Your Questions

Q: Dr. Eppley, are you familiar with 2ndary rhinoplasty.? I also need to correct my septum which is crooked. My projection needs to be reduced and I need cartilage grafts placed in my nose because I can’t breath.

A: I am very familiar with secondary or revisional rhinoplasty procedures. Your use of rhinoplasty terminology suggests that you have not only had a primary rhinoplasty but have done some homework as well.  What exactly did you have done in your original rhinoplasty and how long ago was it done? I assume your septum has always been crooked and was not corrected during your initial procedure or was it the result of an inadequate straightening from the first surgery? Were any cartilages grafts harvested from the septum in your first rhinoplasty? I will assume that your use of the term ‘projection’ refers to the tip. Is it too high now because of the first surgery or has it always been too high? Are your breathing difficulties a result of the first surgery or have they always been present? I will also assume that you did not have spreader grafts placed during the first surgery.

Please feel free to send me any pictures of your nose with these answers. Secondary rhinoplasty can be a very effective procedure but the surgeon must have a thorough knowledge beforehand of what occurred in the initial rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a rhinoplasty in 2010 and I feel that it looks short for my face, nostrils not the same shape or size, alar base too round and wide, nostrils are flared. Nose is upturned and too short for my face. I feel my upper lip has too much space from lip to nose. Would like a softer more feminine appearance.

A: Thank you for sharing your story and photos. I obviously do not know what your nose looked like to start with and exactly what was done to your nose. It would be extremely helpful to see photos and the original operative record from your 2010 rhinoplasty. What types of grafts were harvested (if any), where they may have been placed, and what is left of the original cartilaginous structures will all play a part in what needs to be done. Secondary rhinoplasty surgery is usually much more difficult because of scar, distorted structures and sometimes depletion of easily available cartilage graft harvests.

But that important issue aside, your nose is short with wide nostrils. The tip lacks projection, the columella is short and upturned and the dorsum is low. Such a nasal shape is very characteristic of many ethnic rhinoplasties. (as said by a Caucasian plastic surgeon) In changing your nose to your desired goals, it is a matter of the degree of change. It is an issue of either tip derotation and nostril narrowing or that combined with dorsal augmentation. That aesthetic difference is important as that would determine the type and amount of cartilage grafting that will be needed. But either way cartilage grafts would be needed and most likely that means costal or rib graft harvesting to get the amount of straight pieces of graft needed, particularly if dorsal augmentation is going to be done.

As for the lip lift, I don’t see the benefit in your case. Your upper lip skin is already at a good length with substantial upper lip vermilion show. I think you perceive your upper lips as short, as least partly because of your short and up turned nose. While I doubt its benefits to you, I would at least wait until the nose is done and see what you think about your lip then. An open rhinoplasty and lip lift has to be performed separately anyway due to blood supply concerns of the intervening columellar skin.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was 16 years old when I got my rhinoplasty done. I am Asian and I had what appears to be a very typical Asian rhinoplasty using an implant. I think it is a silicone L-shaped implant. I originally had a very flat nose with a low bridge. It is now 20 years later and I want to take it out. I have never liked the way it feels and the idea of having plastic in my face bothers me. I think the skin has also gotten thin over it as I think I can see the implant when out in bright sunshine. Can it be removed at this point? How will my nose look when it comes out?

A: Your indwelling nasal implant can be removed at any time. The question is not whether it can be removed but whether to do anything else to replace it at the time of its removal. Taking the implant out will deflate the nose so it will get flatter and shorter, perhaps close to what you were before. Certainly that is the easiest option but perhaps not the most esthetic. Replacing it with a rib cartilage graft is the most aesthetic but not the easiest. Intermediate options include placing layers of allogeneic dermis (e.g., alloderm) on the dorsum and a septal columellar strut graft. That would be a good revisional rhinoplasty compromise as it would produce an intermediate aesthetic result without the need for rib graft harvesting. I suspect you really won’t like the appearance of the nose when the implant is removed but may not really want to have a rib graft harvested either.

Dr. Barry Eppley

Indianapolis, Indiana