Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a rhinoplasty. I have consulted with a plastic surgeon who said I had thick skin and results would be minimal. I can accept this, however, I do believe that at least suturing the tip cartilage together would minimize the width. My goal is a narrower nose in general, but particular attention to the tip. Perhaps narrow the bone structure? I have always kind of wiggled my nose down which elongated it and made the tip smaller and less noticeable. Of course it manipulated my upper lip. Is it possible to take a pie shape of skin out of the side of each nostril to bring it down and narrow it? I do always seem to have a congested nose. If I pull outwards beneath my eyes I can breathe significantly better. My profile is acceptable. I appreciate your consultation greatly!
A: By your description, it sounds like a rhinoplasty that includes tip width reduction by cartilage reduction and suturing, nostril narrowing and possible middle vault spreader grafts (although this would widen the middle third of your nose) and/or inferior turbinate reduction would help improve your nasal appearance and function. While it is true that thick skin does not a limiting effect on rhinoplasty results, I would not say that the results would necessarily be ‘minimal’ and that the desired tip changes seem achievable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hello! I spoke to you all a while back about considering plastic surgery. I was very pleased with the results of the face prediction and your wonderful, fast replies. However, I have just a few questions:
1. How would I schedule an in person consultation? I would be coming from way across the country and I am willing to fly out to Indiana. The online Skype consultation will not really work because the internet is quite slow where I live and I am worried it’ll be more trouble than it’s worth. Therefore, I’d be more comfortable with an in-person consultation.
2. What is the estimated recovery time for Chin Reduction surgery and Rhinoplasty? Would I have to stay in Indiana for a certain amount of time? Are we talking days, or perhaps weeks?
3. I would be unconscious during the surgery, right? So, do you guys have a licensed anesthesiologist at all of your locations?
4. I see that you have multiple offices to choose from. Which office location would be the best for me and my procedure?
Thank you so much for taking the time to answer my question, and thank you all for your hard work.
A: In answer to your questions about rhinoplasty and chin reduction:
- An in person consultation can be arranged at your convenience. I will have my assistant Camille contact you next week to make those arrangements.
- The concept of recovery after any surgery can mean various things to different people. But to use a simple endpoint of being able to do most functions and looking only moderately swollen, think 10 to 14 days. You should be able to return home in a few days after surgery.
- Rhinoplasty and chin reduction surgery requires a general anesthetic to be both completely comfortable during surgery and to allow the best extent of the surgeries to be done.While I operate at multiple hospitals, aesthetic procedures are done at my private surgery center which is both AAAHC certified and staffed with board-certified anesthesiologists.
- At stated in #3 above, there is only one aesthetic surgery center at which I operate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty but have one major question. My appearance changes greatly when I smile, my nose really flattens out and I would like it to be more defined when I smile. When my face is at rest, my appearance is satisfactory. My recent pics show no definition. Will rhinoplasty help solve this concern?
A: The concern about nostril flare with smiling is actually a fairly common question from patients considering rhinoplasty. It is important to realize that rhinoplasty is a static operation, not a dynamic one. It changes the nose structures based on their natural non-moving state. While it will give the nose more definition, particularly of the tip, it will not necessarily prevent the nostrils from flaring when you smile. That is a natural phenomenon of all noses as the facial muscles pull on the non-fixed bases of the side of the nostrils. While the nose will become more refined with the surgery, you should not expect that it will solve the flare of the nostrils that naturally occur from smiling. You should consider to undergo rhinoplasty for the changes you may see from computer imaging with your face at rest.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a botched ear surgery and need to come to you for correction for more prominence. I also want to build up my nose for taller nasal bridge. I know it is best to use rib cartilage for surgery rather than a foreign material like Medpor. My concern is that I am a dancer and have to be shirtless a lot for work. I worry the scar needed for rib removal will be big and also will change my physique? Then I read about rib removal for cosmetic surgery purposes. If this is the case maybe it will give me a more defined figure because rib removal gives a more slender slimmer lower waist? Is that correct? Would you be able to use the same scar? I plan to do the surgery separately, first do ear revision and then few months later do nose. Would they use rib from one side for ears and then rib from other side for nose? Or is there not going to be enough rib? Can they use one scar to remove rib and symmetrically remove rib for each side?
A: Rib removal, whether it is done for otoplasty correction, augmnetative rhinoplasty or for waistline reshaping, will create a scar. It is not a large scar, usually about 4 cms in length, but it is a scar nonetheless. If harvesting just for the nose or ear, it will not change your physique or cause an indented chest area. The amount of rib cartilage length removed is not that long.
Because of the recovery from rib harvest, it is probably best to do the otoplasty revision and rhinoplasty at the same time. While two separate surgeries could be done the amount of rib cartilage needed for the ears is small and does not seem worthy of a separate surgery to do it.
