Your Questions
Your Questions
Q: Dr. Eppley, I am interested in a septorhinoplasty procedure. I previously have undergone balloon sinus surgery in order to correct breathing issues. I have been to an ENT doctor and he suggested further reduction of the turbinates. I also have a problem with the sides of my nose collapsing when I breath in heavily. I wanted to correct the breathing problems especially because my chosen career is very physically based, as well as reduce a bump on my nose. I am very interested in if you would have any additional things to add to aid my breathing as well as improve the appearance for my nose.
A: Having not seen any pictures on your nose or examined you, I can only make some speculative opinions based on your description of your nasal symptoms. While further reduction of your inferior turbinates may improve your breathing, collapse of the nasal sidewalls with inspiration suggests weakness of the lower alar cartilages and impingement of the internal nasal valves. Such nasal valve collapse can cause greater breathing difficulties than a mechanical obstruction of the inferior turbinates. Since you interested in taking down your existing nasal hump as part of a cosmetic change to your nose, the incorporation of middle vault spreaders to open up and stabilize the internal nasal valves as well as batten grafts to support the lower alar cartilages would be adjunctive nasal airway maneuvers in addition to the inferior turbinate reductions. This more comprehensive approach to your septorhinoplasty should provide some significant breathing improvement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a septorhinoplasty procedure. I have snoring issues and a previous broken nose. I am curious about price and how much insurance would cover to fix a deviated septum to help with breathing. along with reconstruction surgery to slightly change nose appearance. As far as reconstruction, I would like to make it more defined from the front with a more feminine profile.
A: When it comes to nasal surgery, insurance only provides potential coverage for functional airway issues with the nose. (i.e., breathing difficulties) These include procedures like septoplasty, turbinate reductions and middle vault reconstruction with spreader grafts. Whether they would provide such coverage requires a written pre-determination letter by the evaluating surgeon. For a written pre-determination letter to be considered by the insurance company, a CT scan must first be done to verify that there is internal nasal anatomic derangement. A pre-determination letter that is not accompanied by a CT scan report will be automatically denied.
Insurance will not pay for any cosmetic changes to the outer appearance of the nose. That would be additional costs for the operating room, anesthesia and surgeon’s fee for this type of aesthetic rhinoplasty changes. These are not considered reconstructive regardless of how they developed.
Functional and cosmetic rhinoplasty procedures are commonly done together (septorhinoplasty) with the patient having financial commitments based on the limits of the insurance policy and the extra costs associated with the cosmetic portion. Those exact cost numbers can only be provided now based on what the fees associated with the cosmetic portion.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a deviated nose and feel pressure in my nasal bones. ENT doctor said nasal passage was clear from what he could see and prescribed allergy meds for constant stuffiness and post nasal drainage. Wondering if any chance insurance would cover any of my deviated nose repair procedure to improve how I breathe and the way the nose looks.
A: Insurance can cover internal nasal surgery for breathing issues such as septoplasty and turbinate reductions. These are often done as part of many rhinoplasties and fall under the name of septorhinoplasty when both functional and aesthetic nasal changes are done during the same operation.
Before one can submit to insurance to determine whether coverage is possible, this would require a paranasal CT scan to first be obtained to look at the internal nasal anatomy and see what abnormalities exist. If structural problems exist that block the nasal airway then a predetermination letter can be submitted to insurance to determine whether they would cover the functional surgery to correct it. You can not submit a predetermination letter without a CT scan to document what anatomic abnormalities exist inside the nose.The aesthetic part of the rhinoplasty (any external changes) would not be covered by insurance.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, How much will a rhinoplasty surgery cost me? I have Aetna Insurance and I want to know how much they might cover. By the way I have breathing issues and I went to a doctor and he told me my septum needs correction and my insurance might cover half of the whole surgery price.
A: Let me provide you with some clarification on your nose surgery and a better understanding about the costs of such surgery. The concept the ‘insurance may pay half of the whole cost of the procedure’ is both misinformed and overly simplistic.
What you are seeking is a nose procedure known as a septorhinoplasty. This is a procedure that combines the correction of a functional problem (septum and turbinates) and an aesthetic nasal issue. (rhinoplasty) While they are commonly done together and one does affect the other one, they are viewed economically as two separate issues no matter where you are having the procedure performed. The septum and turbinates are functional airway issues and are often covered by insurance. The rhinoplasty is an aesthetic issue and is never covered by insurance for common aesthetic reasons. Just because the two procedures are done together does not in any way mean that insurance is covering any cost of the rhinoplasty. Those fees must be paid out of pocket and in advance and includes the surgeon’s fee and the operating room and anesthesiologist’s time to do it. When done together a surgeon may choose to lower their professional fee for the rhinoplasty as a courtesy although they are under no obligation to do so.
