Your Questions
Your Questions
Q: Dr. Eppley, I am interested in getting a rhinoplasty. (nose job) I’ve always wanted to have my nose reconstructed so it would look better and more petite. I’d like for it to be a bit pointier and not so flat. I am completely clueless on what steps to take. I have a few pictures so you can see what I mean.
A: When it comes to considering rhinoplasty surgery, you have already identified the the first and most important step…how would I like my new nose to look? In looking at your pictures, what you have is known as a bifid nasal tip in which the lower alar cartilages are completely separated. This accounts for why you have such a wide and flat nasal tip. The key to improvement is that the tip cartilages need support to obtain more projection through a columellar strut cartilage graft and the lower alar cartilages need to be brought together and narrowed.
While the quality of your nose pictures is very grainy which makes them hard to image, I have done some surgical predictions of nasal tip narrowing results that could be obtained through an open rhinoplasty procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am having a rhinoplasty by you later this fall. I was planning on a facelift and breast lift with fat transfer to face and breast. It’s the beginning of a body makeover. I would prefer having you since the surgeons in my area aren’t capable of correcting the nose. Can we do all of the surgery mentioned above, I would really like to do as much as possible.
A: Such combined face and body procedures are often done together and the economy of time, cost and recovery are the obvious reasons why many patients seek to maximize their operative experience. But each patient must be assessed individually to determine if it is the right concept for them. In making that determination the important factors are two-fold; is it safe and is the best result achievable in one combined surgery? From a safety standpoint, 62 years old is perfectly fine for these procedures as long as one is healthy with no major medical problems. (which you are) For your immediate recovery, however, such combination of procedures should only be done if you are observed overnite in the facility. That would be particularly paramount since you are from out of town.
From a procedure standpoint, combining a rhinoplasty and facelift (with or without fat transfers) is very common. The nose is a central facial procedure and the facelift is a lateral facial procedure so one does not affect the other. For a breast lift, however, volume augmentation by fat injections may or may not be affected by the lift. That would depend on what type of lift is being performed and what quadrant(s) of the breast fat may needed to be added. Depending upon your degree of ptosis (sagging) you may only need the Refine internal suspension lift with outward superior nipple lifts. That would allow the maximal volume of fat to be added at the same time. I would need to see some pictures of your breasts to better answer this procedural question.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty. I am 50 years old and was originally born with cleft lip and palate. I have had two previous rhinoplasties for my cleft nose, the last being over a decade ago. I have never really liked the results and was hoping to have one more go at it in my older years. Just recently had a consultation about my nose with a surgeon who is basically a cosmetic surgeon. He looked me in the face and said that due to my anatomy and blood supply, his major concern was that he wasn’t sure if he could correct anything. His concern was necrosis. I have great blood supply and have never heard of that possible complication before. As a matter of fact that remark caused me to realize that I needed an expert in cleft nose deformities. Please tell me what you think.
A: While open rhinoplasty always has the potential for nasal tip skin necrosis, this would be a very rare problem. The surgeon would have been better to say ‘I am not interested in doing your nose’, ‘this is hard and not worth my effort’ or even ‘this is beyond my skill level’ but the idea that the blood supply to your nose is compromised and can’t be operated on is not a valid biologic concept. If that were true, the vast majority of revisional rhinoplasties would never be done, not withstanding the secondary cleft rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a rhinoplasty to help with my congenital nose deformity from cleft lip and palate. I am a healthy 60 year female and my speech is fine. But my nose has never been right and until I read your writings on my problem I did not realize that it is a cartilage memory problem. This seems like it might be a magical solution and I hope you are the magician.
A: Correction of the cleft nose is a particularly challenging rhinoplasty procedure as the anatomy is far from normal. Such a nose appears deviated or twisted from the nasal bones down to the tip. The tip is most noteworthy as it is usually bulbous with thicker skin and deviated towards the non-clefted side. Part of this is due to the twisted septum internally which swings away towards the normal side pulling the tip with it. Trying to correct can be difficult and this where the role of cartilage memory comes into play. But the other major component is the nostril on the cleft side. It is deformed because it has a lack of adequate tissue support. The lower alar cartilage is slumped as it is weak and lacks the amount of cartilage on the other side. In addition the skin is deficient further contributing to the shape distortion. (which also makes it difficult to get a shape like the opposite side)
I will assume you have had some prior rhinoplasty work, perhaps years ago, and substantial efforts were made in the tip area. In my rhinoplasty experience, the cleft tip needs considerable support added including a columellar strut, spreader graft on the cleft side and an alar rim and batten graft above the cleft nostril.
