bone implant augmentation if this is the case. Your opinion on this is greatly appreciated
2. Lip reduction to lower and upper lips. Just minor reduction to counter drooping which I notice and is probably due to me getting on in age. When at rest I can see the pink of my inner lips showing.
3. Alar base reduction in combination with Weir incisions to reduce nasal side walls and inner nostrils as well. When I smile my nostril flare excessively which bothers me, so I refrain from smiling as much as I can.
4. Finally I would like to raise/heighten my dorsal bridge as well as trim the bony area along the bridge to give definition. In addition I would like the bulbous nasal tip defatted if this is something you can do. Again, I just a subtle change as I do not want it looking to pointy.
5. I have had previous rhinoplasty with a premaxillary implant inserted below nasal base and I want to remove this.
Are these procedures you can do? Can you perform these procedures at the same time? Have you any experience performing all the procedures i have mentioned above on ethnic people like me?
A: Thank you for your inquiry and sending all of your pictures. In answer to your procedural questions:
- When it comes to a brow bone implant it is critically important that the decision for total forehead augmentation be considered using computer imaging. That has to be factored into the implant design. With the slope of your forehead I suspect brow bone augmentation only may only make the forehead look more inclined backward. As for the effect on the eyes, I have not really seen much effect on the eyelid position. If anyway I would think it would push the eyelids down lower and not pulled upward.
- Lip reduction almost produces less of a lip reduction effect than most patients want. So a more subtle lip reduction effect is the more likely one to be achieved as opposed to too much of a reduction.
- Reduction of nostril width changes the outer location of the nostril but has no effect on the inner nostril along the midline columella.
- The height of the nasal bridge can be raised and this can be done by either an implant or a rib graft. Since you may already being having a brow bone-forehead implant, I suspect the implant option would be more appealing. Reducing a bulbous tip in thick-skinned men always produces more of a subtle change and never a dramatic or a pointy one.
- The premaxillary implant can be easily removed.
All of these procedures can be done at the same time (custom forehead implant, rhinoplasty, lip reduction and premaxillary implant removal) The only thing ‘ethnic’ about your procedures is that of the nose and I have done many such ethnic rhinoplasties.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty and chin implant two years ago. But I am still not happy with shape of my nose, chin and face overall. I wish I can start over. I feel my nose is still too long and pinched and wish it was straighter and more refined. I also want a more angular facial shape with a masculine defined jawline and cheekbones. I think my chin implant has done only so much to help my desires. See my before and after pictures. Are my expectations and desires unrealistic? Can you help? Thanks so much.
A: Thank you for sending your before and after pictures. I think on both counts (rhinoplasty and chin augmentation) you have had good improvement and I would not agree that there would be any benefit to ‘starting over’…even if you could. You have reasonable results from both your rhinoplasty and chin augmentation. Your nose may be just a tad too long but that is a pretty good result. You are not going to be able to make any drastic changes to it other than perhaps some tip shortening. I do not know what you mean by being ‘pinched’. The refinement of any rhinoplasty is controlled by the thickness of the nasal skin. Having thicker skin there is a limit as to how much refinement can be obtained. You are likely as good as it can be. In that regard you probably do have some unrealistic expectations. Your chin implant has provided a substantial improvement and you would not want any further horizontal augmentation. What you are ‘missing’ from a facial skeletal standpoint is a lack of jaw angles and cheek prominence. The nose and chin have helped but they were not the sole solution to a more masculine face.
In short I would recommend some nasal tip shortening and cheek and jaw angle implants. This will then provide a more comprehensive approach to facial masculinization.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial reshaping surgery. I would like to make a great change on my odd facial appearance. I would like to have a facial reshaping on my interpupillary distance (IPD) and innerouterintercanthal distance (IOICD) because I think I got hypertelorism. I have 4.5cm telecanthus, 3.6cm intercanthal distance, 3cm orbit, 7.5cm interpupillary distance (IPD), around 14.5-15 cm facial width and around 19.5 cm facial length. What surgery should I do at this stage? Decrease interpupillary distance (IPD) by Facial bipartition or increase bitemporal distance and by custom implants? Thanks for your time. I am looking forward to your reply!