Rib removal can help define the upper waistline by removing the lower free floating ribs but whether that is worth that effort and the two scars to do it must be considered carefully.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am unhappy with my nose and I have been considering rhinoplasty for a while as well as jaw augmentation. For my nose, my first main concern is that I don’t like the bulbous tip it has. I’d like the tip to look pointier and to project a bit more. Second, I think my nose is too wide. I would like my nostrils to be narrower from the front view. I have attached a few photos of my face, as well as a couple models whose noses I like.
For the jaw, I have been considering some combination of chin and especially jaw angle implants. Perhaps even sliding genioplasty, the latter I understand is the only way to add vertical chin height. I basically want to create a stronger looking profile that balances my face.
I also have a few secondary procedures I am considering but not sure about. A reduction of my lower lip reduction (I think it is too big compared to the upper, and might make my chin appear larger if it were reduced). And also forehead augmentation (to reduce the appearance of my sloping forehead/prominent brow bone)
I am trying to figure out which procedure/s would produce be the best result in my case.Would it even be possible to do all of them at once?
A: Briefly, all the facial procedures you have discussed can be done as the same time and it would not be rare in my experience to do so. But first we must go through each procedure and determine what is the best approach for each change and how much change you desire for each area. Options in rhinoplasty and jawline enhancement are best done through initial computer imaging. I will do some computer imaging using your pictures of these changes and this will be a good starting point for our treatment planning discussion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am currently looking to have a rhinoplasty later this year. I had a discussion with an anesthesiologist about my needle phobia who advised I speak to the anesthesiologist who will be taking care of me during the procedure. As much as I want to say I don’t have a problem with my needle phobia I do. The last time I had my blood drawn I panicked and passed out. Obviously I don’t want any of that to happen which would make my surgeon’s job harder. He suggested maybe a prescription of Valium before the procedure or something of that nature. I will let you give me your professional advise on this matter. Looking forward to hearing from you.
A: Needle phobia issues are not uncommon in surgery. Known as trypanophobia, it is estimated that about 10% of people have it. While having to get a needle sick is unavoidable since an IV will be needed for your rhinoplasty surgery, there are numerous ways to get past this fear. Your apprehension can be remedied by taking 10mgs of Valium and 25 mgs of Phenergan orally orally one hour before arriving for your surgery. (as there will be someone driving you to and from surgery) Your surgeon can write that prescription for you. Make sure that you have signed your operative consents and had all your questions answered days before the surgery as consent can not be obtained from a mildly sedated patient.
The other management issue that can be done is to apply a topical numbing cream prior to actually putting in the needle. This will minimize needle insertion discomfort.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a long face shape but small forehead. (like Sarah Jessica Parker). I really hate my face shape and would like to make it shorter. My nose is long and I was wondering if it were possible to shorten my nose, raise my mouth and then make my chin a lot smaller so that my face is a lot shorter but still in proportion. I also have a bump on my nose that I would want straightened.
I’m not sure if such thing is possible but if you could let me know if there is anything that could be done. I have attached a picture of what kind of thing I would like done. The picture on the left is what I look like now and the one on the right is kind of how I would like to look like after. The third picture is of the bump on my nose and whether this would be able to be corrected as well. Thanks!
A: Based on your pictures and goals, I would say that two of the three facial changes you would like are achievable with fade shortening surgery. A rhinoplasty can be done to eliminate the bump on your nose and provide some further refinement. A vertical reduction genioplasty can be done and the bone removed behind it back to about the mid-body of the mandible through an intraoral approach. It can achieve the amount of vertical reduction you are showing on our imaged picture but it is the most that can be done. probably about an 8mm reduction in anterior chin/mandibular height. Lastly, it is not possible to surgically raise your mouth (lips).
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I guess my wish list is quite long, but I don’t want to look like a different person. I’d like to reduce or remove the hump and slightly shorten its length. Also, on front view it seems slightly crooked and very wide, especially when I smile. If you could magically decrease my excessive snoring, my husband would probably appreciate that too! I’ve spent a lot of time thinking about this and looking at pictures online. I think a lot of doctors go too far for my personal taste. One common thing I see online is when humps are removed and the nose ends up actually dipping down in the middle where the hump once was. I don’t care for that. I also think some take off too much length and drastically change the side profile. I am looking for something more subtle.
A:Thank you for sending your pictures in consideration of rhinoplasty surgery. The type of nose changes you are after is a straight nasal dorsum and decreased nasal tip length with minimal tip rotation upward. Trying to not make your nostrils flare when you smile is precarious as decreasing the action of those muscles to do that can also affect the way your upper lip moves when you smile…which would not be a good tradeoff. The best you can do in that regard is to minimize the amount that the nasal tip pulls down when you smile. As for breathing improvement that would depend on what the inside of your nose looks like and whether you have any significant airway impingement by septal deviation and/or inferior turbinate hypertrophy.