If only improving the nostril shape to correct the amount of nostril retraction/asymmetry, I would just do a composite ear cartilage-skin graft to roll down the retracted nostril edge.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in rhinoplasty but think I may need more. I’m trying to find a way to make my side profile look nice and pretty. I hate my nose as its quite large and has a small bump on it therefore I really want rhinoplasty. I also have a small slanted forehead and small chin so it looks like my face goes into a point at my nose. What would be best to change this? Please help, many thanks.
A: By your description, your three main side profile features have an imbalance. Your nose is too big and the forehead and chin is too small, creating the profile that you dislike. In trying to figure out what procedures you may need that creates the best change, it would be important to do some computer imaging. The procedures of rhinoplasty and chin and forehead augmentation must be looked at individually as well as in comboantion to see which creates the best change. It probably goes without saying that all three create the greatest profile improvement but do you really need them all. I suspect that the rhinoplasty and chin augmentation alone may be sufficient and produce the best return on the effort but that remains to be proven by the imaging predictions. Please send me a side profile picture at your convenience to help you make that determination.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am 21 years old and I bit unhappy about my profile…I was thinking about doing something on my chin,nose and ears what would you recommend me. I have sent you some recent pictures of me.
A: In answer to your questions, You would benefit by any three of the procedures that you described.
1) Your ears do stick out the left more than the right. A setback otoplasty would be very effective.
2) Your nose is very ‘juvenile’ in shape with a low dorsum and a soft amorphous round tip. An augmentative rhinoplasty to build up the bridge, give the tip more projection but also narrow it would give your nose a more defined structure.
3) Your chin is short both horizontally and vertically. A sliding genioplasty or a combined horizontal/vertical lengthening chin implant would make your profile more balanced and proportionate for a male.
I have attached some imaging which reflects these proposed changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to achieve a more aethetically appealing face, by whatever means necessary. I’ve noticed my forehead protrudes in respect the level my eyes are at, making them look sunken and my face more masculine. I don’t believe it’s my bossing that sticks out, just my forehead in general, so i’m not sure how much of a result I would see with surgery. I’ve been told my nose is large, so I’m considering rhinoplasty as well. Additionally, my lips appear to almost “hang off” my face. I know this isn’t your forte but do you believe jaw surgery could be a solution? In general, I was just wondering what procedures you would recommend. Thank you for your time and I look forward to hearing from you!
A: Thank you for sending your pictures. I have done some imaging predictions based on the one side profile that you sent. What I have done is a forehead reduction, rhinoplasty and chin augmentation . If you look carefully at those changes, the most dramatic effects come from the rhinoplasty and chin augmentation. The rhinoplasty is key because your forehead and brows look so pronounced because you have a very deep radix. (root of the nose). One of the key manuevers in your rhinoplasty is the buildup of the root of the nose. By doing so that makes the forehead less retrusive in appearance alone.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, there is something wrong with my face but I can’t figure it out. I used to think it was all because of my nose which is big but I think it is more than that. There is some other part of my face that just isn’t right that makes me look unbalanced or disproportionate. I have attached some pictures for your insights and recommendations.
A: Thank you for sending your pictures. What I see about your facial proportions are two things:
1) A nose that is very broad at the tip and middle 1/3 and a bridge/dorsal line that is low.
2) A forehead that is narrow and very flat.
Ideally a rhinoplasty with tip narrowing and dorsal line augmentation would make the nose more proportionate. Also a forehead augmentation to give it greater convexity from the brows up to the hairline would also be an aesthetic addition.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am planning on having a scar revision for a vertical scar on the bridge of my nose. At the same time I want to correct sinus problems: turbinoplasty, septoplasty as well as rhinoplasty for some minor aesthetic improvements. I’m hoping the minor nose humps can be grinded so they won’t exaggerate the contours of the scar. How can I minimize the new scar on the bridge from becoming widened over time, developing little arterioles, or the skin getting too thin? What laser should I plan for post-surgery?
A: Based on your question, I would need to have a better idea as to the type of external rhinoplasty you would be having. Will this involve rasping of the bridge or will it require osteotomies as well? Either way, however, I would not perform a scar revision directly over the nasal skin that is being raised during the rhinoplasty. This is not a blood supply concern but one of scar healing. The swelling of the nasal tissues after a rhinoplasty will work directly against having a good scar result. You would be much better to delay the scar revision to after the rhinoplasty, preferably 3 to 6 months later. Scar revision on raised rhinoplasty skin is not a good simultaneous idea if you want the best scar result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley,I was thinking about have a nose job, I’ve been thinking about this for a long time! But i’ve made myself really paranoid buy looking at the bad points, but i am so insecure about my nose! I don’t know what to do?