A: Thank you for inquiry and sending your pictures. For your facial concerns no major craniofacial surgery such as a hypertelorism or facial bipartition repairs would be appropriate. These are major intracranial surgeries with some significant risks that would not be justified for a cosmetic issue such as type 1 hypertelorism or mild increased intercanthal distances. Instead you want to think of other smaller facial reshaping procedures that can help improve that appearance. You have a low nasal bridge and epicanthal folds. Reducing the epicanthal fold appearance and augmenting the height of the nasal bridge (augmentation rhinoplasty) are well known manuevers that will help make the eyes looks somewhat closer. Making the adjoining areas wider (temporal augmentation) is another option to consider also. When you put all three of these facial procedures together they will do a lot to decrease your perception of the eyes being too far apart.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am getting a nasal implant for my rhinoplasty but I am very leary of necrosis and the aesthetic results and safety of a Shirakabe vs. Dorsal nasal implant. I would like to ask you whether the Shirakabe or Dorsal nasal is best for avoiding necrosis. Which one? or does it not matter? Would a dorsal nasal implant have good results since I have a bulbous tip? Aren’t Shirakabe’s better for Black/Afro American? Could you define my nasal tip more (having a dorsal nasal implant in comparison to a Shirakabe) without necrosis developing? Thanks.
A: I think in general one has to be very leery of having any type of synthetic material under the skin across the nasal tip. A nasal implant that puts any pressure on the nasal tip skin is destined for long-term problems. The issue is not immediate skin necrosis but long-term skin thinning, implant visibility and/or infection. Synthetic implants that cross the nasal tip area have a significant long-term risk of these issues. While implants work well for the nasal dorsum and have a much lower incidence of problems, the same can not be said for the nasal tip. The best ‘implant’ for the nasal tip is your own cartilage, particularly that of rib cartilage. If you were asking me what is the best to use both in terms of results and the lowest risk of potential complications, I would choose cartilage over an implant every time in rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley ,How many rhinoplasties have you performed? What is the percent of having to redo a rhinoplasty that did not come out as desired.
A: I have performed over 500 rhinoplasties in my career. The number of medical complications, such as infection, in rhinoplasty surgery is very low as I have seen only two. (both that involved the use of synthetic implants) Revisional surgery in rhinoplasty surgery, however, is not rare and in fact is actually common. These revisions are for aesthetic reasons and the national average is around 15% if not higher. That number is my rhinoplasty surgery experience is about right although it may be a bit lower. There are a large number of reasons for rhinoplasty revisions and some of that is driven by the patient themselves. Some patients can tolerate minor imperfections in their nose while other patients continue to seek absolute perfection and may go on to have multiple revisions. I have seen patients who are quite content with their result even if I has wished I could make some further improvements of it. Conversely there are other patients that desire a rhinoplasty revision when I would have preferred and thought more medically appropriate that they leave it alone. The point is that the risk of revisal surgery in rhinoplasty is real and not rare and one that every patient who undergoes the challenging operation of rhinoplasty must accept.
It is also important to differentiate the risk of revisional surgery based on the type of nose that is being treated. There is an enormous difference in the likelihood of needing a revision in a cleft rhinoplasty procedure that someone who only wants a small bump on their nose to be reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had eyebrow transplants done 3 weeks ago with 50 FUEs to each brow area, I’m looking to get a rhinoplasty with a silicone implant done a month from now. Can I just check and see if it will be fine to do so or will my grafts be damaged if I get a rhinoplasty done so soon after? My surgeon says it is fine but I wanted to get some additional expertise from someone of your professional caliber.
A: The follicle of a hair transplant has taken by two to three weeks after being placed. The hair shaft will have exfoliated by then but the transplanted follicle lies deep to the skin surface where it will be unaffected by any external forces. It will cause no harm to recently transplanted follicles to have a rhinoplasty done one month after the hair transplantation procedure. In fact hair transplantation could be done at the same time as a rhinoplasty if it were not for several logistical issues. (e.g. time of the procedure and the typical environment (office ) where most hair transplantation procedures are done) Rhinoplasty even using a silicone implant will have no negative impact even on hair transplants that are so new.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr Eppley, After a rhinoplasty I was left with a big space between my nose and lips. My surgery was 6 days ago. Do you think this might still change and I should wait longer until considering a subnasal lip lift? Thank you so much!