The best way to avoid having radical nose changes from rhinoplasty is to not over resect or remove too much cartilage or bone tissue. Knowing your nasal change desires as being a subtle change helps your surgeon know how aggressive or conservative to be when performing rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 28 year-old Asian make who is very interested in having cosmetic surgery performed for overall facial reshaping. As you offer a wide range of procedures which may be relevant to my goals, I hope to receive advice on the achievability of my goals.
First of all, I am very conscious in photos of the roundness and wideness of my face. (especially when smiling, at which point my cheeks appear very round and prominent) In addition, I would like to reduce the fullness of my lower face and make it thinner.
Secondly, I was wondering if a sliding genioplasty was advisable, as my chin appears to be relatively normal sized. I wish to make my jawline less round, and increase the vertical dimensions of my face to alleviate the aforementioned wideness.
Thirdly, I was wondering if procedures were available to create a more ‘deep-set’ look for my eyes. This, in addition to rhinoplasty to reduce the hump and raise the nose bridge, to reduce the ‘flatness’ of my face in profile.
I realize that not all of my expectations will be realistic nor all procedures advisable, so thanks for your time and expertise in advance.
A: A wide collection of procedures are available for facial reshaping as you are aware. In addressing all four areas of your facial concerns from top to bottom, I can make the following initial comments as they relate to your face.
1) I am now using performed or custom brow bone implants to build up the brow ridges. They can be placed through a limited incision endoscopic technique. That is the most effective way to create a more deep-set look to your eyes.
2) Your rhinoplasty would include a humor reduction, radix augmentation and some slight increased tip projection.
3) Cheekbone narrowing is the only way to provide some reduction in the mid-arch bizygomatic distance of probably 4 to 5mms per side.
4) I would consider paranasal augmentation, I have a new paranasal implant that I am really happy with that can not be felt and adds about 5mms projection to the nasal base.
5) I do think that a vertical lengthening genioplasty (which may have to be widened in a male) will help narrow the jawline. You do not need a horizontal advancement but when opening the vertical distance of the chin it does rotate it back a few millimeters so I would do a small advancement as well.
These are some initial thoughts. Computer imaging needs to be done to see how such facial reshaping procedures would look on you.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had rhinoplasty two months ago and am worried that I might have a pollybeak deformity? I was given a steroid injection on the supratip from my surgeon a few weeks back. My surgeon is assuring me that the beak-like appearance I am seeing is a result of swelling, but I am concerned that it is left over cartilage that has not been resected all the way. What are your thoughts? Can swelling mimic a pollybeak deformity? For someone with my skin thickness, how quickly can one expect to see a true pollybeak deformity surface? The first steroid injection appeared to have done absolutely nothing aesthetically. Is this normal?
A: You are correct in your assessment that one cause of a pollybeak deformity after rhinoplasty is residual excessive cartilage in the supratip area. In those rhinoplasty patients who had an original dorsal hump taken down, inadequate removal of the cartilaginous portion of the bump (between the nasal bones and the tip) can create excessive cartilage height in the supratip region, giving the tip of the nose a rounded and downturned appearance. (cartilaginous pollybeak deformity) This may be evident right after the splint is taken off but, often due to swelling of the overall nose, may not become evident until weeks to a month later.
A pseudo pollybeak deformity can also occur due to the development of excessive scar tissue in the supratip area. This can develop due to a small fluid collection which can even be unintentionally created by how the tapes and splint were applied right at the time of surgery. This becomes evident as the swelling resolves where, like excessive remaining cartilage, the supratip gets or remains full.
However, the origin of your pollybeak deformity after rhinoplasty is not clear at just two months after surgery. It may very well be swelling and the injections of low dose steroids is reasonable at this point. It takes three weeks to see any result from a steroid injection and their effects are cumulative. It is not a fast fix. Also, how effective they can be is partially dose related.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a nonsurgical injectable rhinoplasty last year but I believe the effect might be over. My question is do you think I should consider rhinoplasty because of the projection of my tip when I laugh and my bump on nose. Or should i just get another nonsurgical rhinoplasty because the tip is bothering me. The problem is my nasal profile from side could be adjusted with injection of the but it doesn’t do anything to the tip and it droops or falls down when I laugh. Please let me know thanks
A: I believe you have really answered your own question about the decision for a second injectable rhinoplasty vs. open surgical rhinoplasty. One of the benefits of any type of non-surgical aesthetic treatment is to determine if its effects can produce an equivalent result as that of surgery. While an injectable rhinoplasty can provide augmentation to a low radix or bridge of the upper nose, it will have no effect on any other areas of the nose other than that of an illusory effect on the overall nose shape. It will certainly not have an effect on an overly dynamic nasal tip that pulls down with smiling or laughing. Thus, some form of surgical rhinoplasty is the only treatment that can treat both both the bridge and tip problems.