A: The first place to start is to list what you do not like about your nose and what you would change if you could. Secondly it would then be important to see what is possible by rhinoplasty surgery by having some computer imaging done of realistic surgical outcomes. Then you can see if rhinoplasty surgery is worth the effort. If you send me some pictures and the changes you would like to see I can do that for you. This will give you good information to decide about what to do with your nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My goals are increased horizontal projection of my chin( no vertical lengthening)and a more square chin. Jaw angles flared out with augmentation of the angle itself and of the ramus but not the body? ( not necessarily a drop down of the angle itself as I think the angle is low enough currently). Rhinoplasty to decrease the hump in the nose possibly decreasing the width of the bony part of the nose when viewed from the front and the tip refined somewhat( picture with red hat)( My morph( lateral view of my nose in the blue shirt) I admittedly got a bit crazy/unrealistic with the tip of the nose. Finally, liposuction below the lower jaw/chin area to get rid of the adipose tissue that has always been there no matter my weight( a good 10-15 mm in various spots under the jaw/chin when I do a pinch test.) Also, wondering if the chin implant can be placed through an existing scar on my chin from my childhood.( picture added of scar 20 mm long and 10 mm long in the 2nd aspect and around 3 mm of width to the actual scar line( the scar is basically a T shape) Attached are some before and after pictures that I’ve done in photoshop as what I’m kind of looking for in general terms. I don’t know if this is even possible / what would be proportional for my face, but thought I would include them as a rough reference since I’m not there in person currently. My overall goals are increased balance in my face as I think the upper 1/3 of my face/ head is much larger then the lower 1/3. Also, I’m looking to do this with IV/ twilight sedation and not general. I’ve had septoplasty (2004) and a hernia operation in the past with just iv sedation(+ spinal for the hernia sx) and prefer this option. Thanks a lot.
A: Thank you for sending your pictures and doing the array of imaging. My review of the imaging matches fairly well with your goal descriptions and I would agree with much of it with the exception of a few minor variations.
For your chin you seek more horizontal projection, a more square shape in the frontal view and no change in its vertical length That would be possible using a square silicone chin implant, probably of at least 7mm to 9mms in thickness placed through a submental incision. It would not be wise to use your existing scar as it is too small, would become more prominent as the chin is pushed forward and would dive through the mentalis muscle in the process. A scar revision can be done on it but it would not be used to place the implant.
Your jaw angles show width expansion, a sharpening of the angles and no vertical lengthening. That could be accomplised by a 9mms silicone lateral augmentation implant placed directly over the existing angles.
The only comments about potential results with these implants is that the angularity of them (point of the angles and sharpness of the chin corner) may or may not be as sharp/pronounced as you have shown. The other issue is the continuity or smoothness of the jawline from the chin back to the angle. While the ends of a square chin and jaw angle implants will overlap, these overlapping areas are not as thick as the other parts of the implants. This it is not clear that the jawline will be as perfectly smooth from front to back as you have imaged.
The nose can be changed through an open rhinoplasty with a hump reduction and tip narrowing and some mild lift. I think those results are very achieveable.
Lastly, this collection of combined facial structura procedures can be done very well under just IV sedation. These are operations that are best performed under general anesthetic to get the best result.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, My face is slightly asymmetrical; the right side of my face is less wide than the left side. Consequently, my jaw line is more square and substantial on the left, and less so (its a little more rounded) on the right. There is also a greater fat buildup in my right cheek, since it has less area to distribute itself over than the left. Finally, my nose has a fatty round tip (I am not sure of the proper medical term for it, but I can feel that the problem isn’t the cartilage, so it must be a fat buildup), and it obscures the definition of my nostrils.
So, the surgeries I would like to have done are 1) rhinoplasty (reducing and defining the tip of my nose; the cartilage and bone are fine), 2) buccal fat removal from my right cheek, and 3) a jaw implant on my right jaw to balance with the left side. Each of these features affects the others, so I assume that it is best done by the same doctor, and at the same time under general anesthesia. The reason I am writing to you about this is because of all the plastic surgeons I have researched, you are one of the only ones who explicitly does jaw implants, not just chin implants or facial injections. I understand my face will not be totally symmetrical after this procedure (my whole left skeleton is slightly wider than the right side), but I do want to balance out the corner of my jaw, the fat in my cheek, and the nose with the rest of the face.