A: It would be entirely premature to judge what effect your rhinoplasty will have on your upper lip length at just six days after surgery. While it is unknown to me as to what type of rhinoplasty you have had, any rhinoplasty surgery that results in tip rotation and/or tip shortening is going to initially create the perception that the upper lip is longer. In reality it be now more exposed with the change (opening) of the nasolabial angle…or it is possible that it may have indeed become lengthened. But until all the swelling from the rhinoplasty surgery has resolved and the tissues have fully settled, any aesthetic judgment on upper lip length can not truly be appreciated. I would not perform an upper lip lift on a rhinoplasty until they are six months out from the procedure, not only because of the uncertainty of the aesthetics, but because of the intervening skin between an open rhinoplasty incision and that of the subnasal lip lift.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing?
A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.
One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.
The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.
The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello! I came across you on RealSelf. I have been wanting to get this small bump in the bridge of my nose evened out. After reading the positive reviews of Dr. Eppley, I am interested in speaking more. Thank you for your time!
I have always had a small bump on my nose and I am looking to fix that in order to have a better profile view. I have always been extremely self conscious about my nose and it also doesn’t help that I do not have a strong jawline either.
I have looked into rhinoplasty surgery, but I thought maybe injectable fillers would be better if my issue is minor.
A: Thank you for sending your picture. Based on this picture, I would say that putting filler above the bump is not a good idea. You have a bump on your nose because the nasal tip is too low, not because the bridge and the edge of the nasal bones is too high. You are a rare example where what you have is a ‘pseudohump’. A hump that is artificially created by other nasal structures that are too low. Your bridge or hip height is actually normal.
In my opinion, rhinoplasty surgery would be much better. But you can always try fillers and if it does not create a better result it will always go away and then you will know for sure about rhinoplasty surgery for sure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, when I retire I will do a general over-all facial rejuvenation/enhancement and possibly a slight rhinoplasty tune-up/reduction. Probably fairly aggressive because due to my life situation, there is no need to “look like the same person, just well rested”. Now, is there any logical/preferable order in which to do these things? I had a successful facelift several years ago. I can say that I I don’t care if I spend the first three months looking swollen and feeling pain – the end results are well worth it, plus I am just not a whiner. But I thought I might do the rhinoplasty first/separately, so that the follow-on surgeon can correctly judge the amount of change needed with the “new nose”. Thus the question: how much of the facial implant work can be done all at once?
A: Without knowing what you look like or exactly need, I can not give a very precise answer. In general, I routinely perform all facial procures at one time including any implant work and rhinoplasty. How one facial procedure affects another can really be determined before anything is done by computer imaging. But certainly there is no reason you could not do the rhinoplasty first and then three to six months later do the remainder of any facial reshaping procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a chin augmentation and rhinoplasty after our consultation? What are the logistics of the actual procedure…i.e, time needed to recover, possible adverse short and long term effects, are the results permanent or will it need to be altered down the road to maintain its new shape, and are allergic reactions to the implant material common?
Another concern of mine is that I train in jiu jitsu (it’s like wrestling pretty much) so would the implant possibly be jostled loose if I were to get knocked in the chin? If so, would the sliding genioplasty yield similar results or no? I do like the chin implant.. just worried that it could be a potential problem.
A: The combination of rhinoplasty and chin augmentation is a very common facial reshaping surgery because of its dual benefits in changing two important areas of facial prominences. These are outpatient procedures done under general anesthesia. The most significant recovery is the first week when the nose will have a tape and splint dressing and the chin will be the most swollen. After the first week the nasal splint comes off so it is easier to be seen out in public without having had obvious surgery. Most of the swelling is gone by about three weeks after the procedure although it really takes a full three months before one should critique the results.
Both the rhinoplasty and chin augmentation create permanent effects through bone and cartilage modifications (nose) and the placement of a non-degradable implant. (chin) There is no such thing as an allergic reaction to a silicone implant although there is the rare occurrence of the risk of infection (1% or less) The chin implant will be secured in placed by small screws so between screw fixation and the enveloping scar that occurs around any implant, it will never move regardless of almost any degree of physical contact. You would have to break the bone to move the implant.
The biggest risks or need for revisional procedures for either a rhinoplasty or chin implant are aesthetic in nature…how does it eventually look and is the patient satisfied. The overwhelming reason for revision of any facial aesthetic procedure is the patient desire for additional changes/improvement in the shape of the nose or chin.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting a rhinoplasty to straighten and reduce the hump on my nose. My questions concerns that I do not wish to go under general anesthesia and wish to be sedated and under local anesthesia instead. Please also let me know what you think in regards to whether I should also consider reducing the size of the nose overall or nostrils.