Thus the only thing that insurance covers has nothing to do with the rhinoplasty. And if you do not do careful financial analysis beforehand (how much is your deductible, what is your percentage of costs beyond a certain dollar amount of what insurance pays), you could easily end up paying more for the whole procedure using insurance than if you paid the entire septorhinoplasty as a complete cosmetic procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in nose reconstruction (cleft rhinoplasty) for my teenage daughter who was born with a cleft lip. She is fourteen and is looking to have surgery this coming year. I am looking for a plastic surgeon who is experienced with rhinoplasty in clefts and just want her to be comfortable with her appearance.
A: All orofacial clefts (with the exception of isolated cleft palate) has some detrimental effects on the development and appearance of the nose. While the entire nose is almost always affected, the greatest deviations from normal occur in the nasal tip. Because the tip shape is controlled by the underlying septal end and the paired lower alar cartilages, it is particularly susceptible to very noticeable and classic tip shape deformities. Most commonly the lower alar cartilage on the cleft side is weak and misshapen, resulting in it being positioned lower (slumping) and having a widened and oblong nostril. This is exaggerated as the end of the septum is deviated away from the cleft side into the opposite nasal airway. This causes the entire nasal tip to be asymmetric and have the classic slumped appearance. For reasons unknown, the vast majority of cleft noses have a thicker skin cover, an issue that has great relevance in the outcome of rhinoplasty correction efforts.
Most cleft noses need a full septorhinoplasty approach to both optimize correction of the bony cartilaginous framework but also to correct any internal airway obstructions (septum and turbinates) which are almost always present. The relevant question is always the timing of the rhinoplasty surgery given the congenital nature of the nasal problem and the sensitive psychosocial development of children and teenagers. The traditional thinking of doing any rhinoplasty is when facial development is near complete, age 16 or older. However, I have always taken an earlier approach to some rhinoplasty patients particularly the cleft patient and I don’t think age thirteen or fourteen is too young.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in nose reshaping, but I also have been told that I would need nasal surgery. Do you do both at the same time?
A: I believe you are referring to needing improvements in your breathing inside the nose as well as external nose reshaping. It is most common to do both functional and cosmetic nasal surgery at the same time, a procedure better known as a Septorhinoplasty. It is always better done together as external nose reshaping often needs cartilage grafts which are most easily obtained with the septal straightening to improve the breathing. Thus the septorhinoplasty ends up after healing with better breathing as well as a more balance and pleasing external nasal shape.
You may feel free to send me some picture of your nose and I would be happy to do some computer imaging of them to see the possibilities of what can be done. A front and side view pictures are best for imaging purposes.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley, I am interested in having the following procedures done:
* Ear surgery – ear pinning + fix right ear that sits lower than left ear or fix left ear that sits higher than right ear + improve general appearance of ear cartilage
* Blepharoplasty – lower eyelid of my left eye (when I smile, it creates a prominent bag under the eye – not the case with my right eye though)
* Septoplasty – nose veers a little bit to right (possibly due to deviated septum)
* Rhinoplasty – remove slight bump & also looking to have a thinner nose
* Lip augmentation – improve general appearance
* Liposuction under chin – just to get rid of dreaded dubble chin
* Other possible procedures (if doctor recommend them): cheek implants, jaw implants and chin implant – I would like to have more masculine facial structure
Other possible procedures, if you offer them: tear trough implants, cheek lift
PICTURES:
First pic: how I actually look
Second pic: alterations I made to my face on your website (not perfect, just played around).
A: In answer to the facial procedures:
1) It is possible to raise an ear .5 to .75 cms but it is not possible to lower an ear. Ear pinning or antihelical fold setback can effectively reshape the outer ear cartilage.
2) The ‘bag’ of the left lower eyelid is hard to appreciate in your non-smiling views so I am not sure if it is a skin issue or a fat issue.
3 and 4) A septorhinoplasty is needed to straighten the nose, reduce the bump and have a thinner tip.
5) To make that amount of lip augmentation change, you would have to think about fat injections even though their survival in the lips is anything but assured.
6) Submental liposuction can be done but, more importantly, significant chin augmentation will eliminate that concern on its own. Cheek and jaw angle implants would be complementary to the chin and, in your thin face, would make it very sculpted and angular.
7) Cheek implants will obviate the need for a cheek lift. Tear trough implants can be done to fill out the under eye hollows.
Dr. Barry Eppley
Indianapolis,Indiana
Q: Dr. Eppley,I have been considering a rhinoplasty to straighten the bridge of my nose, smooth it, and possibly narrow it (it is a little wide). It is difficult to see from some of the photos but my nose goes a little to the right side of my face and has a slight “S” shape. In one of the photos the “S” shape of my nose is exaggerated from shadow and theuse of a poor camera. I am also considering slightly reducing some of the projection on my chin.