I have attached an informal frontal shot of my face, so you have some sort of visual to accompany my description.
A: Thank you for your inquiry. I believe your description of your facial asymmetry and your approach to improve it is spot on. I would just make a few modifications/clarifications on your proposed procedures. First, the round tip of the nose is not primarily caused by the subcutaneous fat under the skin. It is a component to it and minimally modifiable due the risk of skin necrosis of the overlying skin. The major component to making one’s nasal tip less ‘fat’ is to modify the underlying lower alar cartilages, particularly that of the dome area. Thus a tip rhinoplasty changes the size and width of these cartilages to make the tip more refined. Second, a buccal lipectomy affects the fullness right under the cheekbone and not further out on the face. Lastly, the type of jaw angle implanted needed would be a lateral augmentation style that only adds width and not length to the jaw angle area.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I do like the rhinoplasty images that you have shown. However, I’ve given it some more thought and was wondering if you thought I could have a more sculpted tip?
A: What I was showing on the frontal images is the amount of refinement or sculpting of your tip that can be achieved. There are limits as to much tip refinement can be obtained in any patient and that is based on the thickness of their nasal skin. Thicker skin, like yours, will only shrink down so much no matter how much the underlying nasal cartilages are modified and narrowed. I try to show predicted results that are realistic so patient expectations are in line with what may actually happen… that is the best way to have a happy patient should they ever have the actual imaged rhinoplasty surgery.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I like what I see, much more “chiseled” appearing. Would it be unnecessary to or insensible to increase the length of my chin to make it sort of protruding? I’ve always found that to be appealing/masculine. I know people get chin reductions to avoid that, but I’ve always liked that. If not, I feel that I see some flaw in my chin/jaw line that stands out to me. I’ve always wanted a stronger jaw/chin, maybe overly strong, beyond typical. Maybe it is my jaw? Would you recommend a possible jaw implant along with the rhinoplasty and chin implant? Do you think this would match my desired traits? I desire an angular sort of jaw, with a square appearing and strong chin, and my nose looks great after, but is there a way that it could be made that you couldn’t see the bottom of my nose? Its always made me self conscious that the bottom of my nose has been visible when i am looking at someone. I am sorry I’m asking so much, I just want to make sure that I am 100% pleased with the procedure and I want to get as much done at once as possible by the same person and you seem to know exactly what I want.
A: When it comes to vertical lengthening of the chin, that can not be done with an implant by more than few millilmeters. It would require a chin osteotomy or a custom chin implant to do that which, although can be done, adds to the cost of the procedure. I would just use a square chin implant of 9mms augmentation and position low on the chin bone so that is some degree of vertical lengthening. I believe that will more than suffice.
The trifecta of jaw angle implants and a chin augmentation are the best way to create a chiseled jawline. The key question in jaw angle implants is whether they should just be of the lateral augmentation type (just adds with to the jaw angle) or whether they should be of the vertical lengthening type with variable amounts of width addition. What most men who seek the chiseled jawline look need is the latter, some vertical lengthening and width addition to create a sharper and more defined jaw angle at the back of the jaw.
Your nose is slightly over rotated (tip up too high). The tip could be rotated downard to some degree using septal extension and tip only grafts during your rhinoplasty.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I know rhinoplasty involves a lot of different surgical steps that affect the outcome of the surgery. But there must be different types of rhinoplasties based on whether you change just one part of the nose or different parts. I am trying to figure out what type of rhinoplasty is best for me.
A: You are correct in your assumption that rhinoplasty involves a lot of different steps and no one rhinoplasty is exactly the same as the other. But there are some basic types of rhinoplasty which affect not only what part of the nose is being changed, but how long the operation lasts and how the length of recovery. I like to think of rhinoplasty as involving three different types which can be described as follows.
Type 1. This is a true tip rhinoplasty where the work lis imited to just the lower alar cartilages. No nasal bone or middle vault cartlaginous work is needed. Also there is no internal septal or turbinate work done. A tip rhinoplasty would actually be done most commonly in revision work for tip asymmetry and/or an adjustment but may occasionally be done as an isolated primary rhinoplasty. This is the quickest recovery of all the rhinoplasties. For the obvious reason I like to call this a TIP RHINOPLASTY.