A: Thank you for your inquiry. When it comes to anesthesia options for rhinoplasty surgery, that is highly influenced by the type of rhinoplasty being performed. If nasal osteotomies with hump reduction and/or internal nasal surgery is being done (septoplasty, turbinate reduction), local anesthesia with sedation is a poor and unsafe choice. These types of rhinoplasty induce bleeding down the nose and into the throat and risk aspiration and laryngospasm, two potentially deadly problems. A general anesthetic with an endotracheal tube is the only prudent way to have such a rhinoplasty. If no bone work is being done and no cartilages grafts are needed such as in a tip only rhinoplasty, then local anesthesia with sedation would be safe and tolerable.
I would need to see pictures of your nose (front and side views, non-smiling) to see what type of changes you desire/need by doing some computer imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I hate my nasofrontal angle, it is very deep. I am not sure if I need to build up the bridge, reduce the projection of the tip, or both… I would value very much your learned opinion and recommendations.
A: A deep nasofrontal angle is often cased by a combination of factors including a low nasal bone height, an overprojecting nasal tip and low dorsum and, of equal importance, brow bone bossing/protrusion. In doing some computer imaging (which is attached) you can see that the effects of a rhinoplasty (radix/dorsal augmentation and tip deprojection/rotation) lessen the depth of your deep nasofrontal angle by about half. When you add in a brow bone reduction with the rhinoplasty (see attached imaging) the deep nasofrontal angle problem is completely solved. So you see in your case, which is not rare, that it is really a combination of low nasal bones (45% of the problem), brow bone bossing (45% of the problem) and very minimally impacted by nasal tip changes (10% of the problem). For a female you have fairly prominent brow bones and that is most certainly a big part of the problem. There is nothing wrong with a rhinoplasty alone you just have to realize its limitations…it will make it better but is not the complete cure for it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, it’s been almost one year since my rhinoplasty. Today I wore snow goggles for about an hour and now I have a red small bump on the bridge of my nose. I’m pretty concerned. I iced it for a bit and it hasn’t gone down. Is there anything else I can do? I don’t want to ruin your beautiful nose work. Thanks!
A: Being a year after a rhinoplasty with hump reduction and osteotomies, your nose should be sufficiently healed to handle any type of eyewear. It is not possible that snow googles would cause any change in the underlying nose structures. It is important to realize that snow googles press on a broader area of the nose than regular glasses and thus cause more pressure. I would suspect that by tomorrow or even later today the red area on the nose will be gone. It may be a year after your rhinoplasty but your nose skin is probably a bit sensitive still. So the pressure from large snow goggles may cause the temporary skin deformity that you are seeing.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery and have been studying face and body proportions. Does the master sculptors of the Middle Ages use a formula in order to determine the length of the face in a statue? Was it one-eighth the height of the statue?
A: The use of numerous face and body proportions, often called the classical canons, comes from figure drawing and sculpture. Such concepts are based on ancient history that goes back as far as over 3,000 years ago. Clearly there are subtle and sometimes not so subtle differences between people and their features, but there is a fairly standard range of human proportions that seem to be most aesthetically pleasing. Artists and sculptors have made numerous attempts to put these to numbers and ratios and this forms the basis of almost accepted human proportions today. More scientific anthropometric studies have been done more recently and these have established some variations amongst ethnicity and gender. Most artistic body proportions are based on how they relate to the length of the head. Using the head as a unit of measurement, the height of the person is ideally at 8 heads tall. Thus your question of whether the length of the face was ‘one-eighth the height of the statue’ is correct by human drawing standards.
But I would be careful about trying to extrapolate any of this to plastic surgery and specifically rhinoplasty. These proportions were really established so that artists and sculptors could create a figure and face that was proportionate…and humans have a very difficult time drawing proportionate anatomical structures as there is nothing innate about doing so. Trying to translate these concepts to surgery is far more difficult and often unrealistic as people do not develop and grow in perfect proportions and there is a limited range of surgical changes that can be done to make them so.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like a shorter, fuller face with softer, more feminine features. I am wondering if I need corrective jaw surgery or could a chin reduction and facial fillers alone achieve the look I want. If there isn’t a great difference in the results of corrective jaw surgery and chin reduction surgery, then I would be more inclined to just get chin surgery because it is less invasive and costly. I do not like the large space between my nostrils and my upper lip. Could rhinoplasty help to shorten that distance? You might not be able to tell from these pictures but as far as my nose. I do not like the hump and I do not like my nasal tip. It is very bulbous and when I smile I feel the span of my nostrils becomes very wide. Finally I feel that I have a very prominent brow bone and feel it makes me look even more masculine. I am wondering if I am a good candidate for brow bone reduction surgery and also hairline lowering in order to decrease the length of my face. Thank you in advance for your help. I look forward to communicating with you soon and seeing the computer facial images.
