Q: Dr. Eppley, I had a revision rhinoplasty several weeks ago. My first rhinoplasty left me with an obvious silicone nose with a dropping tip and big flare nostrils since I am Asian. At that time I was concerned about the bridge only. After the revision (they used rib), it looks natural and even a bit slimmer since they did fracture it as well. But somehow I feel it was shorter than my silicone nose. I asked my surgeon about this and he told me that my skin is so thin that it would look fake if they put something in to increase the height of the bridge. He even said he had to dice the rib bcause of this. I just wanna know is there still any hope to make it higher without being unnatural because of this thin skin. Thank you.
A: I believe what you refer to as a ‘shorter nose’ really refers to the height of the dorsum rather than the actual length of your nose. By your description, your silicone implant was bigger than the rib graft that replaced it. This is particularly evident as the rib graft was diced, most likely done because the harvested rib was not straight and dicing it ensured that the risk of warping after surgery was eliminated. Large silicone implants do tend to thin the overlying nasal skin due to pressure and the lack of an underlying vascularized surface doing the outward push. When replacing such an implant one certainly doesn’t want to place a bigger implant or even one that is exactly as big in height. (implant thickness) But in using rib grafts in rhinoplasty, particularly in a diced form, the graft size could have a good height as this more natural material allows blood vessels to grow through it. This rduces the risk of further thinning of the skin or skin compromise.
Dr. Barry Eppley
Q: I have already had three rhinoplasties. And at the moment, I have no cartilages, just a scar tissue. If a cartilage from the rib is inserted during my fourth rhinoplasty, does it mean that the size of my nose will increase? what effects can I expect for the fourth time? Can the size of the nose get bigger?
A: While your nose may have collapsed and cartilage has been removed from the three prior rhinoplasties, I am certain you have some cartilage left in your nose. The septum and the upper cartilages undoubtably persist but the most severe cartilage loss is in the lower alar or tip cartilages. This probably causes problems not only in its appearance but also in how well you can breathe through your nose.
When significant cartilage grafts are needed and the typical places for graft harvest have been previously used or can not offer enough, a rib or costal graft is the next and last harvest area. The rib(s) has more than an ample amount of cartilage for any single nasal reconstructive procedure. How the rib graft is harvest and used, however, is based on what is needed in the nose. Typically, a solid rib graft is used to built up the nose along the dorsum or as a combined dorso-columellar strut construct. This will make the nose bigger in terms of more projection and dorsal and tip height. Rhinoplasty with the use of a rib graft always means that the structure of the nose will be more built up or moved outward from the plane of the underlying face.
Dr. Barry Eppley