Type 2. = This involves work done to the ip and middle vault cartilages of the nose but does not involve nasal osteotomies. (breaking the nasal bones) It may involve some rasping or smoothing of the nasal bones for minor hump deformities. Septal grafts may be harvested but not overall septal straightening or turbinate reduction most of the time. This collection of nasal procedures I call a RHINOPLASTY.
Type 3. This is a complete ‘overall’ of the entire nose. It is complete nasal work from the tip to the nasal bones including osteotomies. Always needed when there is a signifincant hump reduction. Will almost always include a straightening septoplasty, graft harvests and inferior turbinate reductions. Because of treating both the internal nasal breathing and external appearance, it is called a SEPTORHINOPLASTY. This will involve the longest recovery of all the rhinoplasties which often causes temporary undereye bruising and nasal congestion and stuffiness.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I wanted to ask a rhinoplasty question. Since my primary motivation for getting any work done is to improve my smile. In a rhinoplasty where you reduce the nasal spine as we discussed, would there be a possible side effect of lengthening the distance between the nose and mouth? In my imagination, by eliminating some of the protruding cartilage in that area, the tissue and skin that currently exists there would be pulled back into that void, thus pulling up the lip slightly. However, I’m not sure if that’s even how the anatomy works. Is the tissue anchored to that area and would it need to re-anchor itself or would it just drape down further, thus lengthening the lip?
A: Your question is a good one. Theoretically by removing the nasal spine, your assumption is most likely correct that the tissue should be pulled back up into the removed area potentially lifting the lip somewhat. In reality, probably very little lip lift actually occurs. There have been a few reported instances where lips have lengthened as a result but that is not something that I have ever seen. One would not, however, try to anchor the tissues to the removed nasal spine area as that may potentially cause a tethering/tightness when one smiles. It is much better to let the area heal naturally rather than try to treat a potential problem which may never occur…and in the process create a whole new one.
The way I view your rhinoplasty, and is the reverse of the the concern of upper lip lengthening, is that the rhinoplasty is potentially setting up a subnasal lip. So whatever happens to the lip length (particularly if there is some lengthening) does not matter because you likely moving on to a lip lift anyway.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 21 year-old transsexual male. (female to male) I have been on hormones for a year and a half and my face has changed in sufficient ways. However, I still lack much masculinity in my facial features, and the bones don’t face drastic changes at my age. I also know that I have a bulbous tip to my nose and a weak chin. I have been considering plastic surgery not only for aesthetic reasons, but for the more masculine appearance I could gain from it. My goal isn’t to correct the flaws in my facial balance as much as it is to “masculinize” it. A strong chin, a strong straighter tipped nose would be my goals. I am wondering if you think you could achieve what I am asking of you. I can send pictures and you could give me your input. I will send them from different angles, completely neutral appearing. Thank you for your help in this matter.
A: As a general statement about facial gender transformation, it is usually easier to make a face appear more masculine than more feminine. This is because augmentation of the facial bones, usually by implants, can produce a more noticeable change than trying to reduce the size of any facial bone. This, of course, depends on the facial bone structure that one has to work with but augmentation by millimeters will always be greater than what bone reduction in millimeters can be achieved.
In making a face more masculine the jawline is always of great importance. Whether it is just chin augmentation or a more complete jawline enhancement including jaw angle implants, one of the defining male features is a strong jawline. While the nose is not as important a male feature as the jawline, a nose and a rhinoplasty that creates a high dorsal line and a well defined tip goes along with a good jawline that makes a very masculine statement in profile. Computer imaging will show how much of a difference these changes can make in the appearance of your face.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am going to have rhinoplasty and otoplasty and, for a variety of reasons, will need to not do them together. I have some questions about the procedures:
1. How realistic is the imaged “after” rhinoplasty result on the nasal profile? While the projection itself is noticeably smaller, I think half the effect comes from changing the slope of the upper lip. Is that something you could do along with the 1/3 to 1/2 reduction to avoid tip skin problems?
2) I’m getting an otoplasty on March 11th. Is there a minimum time I need between the otoplasty and the rhinoplasty?
A: In answer to your questions:
1) The lip coming forward may have some impact on the perception of the dramatic change in tip projection. But, regardless of who did that imaging, you should know that is a ‘best case’ scenario and there is no guarantee you will ever get that much tip reduction. If you walk into surgery expecting that result and will be very unhappy if you do not get it, then you are setting yourself up for disappointment. Conversely, if you go into surgery hoping for that result but would still find it a big improvement to only halfway reach that amount of tip shortening then you will no doubt end up in a happy place.