A surgical rhinoplasty for you would augment the bridge with either an implant or cartilage graft and resection of the depressor septi muscle if the only tip issue is its downward pulling.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. Is it possible to to do nostril narrowing making my nostrils smaller and the tip of my bulbous nose smaller, what would you suggest ? I want a thinner and more defined nose altogether.
A: Your rhinoplasty questions are good ones and are fairly common in ethnic African-American rhinoplasty. What you have is a nose that has little underlying cartilage support with thick overlying skin. This is why it is wide, short and ‘turned up’ so to speak. It simply lacks much underlying support to hold the skin up. While it is tempting to think that just thinning out the cartilages on the nasal tip, defatting it and then narrowing the nostrils will create the desired effect, it will not. In fact, such an approach may likely end up making it look worse. What you need is an augmentative rhinoplasty (not a reductive one) that builds up the bridge of the nose and tip and pulls the skin upward (and somewhat downward at the tip or derotation) to create a thinner and more defined looking nose. If the nose is augmented then narrowing the nostrils will be more effective. I have attached some imaging of your nose to demonstrate that effect. How to achieve the augmentation is a classic debate between a rib graft or an implant.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty and chin reduction surgeries. I am very unhappy with the profile of my face. I feel it looks very masculine. I do have a twisted nose and large tip. I feel my nose doesn’t fit in with my face and looks rather big when I start to turn my face from certain angles. When I use a plastic surgery simulator it makes a big difference when I make my chin and nose smaller. I would like to know what your opinion is and what would you think would help balance my face? I have been wanting surgery for a long time now and over the years wasn’t sure exactly what the problem was with my face but I believe it is do with the angle of my chin and nose.
A: The nose and the chin make up a major portion of one’s profile so it is no surprise that changing these two structures can make for a major facial change and not just in the profile view. I would agree completely with your assessment that your nose is too big in various dimensions and is a major culprit in your facial concerns. But as you have also pointed out, and astutely so, is that your chin is also a little too strong. That would become very apparent when the nose is reshaped and made smaller. Thus doing a concomitant chin reduction with a rhinoplasty would produce the greatest effect in make your face have an overall more feminine/less masculine appearance.
I have done some imaging of the one picture you sent to illustrate those potential changes with a rhinoplasty and chin reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Could you tell me when diced cartilage injections are recommended in rhinoplasty? Five years ago I received a septal cartilage graft on my nasal dorsum but there remains a little gap on the side of the dorsum between the eyes. Could a diced cartilage injection resolves my problem? Does it need a lot of spetal cartilage which was used initially for my dorsal cartilage graft?
A: Small cartilage deficient areas of the nose are fairly ideal for an injectable diced cartilage rhinoplasty. What you are ‘missing’ is that the dorsal augmentation has created a relative deficiency along your nasal sidewalls. That could be filled in with diced cartilage injected from an intranasal approach. A small septal or ear cartilage should suffice as the cartilage donor source.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in improving my profile with a chin implant (custom or pre-shaped implant – whichever you feel would achieve the best desired results), along with possible injection to my nose. I have always wanted a stronger jawline and chin. I have always felt that I look this way, but in reality I just don’t have that masculine look. By adding a chin implant, will that also improve the jawline since the skin is being stretched further forward? I’ve attached a side-by-side of the results I’m looking for versus my actual face. For my nose, I’m interested in very minimal nose work. I’m fine with my turned up nose as I believe it’s unique, but would like to know if injection was possible to smooth the “slope” to make it appear less concave where the bridge and tip merge?
A: You have demonstrated well the benefits of a chin implant with your prediction imaging. That amount of horizontal advancement is around 9 to 10mm and, when the chin is lengthened, will improve your jawline. The key chin/jawline feature which you have not evaluated yet is how the chin will change in the frontal view and whether it should become more narrow or wider. Such an assessment will help make the determination of whether a preformed stock or custom chin implant will be needed.
From a rhinoplasty standpoint what you are seeking is simple dorsal augmentation. But using an injectable material, even fat, is not going to produce a successful or sustained result. This is going to require the use of either a septal cartilage graft or an implant, both of which can be done through a closed rhinoplasty result. A dorsal augmentation closed rhinoplasty is a fairly minimal nose surgery with a very quick recovery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I definitely want to remove my acne scars, but other than that, I’ve been given so many different suggestions, I’m not even sure anymore. For the acne scar laser resurfacing, I was told my skin type has a high chance of pigmentation. What are safe options? I do want a rhinoplasty, but I want it to be very subtle, and I’m mainly interested in fixing the tip that sort of goes down like a beak. How is this usually corrected? Also, you mentioned that it appears my buccal lobe was removed. Does this mean the maximum amount was taken out? I am now 2.5 weeks post op. Do you think my final results will give me the skeletonized appearance I desire? I still feel 2 grape sized bumps, hard as rock, when I push down on my cheeks.