A: All of the facial fershaping procedures you have mentioned would be helpful in shortening the appearance of your face from hairline lowering, rhinoplasty, subnasal lip lift and vertical chin reduction. It is impossible to comment on whether corrective jaw surgery or chin reduction would be better since that decision requires knowing the state of your bite. (occlusion) If your bite is good, then chin reduction would absolutely be the better procedure.
Brow bone reduction would be helpful to feminize your forehead and would be needed with your rhinoplasty to help bring back the glabellar (central) area of the brow. Otherwise the hump reduction with your rhinoplasty will make a deep nasofrontal angle which is more of a masculine facial feature.
While a subnasal lip lift would be helpful, it can not be performed at the same time as a rhinoplasty due to blood supply concerns to the intervening columellar skin between it and the open rhinoplasty incision.
To properly do computer imaging, I need more than just a lateral or side view. Additional views from the front and even a three-quarter (oblique) view make for a complete imaging assessment of the aforementioned facial changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty done a week ago and my nose splint is still stuck tight despite my repeated showers and letting water run over my face. Do you have any suggestions that will help me remove it?
A: Sometimes the nasal splint gets very loose and other times it can be very adherent. But eventually there comes a time to try and remove it. That time would be tomorrow. If you want to try and do it, you start from the top to peel it down as that is here it is ‘open’ from a taping standpoint. The first thing you do is grab the wings of the metal splint and bend them up so they are flat. That will reveal all the tapes underneath it. Then you start to peel the tapes off from above by lifting them off the skin. this will create a loose dressing that is just peeled off down to the tip of the nose. This is where it will be the most adherent as the tapes wrap around the tip of the nose and are often partially stuck there by any dried blood in the nostril. You will not hurt anything as you keep peeling the dressing forward (I did not say that it was comfortable in doing so), you just have to be slow to get all the tapes off from around the tip of the nose.
If you are uncomfortable doing so and just can’t seem to do it, let me know and you can always come in and have me remove it for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Do you have experience with facial feminization surgery? Particularly with forehead recontouring, rhinoplasty, adam’s apple shaving, and hair line lowering?
A: I have considerable experience with facial feminization surgery (FFS) procedures, particularly the four that you have mentioned which are some of the most common FFS operations. All can make very successful feminizing effects. The key to the hairline lowering is the density of the frontal hairline where the incision has to be made. If this is adequate then the hairline can usually be lowered in a single stage of up to 2 cms based on one’s natural scalp laxity. Combining forehead/brow bone contouring with hairline lowering is particularly convenient since the pretrichial incision provides direct access to the entire forehead. Adam’s apple reduction (aka tracheal shave) is the simplest of the procedure and how much is can be reduced is dependent on what incisional access is used. (directly over it or the more remote submental incision) Reshaping the nose through a rhinoplasty to create a smoother and less prominent nose result depends on the thickness of the overlying skin. The thicker the skin the less it will contract and the size of the nose will reduce less.
Please send me some pictures of your face for my assessment and computer imaging to see what changes may be possible for you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How accurate is computer imaging for various facial surgeries? I have had several plastic surgeons do imaging for a future rhinoplasty and it is interesting that are significant differences between what they show. It is hard to know what is realistic. I thought computer imaging would show a very accurate result. So why are these plastic surgeons imaging results so different?
A: While computer can take a picture and change a facial feature like a nose, the only way the software knows what to do is based on who is controlling the mouse. In essence, computer imaging is a reflection of what the plastic surgeon THINKS he/she can achieve. They are showing the type of changes they want to illustrate to you presumably based on their experience…and hopefully it is a reflection of what is likely to occur in their hands.
Therefore it is important to understand that facial computer imaging is a prediction…and hopefully that prediction can be achieved by actual surgery.
What I try to show in computer imaging is the MINIMUM result that I think can be achieved as that should be the basis of what motivates one for surgery. More may be able to be achieved but that should be viewed as a ‘bonus’ and not the basis of one’s satisfaction with the result. This becomes critically important in an aesthetic operation like rhinoplasty which is highly scrutinized by the patient afterwards.
Dr. Barry Eppley
Indianapolis, Indiana