2) There is not really a minimum time between two surgeries when they could be done either together or separately. The ears do not influence the nose or vice versa. It is more an issue of logistics for you such as work and other recovery issues. That being said, I would space an otoplasty and a rhinoplasty at least 6 weeks apart if the patient needed to separate them into two surgeries.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions regarding cranioplasty, rhinoplasty, and septoplasty. I have a form of craniosyntosis and my skull has indentations that could be improved by a cranioplasty, I also have a severe deviated septum and crooked nose that needs correcting by having a combination of rhino/septoplasty. Insurance will cover the procedures for my nose to get corrected. I believe I have seen somewhere on your website where someone asked a question similar to this, and you said something along the lines of it is ideal to get the cranioplasty and rhino/septoplasty all done at once. That probably is not a possibility in my case, because getting my insurance to cover the cranioplasty is going to be difficult, so I am going to have to put that off for now until I have the money to get it done.
My questions are:
1.Would it be OK to get rhinoplasty/septoplasty done before getting a cranioplasty?
2.Or is it better to get the cranioplasty done first?
3.Or does it not matter at all in which order I get these procedures done?
Thanks
A: In answer to your questions:
1) Insurance may cover the septoplasty portion of your nasal deformity but not the rhinoplasty portion.
2) Insurance will not cover any type of cranioplasty for skull recontouring. Indentations of the skull are not a medical condition but a cosmetic one.
3) The order of septorhinoplasty and cranioplasty is a matter of personal preference. There is no medical reason as to how they staged or in what order.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting my nose. I am a 22 year-old female who has a nose in which the tip does not match the rest of my face. My nose tip is too fat and there is like a line running down the middle of it. The rest of my face and nose is actually small and well proportioned. The tip of my nose does not match the cuteness of the rest of my face. Can this be fixed? I have attached a few pictures for you to see what I mean.
A: Thank you for your inquiry and sending your pictures. What I see is that the tip of your nose has the classic bifid tip deformity. This means that the lower alar cartilages do not come together or meet in the middle of the tip of your nose. As a result, this leaves a central groove down the tip of your nose the whole way down to the base of the columella. This also creates a wider or fatter tip due to the lateral cartilage displacements. Outside of tip the pictures show only one angle so I can not comment on the shape of the rest of your nose. The bifid tip deformity can be corrected by bringing the lower alar cartilages together by sutures as well as thinning their size. This will make your tip more refined, narrow and get rid of the groove or cleft down the middle of it. I have attached some rhinoplasty imaging based on these potential changes.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a combined forehead augmentation and rhinoplasty. Please see the file attached for my thoughts on how I want to look on the front of my face. Please forgive the crudeness of the drawing, I only have Windows Paint on my computer to play with, which is very limited in abilities ;-). It should give you a general idea however. One of my questions is will the forehead augmentation result in a possible simultaneous hairline lowering? Also, how long would the recovery period be?
A: That is actually a very good drawing as it is always important to understand what the patient actually wants. Any forehead augmentation procedure requires a scalp incision which is almost always placed way behind the hairline and does not really result in hairline lowering. That raises the other possibility of making a hairline incision (what we call pretrichial) to do the forehead augmentation and then try to bring the scalp forward to lower the hairline. This would obviously place the incision at the hairline. Just an additional thought although I always feel it is better to have the incision way away from where the cranioplasty material is placed.
When it comes to recovery from a combined forehead augmentation and rhinoplasty (which is actually not a rare combination in my experience), you would expect to look pretty reasonable in about 10 to 14 days. (although all swelling takes about 6 weeks and final refinements up to 3 months after surgery) It is not really a physical recovery but one of appearance.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in the procedures of jaw enhancement, facial fillers, and nosejob. I would like to achieve a more defined and symmetrical jaw line. I want a more filled out face. Perhaps cheek fillers or cheekbone reduction also? I am not sure which approach would be best to give me a fuller face. I want facial features more similar to Brad Pitt.
A: I can see your concerns in regards to a fuller face. You have a very skeletonized face with virtually no fat between the prominent cheek bones and your jaw line. I have done some imaging based on the procedures of jaw angle implants to widen the lower posterior face, a rhinoplasty and fat injections to the sides of the face below the cheekbones down to the jawline. This combination appears to give you better facial proportions and also demonstrate that the cheekbones are not really so prominent. It is the lack of soft tissue fullness (fat) that is why you have your current facial appearance. While cheek bone reduction is an option, I used fillers just to see how the face would look without changing the width of the cheekbones. This confirms their benefit over cheekbone reduction.