A: What would structurally benefit your face is not a mystery and is very straightforward…it lies with your nose and chin. Your chin is very deficient, by at least 9mms, and is one feature that will keep your face from ever having a very defined and angular appearance., By using a sliding genioplasty to bring it forward it will improve your facial profile and help create a more defined appearance in the front view.
You have a very classic ethnic nose with a broad flat tip that has little support and no projection, hence a rounded tip that droops down. An open tip rhinoplasty will reshape the tip and give it a better profile and a more narrow appearance in the frontal view. You would also need some upper dorsal/radix augmentation.
Fractional laser resurfacing is the only type of acne laser resurfacing that you should have as this has a very low risk of any hypopigmentation problems. It will take more than one treatment and the best result you can hope for is about a 50% improvement in the appearance of your facial acne scarring.
It takes a full 3 months for the buccal space where the fat pads were removed to become soft and not feel as hard lumps, this is perfectly normal to feel what you are feeling at just 3 weeks after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was told in a consultation with a local plastic surgeon that I needed cheek implants, chin reduction (just shaving the bone down and removing some fat/skin), and a little off the hump in my nose. That is the basis for my inquiry. Even though those were his suggestions, I still wanted to keep looking because I didn’t see that he had a very extensive client base where he had performed all of those at once…or more than one procedure at the same time.
I normally pose differently and make myself look better in pictures, but my profile is very flat in the cheek area and prominent in the chin. I’d like to get this corrected somehow, but I think with so many things to address at once, I get concerned that the surgery would be very noticeable and I would look like a different person all together…
A: In reviewing your pictures, I could make the following comments:
Your vertically long but non-projecting chin would be best treated by an extra oral vertical reduction ostectomy. (submental chin reduction) A burring technique would not remove nearly enough. You need at least 8mms or more off to really make a difference.
Your flat mid facial profile is ideally treated by a combination of paranasal and malar shell cheek implants. This will help pull out the entire midface. (both the nasal base and the cheeks)
You do have some significant facial asymmetry that actually affects the whole left side of the face. (which is shorter) The chin reduction will help with the lower facial asymmetry. The eye asymmetry, however, will not be improved.
One realization is that these changes will make a facial difference with much better balance…but it will likely be noticeable as your face gets vertically shorter and more horizontally projected.
Dr. Barry Eppley
Indianapolis, Indianapolis
Q: Dr. Eppley, I am interested in rhinoplasty surgery. As you can see from my attached pictures, I have a bulbous tip and a deviated septum. I hope to reduce the bulbous tip as well as straighten my nose. Can you please notify me if this can be done? Also from the pictures can you tell me whether or not I have thick nose skin? If I do have thick skin, will I still be able to reduce my bulbous tip and gain a more straighter profile on my nose?
A: I think you are an excellent candidate for rhinoplasty. You have a wide bulbous tip with played domes of the lower alar cartilages with intervening fat. But it should shape up nicely with an open rhinoplasty where the cartilages can be reshaped and brought together to create a much more narrow tip with more refined definition. I do not see that the thickness of your skin as being a limiting problem for getting a good rhinoplasty result. You have intermediate skin thickness which will shrink nicely when the underlying cartilages are reshaped.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to know if the following facial surgery results are possible.
1) With a custom cheek/orbital implant can I augment all of the inferior, lateral, and superior orbital rims along with a small portion of the malar bone?
2) Can off-the-shelf jaw angle implants guarantee that my jaw angles will look more squared/pointed rather than U shaped and heavy?
3) With a rhinoplasty do you believe you can achieve an aesthetically pleasing nose job that keeps a lot of masculinity to my nose. (i.e., keeping a majority of the nasal bone projection and width while still projecting the tip out a slight bit and straightening the nasal bone and cartilage from a frontal view?
A: In answer to your questions:
- While any design can be made for custom cheek and orbital implants, there are limitations to the surgical access to place them. Through a lower eyelid incision, a custom implant can be placed to cover the inferior and lower lateral orbital rim and cheek, but not the upper lateral orbital rim or superior orbital rim. (those require a coronal scalp incision for placement)
- A preformed off-the-shelf jaw angle implant that I commonly use has a more flared and square jaw angle point to it that does not usually cause a rounded jaw angle look. (that patient undoubtably has the traditional rounded style of silicone jaw angle implant that is what is available to most surgeons)
- I believe your thinoplasty goals are achieveable as you have defined them and as we have looked at them with computer imaging in the past.