A: The S-shaped nasal deformity is one of the most challenging of all rhinoplasties because the entire nasal structures down through the septum is crooked. In looking at your pictures you have exactly that issue with right nasal bone outward deviation, left nasal bone inward deviation, complete left middle vault collapse with right-sided septal deviation and a wide broad tip. The challenge is to do a rhinoplasty in which the nose is perfectly straight afterword. This requires an open septorhinoplasty with correction of the septal deviation, reduction of inferior turbinates (I suspect you may also have some breathing problems), large septal graft harvest, nasal osteotomies, reconstruction of the middle vault with spreader grafts, nostril narrowing with a columellar strut graft nasal dorsal augmentation with septal cartilage. I have attached some computer imaging to show what the goal of that effort would be. A small amount of chin reduction was done as well, perhaps a 5mm bone reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am inquiring about a rhinoplasty. I am a 35 year old male in great shape. My nose history is that I played high school and college basketball and probably broke my nose 3 or 4 times so there is an obvious bump on it that is visible from both sides and then I would like it to be smaller or just fit my face better. Also, I think because of the number of times it has been broke it affects by breathing which is heavy through my nose. I have had my tonsils taken out to try to help but it hasn't. I have attached some pictures so you can see the nose problem that I have.
A: Thank you for sending the pictures of your nose. Your story is a fairly classic one and represents what I call the athletic or ‘sports’ nose deformity. This is the result of numerous nasal injuries and presents a story and nose that looks very much like yours. There is a visible nasal hump which is somewhat due to a severe middle vault collapse due to internal septal shortening and deviation. The internal inferior turbinates are usually hypertrophied. The combination of septal deviation, large turbinates and middle vault upper cartilage collapse undoubtably makes some contribution to your breathing difficulties. In addition, the nasal bones are displaced and often deviated. The nasal tip is large and too wide and long for good nasal balance.
To correct such a nasal problem, a complete open septorhinoplasty is needed to straighten the septum, reduce the size of the inferior turbinates, reconstruction of the middle vault with cartilage spreader grafts, nasal hump reduction with straightening osteotomies, and tip cartilage reduction and narrowing a columellar strut cartilage graft. I have done some computer imaging in profile to show you a potential result on the external nose shape. Unfortunately, the quality of your frontal picture is not adequate to do any computer imaging and will have to await better photographs taken in my office.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, my son was born with a bilateral cleft lip and palate. He just turned 9 years old. He is about to get his bone graft surgery in December. What is too early to have nose reconstruction? The surgeons said he would rather not touch his nose until he is age 15 or 16.
A: The nose deformity in bilateral cleft lip and palate is uniquely different from even that of a unilateral cleft. The lack of columellar skin and weak and short tip cartilages poses a significant reconstructive challenge that is present at any age that a patient undergoes any form of a rhinoplasty.
It is best to think of the nose reconstruction in bilateral clefts as done in stages. There are many variations as to how it is approached and will vary by surgeon. Fundamentally, it is divided into stages based on age and development. Under 12 years of age, the focus is on columellar lengthening, nostril narrowing and/or tip cartilage manipulation. After the age of 12, a full septorhinoplasty is done where the entire nose is reconstructed from the nasal bones down to the tip cartilages including the septal and turbinate deformity. At what age this full septorhinoplasty is done is open to debate but most plastic surgeons think more around the age of 14 or 15 years old when the face is essentially fully developed. There may be some modifications to this age based on the extent of the nasal deformity and the timing of orthognathic surgery (LeFort osteotomy) if needed.
In short, major manipulations of the septum and nasal bones should not be done under the face is more fully developed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My nose has been broken a couple of times, and I have a deviated septum. I am curious what it would take to straighten everything out–and what it would look like.
A: Based on this one picture, I have done some imaging based on what I think is achieveable in an open septorhinoplasty procedure. Straightening a crooked nose is one of the most difficult challenges in all of rhinoplasty because it is never just one element of the anatomy that is off. It is never simple and requires a complete dismantling of the support structures and rearrangement. This means an open septorhinoplasty with septal straightening and graft harvest, inferior turbinate reductions, nasal osteotomies, spreader grafts to the middle vault, a columellar strut and nasal tip narrowing. As you can see your nose would be much straighter and as assessed by the flow of the dorsal lines from the forehead down to the tip of the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My nose has a lot of things about that I don’t like and want to change. It has never been broken or anything so I think I was just born with this shape of a nose. What bothers me about it are several things. First, I don’t like the thick broad tip that I have. It needs to be thinned and made more narrow. I also think the tip is too long. Second, I don’t like the nasal bump that I have. My nose is not smooth from between the eyes down to the tip due to this bump. I also think that the bump makes the nose broader up top. I guess when you put these two things together, I pretty much want a whole new nose. I am wondering if a lot of these changes are possible.