The pictures are not of good enough quality to reveal what a rhinoplasty can really do but I made my best effort.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in forehead augmentation and possibly rhinoplasty. I have put together a compilation of my head shots along with some of the “standard” head models. In short, I feel that I have a huge face and no skull. I would like to achieve a better balance between the two. So the procedures I was thinking of are 1) Forehead augmentation and 2) Skull Augmentation to the sides, up and back (if possible of course, sounds like a lot). I am also considering a rhinoplasty to reduce the width of my nose. Please see the attached compilation and let me know what you think. Thank you so much for a prompt response.
A: I have done some imaging based on what I see as the causes of your face:skull disproportion. Your forehead is sloped at a near 45 degree angle with no brow prominence. When combined with a long overprojecting nose and a short chin, your face looks out of proportion to your skull. By doing a forehead augmentation, shortening the nose and bring the chin forward with a central button implant, there is much better balance between your face and skull. I have attached some imaging to show what effects those procedures might have on your appearance. These imaging predictions are just a first pass on the procedures and more or less changes are possible.
Dr. Barry Eppley
indianapolis, Indiana
Q: Dr. Eppley, my goal is a harmonious and ideal ‘male model’ look profile via rhinoplasty and possibly horizontal and vertical chin augment if rhinoplasty is not enough. I want to have rhinoplasty done to correct my deviated septum, hanging columella, raise my tip slightly and smooth a slight nasal hump. I’m wondering if I can get away with rhinoplasty alone to enhance my profile? I feel my chin is a little weak (I have an overbite ~ class II). I did orthodontics/braces to correct my crooked teeth only, but not my bite. I don’t want jaw surgery because I’m OK with my bite function.
Concern: My deep labiomental fold that is between my lower lip and chin. Will a chin augmentation hurt, help or not effect this crease? I don’t want to make this crease worse, I either want it unchanged or improved.
Questions: Chin
Which procedure is recommended to produce an ideal result. Implant, genioplasty or doing nothing?
If implant, how big and what type should be used?
If genioplasty, what kind of cut would be done horizontal?
Will a chin augmentation hurt, help or not not effect labiomental crease??
A: In answer to your questions;
1) You absolutely can not get away with just a rhinoplasty alone to improve your profile. Your chin position is just too short. For your profile and overall facial aesthetics, chin correction is actually more important than the rhinoplasty.
2) Your chin correction should ideally be done by a sliding genioplasty because you have both a horizontal and a vertical chin deficiency.
3) The vertical component of the sliding genioplasty will allow the depth of the labiomental sulcus depth to remain unchanged as the chin comes forward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking to have breast implants, rhinoplasty and mentoplasty. (no implant) Do you offer mentoplasty? If so would I be able to do these 3 procedures at once or if not I would wait to do the implants. I can send some detailed pictures if needed.
A: Thank you for your inquiry. You certainly can do breast augmentation, rhinoplasty and chin augmentation all during the same surgery. When you refer to a non-implant mentoplasty, I assume you are referring to a sliding genioplasty in which the chin bone is moved forward. That accounts for about 25% of all chin procedures that I do so it is a chin augmentation technique in which I have great familiarity.
To help prepare accurate quoting, please send me some pictures of these areas so I can see exactly what needs to be done and the time it takes to do it. This is most relevant for the nose as there is great variability in rhinoplasty surgery depending upon how much of the nose structures need to be changed.
Once I have received the photos, I will do some computer imaging for the nose and chin and have my assistant send you a collective cost quote.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I want a smaller, less frightening nose. I inherited this nose from my father. I’ve always been self conscious and I hate that I feel self conscious about my nose. Over the years my father’s nose has started to kind of go off to the side and developed one of those bumps and look even worse and I hope that same thing doesn’t happen to me. It’s not so bad from the front, but from the side, oh man. I just want it to not stick out quite so far, just a smaller slope and smoother point I suppose. I don’t know if that makes sense.