With that being said, let me make some general statements based on a lot of experience with male facial structural surgery. (of which all your procedures would qualify) It is important to understand that there are no guarantees in surgery. No surgeon can guarantee that any specific outcome will be obtained no matter how much thought goes into it beforehand. Aesthetic surgery involves risk of which the biggest one is less than the desired result. I mention this as you have used the term ‘guaranteed’, this is not an assurance I can give you. In the same vein, it is important to also understand that male facial restructuring is associated with a notoriously high rate of revisional surgery, probably approximating 25% to 33%. This is of paramount note in the young male patient who often is very difficult to please in their search for an optimal result. A good rule of thumb is that the patient will put twice the amount of time assessing their result after surgery than what they spent beforehand…hence leading to such high revisional rates. Slight asymmetries and imperfections are very poorly tolerated in the young male patient.
I mention these issues as you need to factor these considerations also into whether the facial surgeries we have discussed are for you, your expectations and your level of risk tolerance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was scheduled for a rhinoplasty but one week before the surgery I broke my leg playing basketball. I had it fixed and will be unable to to bear weight for another four weeks and therefore was unable to make my rhinoplasty surgery. I am still interested in doing the surgery as early as is possible. I have a follow up appointment for my broken leg this week so I should know more about the length of time I will be on crutches. I just wanted your input and opinion on what you think I should do next.
A: There are two schools of thought about any type of surgery while recovering from another surgery/injury. One approach is to wait until one is fully recovered and then do the elective surgery at a more convenient time. The other approach is to have the elective surgery while one is recovering from the first surgery or injury since one is laid up anyway. Which approach is better depends on the nature of the injury and what the elective surgery procedure is. When one is young and healthy, the recovery from one surgery (a broken leg) does not affect the healing of the subsequent surgery. (rhinoplasty)
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, how soon after having a rhinoplasty can I play basketball. I am having a rhinoplasty in two weeks and would like to be ready to play sports again in a month after surgery. Do you think this is possible or is it too early?
A: Whether one is having a more limited tip rhinoplasty or a more complete one with osteotomies, there are always important recovery issues of which patients are understandably concerned. One of these frequent recovery issues is that of physical activity. When thinking about physical activity after rhinoplasty there are issues of being able to breathe comfortably through the nose (for exercise) and the risk of trauma to the newly reshaped nose. (participating in sports) It would be fair to say that participating in sports will be delayed longer than just non-contact exercise so let’s focus just on that issue.
The bone and cartilage of the nose takes months to heal after a rhinoplasty and that could be anywhere between three and six months after surgery. So yo can see that is a long time and many people simply aren’t going to wait that long. Thus it is all about assessing the risks of being hit in the nose based on the activity being done. If you are just shooting a basketball by itself, then three to four weeks afterwards should be fine. But if you are playing in a team situation where contact my be likely, it is all a gamble for many months after surgery. Getting hit in the nose within three to six months after a rhinoplasty will likely cause undesirable changes so that is a risk you will have to determine if it is worth it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty that changes the upper part of my nose. The lower half of my nose is fine but I have a large nasal hump and would like to get it reduced. In playing with some online imaging programs, I have noticed that removing the nasal hump actually looks worse in my opinion of the nasal radix is not also reduced. If the radix is not reduced it makes my nose and forehead appear as one with a sloped straight line, making more forehead looking like ‘volvo windshield’ in a profile view. If I am not given more of an obvious nasofrontal angle, my forehead will look weak Getting a good nasofrontal angle is the most important point of a rhinoplasty to me. How can this be effectively be done?
A: One of the more obscure aspects of rhinoplasty surgery is radix reduction. Radix augmentation is more common in many hump reductions. But in very large hump reduction in which the nasal bones are high and extend into the glabellar region of the forehead, radix reduction may be needed. In looking at your pictures your assessment is correct, a break between the forehead and your nose is needed to avoid a complete connected slope effect of the forehead down through the nose. Significant radix reduction as part of a rhinoplasty can be done by one of two methods; a guarded rotary burr or a percutaneous osteotomy method. Having done both, I find the osteotome method to work well when a really deep notching of the frontonasal angle needs to be done. This is done by using a 2mm osteotomy placed through the skin at the bridge of the nose creating one bone cut into the frontnasal angle, The other osteotome cut is done from inside the nose to complete the 90 degree angle creation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a rhinoplasty that can get my nostril size reduced. I would like to reduce how much of my nostrils you can see from a front profile ( basically bring the front of my nose down). Lastly I don’t like how you can see in my nostrils from the side profile. Does this all seem possible?
A: From a rhinoplasty standpoint, the size of one’s nostril’s is controlled by several anatomic factors. These include the length of the lower alar cartilages, the amount of caudal septal support, the angulation of the lower alar cartilages away from the dome and the width of the nostril base. When looking at your nose, the main reason you have a lot of nostril show is that the length of your nose is short making the tip of your nose rotated upwards. (which is why there is excessive nostril show in the front view) In addition, you have alar rim retraction with a bowed rather than straight alar edge. (which is why these is too much nostril show in the side view)
To increase your nasal length and decrease nostril show, your rhinoplasty must have increased structural support. This is done through cartilage grafts, harvested from the septum or ears, placed to push the tip of the nose down (septal extension graft) as well as along the edge of the lower alar cartilages. (alar rim grafts) You may also benefit from nostril narrowing as well but that can only be determined by a front view picture which you did not provide. I have attached some imaging to show what this type of rhinoplasty can do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty to permanently build up my radix. I had some fillers placed in my radix and glabella a few months back, and I really liked the augmentation. Anyway, I’m intending to get a rhinoplasty to augment these areas permanently next year. As such, I was wondering if it were possible to do so and if so, what kind of material will be used? I understand that rib grafts are used for the bridge, but can it also be used for the radix/glabella? Secondly, I’m hoping to get a touch up with some fillers some time in December. Will it be fine for me to do so, or will repeated treatments of dermal fillers complicate the rhinoplasty?
A: A radix augmentation rhinoplasty can use either autogenous or synthetic materials. But, in my opinion, cartilage grafts are the best material to use for radix augmentation. They will hold up for the rest of your life without any risks of complications. The size of the radix defect and the volume needed will determine where the cartilage should come from. (i.e., donor site) While rib cartilage is always ideal in terms of unlimited volume, most radix augmentations can be done with septal or ear cartilage the vast majority of time. There is no problem with getting fillers again next month. It does not complicate placing a radix cartilage graft later.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m an Asian American and I’ve been thinking of a few cosmetic procedures to enhance my flat face and that is rhinoplasty and midface augmentation.I’ve decided to go with the midface first. Being that, I’d like to know your inputs on the area of my midface that needs to be augmented for a more chiselled, three-dimensional look. I know that there a few parts to the midface – premaxillary and maxillary area for the anterior cheek ( I may be wrong on that ). So with that being said, what would you say about having both paranasal and malar implants done together? (for the case that I may need both) Would that cause a great incremental change in my facial projection compared to just one procedure done?
A: In looking at your face, which is not atypical for many Asian males, you might consider a somewhat different approach. The best procedures for ‘pulling your face out’ (increasing midfacial projection is a rhinoplasty combinjed with paranasal implants. It is very difficult to give much definition to broad wide cheeks without burying the rest of the midface behind them. (making the nose look even smaller) Look at the imaging I have attached to see what effect is created by initially pulling the nose and its base out. With your specific facial shape, this is where the real value is in any plastic surgery for you. The cheeks can be enhanced by probably not in the ideal chiselled fashion that you seek, I don’t think that is realistic for your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty and want to know if it is better to have it done open vs. a closed approach. My nose has a big and wide tip and hump that I want changed. Does one approach offer a better result for my nose?
A: The question of whether a primary rhinoplasty procedure should be done with an open or a closed approach is an historic debate. When it comes to revisional rhinoplasty, there is no debate that an open approach is almost always better depending upon the nasal problem being addressed. But in an unoperated nose like yours (thick skin, bulbous tip, dorsal hump) the operative approach is largely based on surgeon experience and preference. But most rhinoplasty surgeons today would opt for an open approach because it provides a more complete assessment of the structure changes and the prevention of complications that can occur from these structural changes. (middle vault collapse, asymmetries, supratip defomities) Open approaches do tend to have more prolonged tip swelling but that is a small price to pay for a more exacting result long-term. Many patients are concerned about the scar from an open rhinoplasty but an incision is this small strip of skin between the nostrils heals remarkably well and rarely can be ever seen afterward even on close inspection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping. The occipital bone on my skull is flat and I am interested in correcting this, preferably with an implant. Surprisingly, you and a Korean clinic are the only 2 places I have found so far for this procedure. I have already ready about the risks and complications for elective surgery, I have read some of your blogs and had a few other questions. How many skull implants have you preformed and what complications have you seen? Do you recommend the putty over implants or no? I would worry that the putty would cause more complications and would be harder to remove if something went wrong. How much do you charge of this surgery? How long does the surgery take and what is the procedure? Could a rhinoplasty be combined with tis surgery and at what additional cost? If I opt for a rhinoplasty, would it be better to do the skull reshaping first and base the amount rhinoplasty on the new skull shape or vice versa? Thank you for your time and consideration.