A: Your nose concerns make perfect sense when seeing your pictures. Your nasal tip is overprojected (too long) due to very strong and long lower alar cartilages. Your nasal tip needs to be shortened and lifted slightly to correct a tip that is too long for the rest of your nose. In addition, I would take down some of the dorsal septal height up to the nasal bones and add a crushed cartilage to the radix area. (these are all manuevers to match the dorsal line line better to the shortened and lifted nasal tip in profile) I have attached some images of these proposed changes in the side and front views based on this type of rhinoplasty.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want to create dimension to my face by making bony features more prominent. I would like to correct my flat midface, drooped nasal tip, recessed chin, flat cheeks and forehead, and create a more prominent bridge to my nose. What procedures would you use and how would you make these changes?
A: To make those facial changes, I would perform forehead augmentation with PMMA, a rhinoplasty using either a synthetic implant or rib cartilage grafts, and cheek and chin implants. I have done a side imaging photo to illustrate what I believe you are after with this compilation of procedures, to pull your face out and provide projection to a face that is naturally flatter and more wide. The only thing that I couldn't properly illustrate in the imaging is the bridge of the projection that would be achieved. Your natural bridge is hidden behind the eye so its profile can not be pulled based on this one photo. Always remember that computer imaging is just a visual way to start the discussion about what changes one wants and how much they want those changes to be. All of these facial changes can be done in varying degrees. Finding the correct amounts when multiple facial areas is being done is the key to a successful result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, if I was to have a rhinoplasty to augment the bridge of my nose and a forehead/eyebrow augmentation, which should be done first? Will having the raising of the nose bridge first and then the forehead/ brow augmentation mess up the profile of the nose together with the brow ? Which procedures should I do first for best results ? Does it make a difference ?
A: I think the best aesthetic sequence is to do the forehead before the rhinoplasty. That way the position of the nasal implant can be optimized to that of the frontonasal level of the brow augmentation. That is a lot easier to do than the other way around. Getting a significant augmentation of the brow, particularly in the glabellar area, is more difficult that just forehead augmentation where you leave the brow area alone. Once a forehead/brow augmentation is done it is very difficult to change particularly if you are trying to add more to the brow or glabellar area. Therefore, create whatever brow/forehead augmentation that can be done and then set the level of the nasal bridge to that. In essence, work your way down from the top based on the difficulty of doing the procedure. When brow augmentation and rhinoplasty is done at the same time, it is easier to make both meet in the ‘middle’ so to speak.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a variety if procedures including brown bone reduction, rhinoplasty, chin augmentation and correction of my chest which I think is a pectus excavatum deformity. I have attached a variety of pictures so you can see all of the problems. I would like to know what you think.
A: I have taken a careful look at your pictures and can make the following comments.
1) Your chest deformity is very slight and not a true form of pectus excavatum. Regardless of what it may be called, I see no surgical procedure that would be worthwhile. Given the mild nature of the sternal groove/depression, the only option would be to build up the sternum with an injection technique to avoid any significant visible scarring. The problem is that it would be virtually impossible to get a smooth result. Without such a result, you would end up with an equally distracting aesthetic problem.
2) Forehead/brow bone reduction is not an option for you due to the mild nature of the bossing and the need to have a scalp scar to do it. That is always a challenging problem in a male. The trade-off of a scalp scar is not a worthy exchange.
3) Your chin shows both a significant horizontal and vertical deficiency. Its amount of deficiency makes your nose look bigger than it really is. It is the one feature on your face that would make the most dramatic change. Because of these three-dimensional chin deficiences, a chin implant is not a good option as it only brings it forward. Only a sliding genioplasty can bring the chin forward and down which are the changes that you ideally need.
4) The only beneficial changes that I see in your nose is the tip. It could be made thinner. But I would not change the height nor the smoothness of the dorsal line. I would also not change the tip position by making it any shorter or have anymore upward rotation. In essence, a tip rhinoplasty is all that you need.
I have attached some computer imaging based on the chin and nose changes.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am considering having Lasik eye surgery. If I did get it, how long after Lasik should I wait until being able to safely have a rhinoplasty. Would it be safer to wait to do Lasik until after having the nose surgery?
A: Rhinoplasty does not affect Lasik (corneal) eye surgery in any direct way. So, in theory, it should not matter whether rhinoplasty is done before or after corneal modifications. However, rhinoplasty does involve working around the eyes and often the eyes are either protected by corneal shields or the lids are closed over the cornea by tape. Such protective manuevers always run the risk of causing a corneal abrasion even though their intent is to prevent that exact problem. Therefore, if I was a patient I would prefer to have my rhinoplasty done first and then have the Lasik surgery done afterwards so the rare risk of that problem which could be occur during a rhinoplasty is eliminated.
Dr. Barry Eppley
Indianapolis, Indiana