A: Skull reshaping surgery is commonly done for a flat back of the head. When it comes to occipital augmentation for a flat back of the head, there are different types of augmentation approaches as you have mentioned. Bone cement or bone putty (PMMA or HA) and a preformed silicone implant can be used. There are advantages and disadvantages to either approach. Bone cements offer materials that do bond to the bone and can be impregnated with antibiotics as they are mixed intraoperatively which are their advantages. I have yet to see an infection with a bone cement cranioplasty. Their disadvantages are that they must be molded and shaped as they are applied as a putty so they can have some irregularities and palpable edge demarcations which is the number one reason a revision on them may occasionally be done. A preformed silicone cranial implant is perfectly shaped and its flexible characteristics makes it very adaptable to the bone without edge demarcations. Its softer material also allows it to be placed through a smaller incision. But the material does not bond to the bone and ideally should be secured in place by a small titanium screw. Its infection risk is somewhat higher and it is the only cranial implant that I have ever seen develop an infection and had to be removed. (one case)
Regardless of the material, both are easy to remove and the actual material cost is not significantly different. Most occipital cranioplasties take between one to two hours to perform and total cost will be in the $8,000 to $9,000 range.
Rhinoplasty can certainly be done at the same time as any skull reshaping surgery and actually commonly done, regardless of the type of rhinoplasty needed. If one separated the two procedures, the order that are done on does not make a difference.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty surgery. I have always hated my nose. It has a large bump on it and it slopes down at the tip. I have always wanted a smaller and more shapely nose. What type of rhinoplasty do I need?
A: Based on a review of your pictures, you are an ideal candidate a good rhinoplasty result. This is based on your pictures which show the type of nasal anatomy which is very favorable for surgical change to get near ideal nasal proportions and shape.
Patients with nasal nasal skin have the capacity after surgery to show quite quickly and completely the changes that have been done to the cartilaginous/bony framework. In addition, thinner nasal skin does not get as much swelling after surgery and it does not take as long for most of the swelling to subside. Such is the type of nasal skin that you have.
A very common and favorable type of nasal problem is the convex dorsum which patients know as a nasal hump or bump. This overgrowth of the cartilage always makes the tip of the nose look like it is pushed downward, even if it is not. Reduction of this hump completely changes the shape of the nose and the profile, which make the nose looks smaller and more proportionate. The tip of the nose can also be narrowed at the same time. The other consideration in your rhinoplasty is the potential benefit of a small chin augmentation at the same time. Your chin is naturally shorter which is common in a nose with a hump. Reducing the size of the nose (dorsal reduction) and bringing the chin forward creates a diametric change in the facial profile which makes it more balanced overall.
Computer imaging will demonstrate these rhinoplasty and chin changes and I will get those prediction to you tomorrow.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I know I need rhinoplasty but am not sure what else I need. I would like you to analyze the attached photos in order to determine the ideal procedures to bring better balance to my face. These are my own assumptions about my facial appearance, both what I see as out of proportion and how to go about fixing it along with the objectives I hope to achieve
1. Droopy asymmetrical nose – It would be optimal to both straighten the entire nose and strengthen the tip (add cartilage). The tip would look best projecting forward more. I would still want to keep a high strong nasal bridge, so little shaving should be done there. Tip should still be turned down slightly a few degrees further than perpendicular to the face.
2. My eyes are too prominent relative to my other features and I would like a stronger, masculine look to eyes. I have looked at everything from malar to inferior, lateral, and superior orbital rim implants. I am less sure what would prove ideal for this issue, so your own suggestions here would be much appreciated (though if you think it is a bad area for me to augment please let me know as I want your complete objective opinion). Be as specific as possible, referencing both the individual anatomy and procedures that are possible.
A: Based on the one side view picture that you have provided, I did some imaging for the rhinoplasty based exclusively on tip rotation and elongation with minimal reduction of the middle vault height and no reduction of the nasal bridge bone. With this change I see no reason for chin augmentation which is the first other facial feature to think of when the nose becomes derotated.
From an eye standpoint, the only consideration you want to make is for infraorbital rim-malar augmentation. While superior and lateral orbital rim augmentation can be done, the effort to do does not justify the minimal benefits and risks. The focus for making the eyes less prominent should be on the recessed infraorbital-malar complex. I have factored this into the imaging.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of facial freshaping. I have some issues regarding a long face, and more importantly a long midface. It’s just been seriously bothering me for years to the point where it is causing problems. If you could take a look at these pics and just figure out what is so wrong with it, i would really appreciate it.
A: While I would not disagree that your face is a little long and the guilty component is your midface, there are other facial structural issues that are magnifing that impression. A horizontally short chin and a long nose with an acute nasolabial angle make the midface loo longer than it already. When you combine that with a very skeletonized face (little facial fat), the effect becomes even more so. There really are no true midface shortening procedures other than a maxillary impaction which is only used for vertical maxillary excess that has a gumkmy smile. (which does not apply to you) But what you can do is change some of the other factors that are accentuating the midface elongation effect. This includes a sliding genioplasty to bring the chin forward, a rhinoplasty to rotate the tip and decrease its length and submalar cheek augmentation to procide some more width to the midface. Together, these facial structural procedures can help shorten a long midface appearance.
Dr. Barry Eppley
Indianapolis, Indiana