A: Essentially your redo of your whole nose is known as a complete septorhinoplasty. Through an open approach all segments of the nose are addressed. The hump is taken down, the upper nasal bones are narrowed, the tip is reduced and narrowed and the dorsal line of the nose is made smooth. If needed the septum is also straightened, or at the least, used for cartilages grafts which are almost always needed. This is a complete overhaul of the nose and substantial changes can be obtained. All of what you are describing is both possible and also common im rhinoplasty surgery. Make sure you get some computer imaging done before surgery so you will be prepared for what these structural changes will potentially look like.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am 17 years old and want to get my nose fixed. I can’t breathe real well through the left side of my nose. I also don’t like the bump on it and the tip of my nose is too fat. Is it safe to get a rhinoplasty and septoplasty at the same time and does the bone grow after the thinoplasty?
A: The usual recommendation is to wait until the nose have completed its growth before having it surgically manipulated. On a practical basis this is going to be in the mid- to late teens. A female’s nose mature earlier than a male’s so for a teenage girl the nose is usually done growing by 15 to 16 years of age while a teenage boy’s is closer to 17 or 18 years of age. Depending upon the magnitude of the breathing difficulty, surgery may be done at any earlier age than these ‘minimums’. At 17 years of age, your decision about a septorhinoplasty is not a growth issue but one of parental consent.
Much of the makeup of the nose is not bone but cartilage. Regardless of bone or cartilage, there is no growth of the nose after skeletal maturity is reached.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a septorhinoplasty done late last year and I just don’t like the way it looks now. I didn’t know that my bridge would be built up to be higher and more prominent. I went in to just have a septoplasty to try and help me breathe better. The doctor suggested that my bridge be changed and the tip narrowed a bit, both changes which I now regret. I used to have a nice slope to my nose before and it looks so different that the bridge is so high. Do you think this could be just swelling? Is there any way to reverse these nose changes?
A: It is extremely common for the outer appearance of the nose to be changed at the same time that the internal breathing function (septoplasty and turbinates) is being improved. While plastic surgeons may suggest these changes in the patient who just appears for breathing problems, such recommendations are often welcomed very enthusiastically. The convenience of having both nose issues addressed simultaneously is obviously appealing…provided that one does have some real concerns about their nose appearance and they are very clear on what is going to be done. It appears you now have some early ‘buyer’s remorse’. This could be premature regret since it has only been a few months from surgery and swelling is most certainly present. It may also be that you did not have a clear understanding of what the objectives of the rhinoplasty were. This could have been avoided by computer imaging analysis before surgery. While you may have a rhinoplasty revision to try and reverse some of these changes,it is too early to consider that now. You should give your nose up to a full year after surgery for all swelling to go away and you to adapt to the new look. It could very be how you feel now may change at this time next year.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I had my nose broken seven years ago that has left me with a crookedness to it that I am pretty sure is due to the bone. I also have had trouble breathing since the injury through the left side of my nose. I would like to get my breathing problem fixed and the nose straightened again like it was before. In addition at the same time I would like to get the tip narrowed and shortened which I think would make it look better overall as well. Will insurance cover all the costs of the procedure since most of my nose problems were due to the injury?
A: The complete corrective procedure to which you refer is known as a septorhinoplasty. This is a combined reconstructive and cosmetic procedure. Insurance will usually cover the medical necessary parts of the operation that relate to breathing improvement, the septoplasty and turbinate reductions. Changing the outward appearance of the nose known as the rhinoplasty portion, however, is not covered by insurance since it results in improvement in appearance not function. Both septoplasty and rhinoplasty are commonly done together and the out of pocket expense for the rhinoplasty is often less when done together with an insurance procedure than when done as a stand alone operation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had orthognathic surgery over a year ago where my upper jaw was shortened and my lower jaw was brought forward. Ever since my septum has somehow shifted off to the left side and my nose is slanted that way as well. The left nostril sags down and looks wider as well. The right side looks more normal. What can be done know to correct these nasal problems? I am certain they are the result of my jaw surgery since my nose didn’t look like this before my jaw surgery.
A: Septal and nasal deformities as a result of a LeFort (maxillary) osteotomy are not rare. A LeFort I osteotomy has three potential adverse effects on the nose if certain steps are not taken during the surgery to avoid them. The septum may become deviated afterwards as the floor of the nose is part of the upper jaw. When the maxilla is impacted (shortened, moved upward), the septum must be similarly shortened. If not, the impacting upper jaw will cause it to be bent or deviated as it impinges on it. The nostrils can become wider afterwards as the paranasal muscles are disinserted with the incision under the upper lip. If these muscles are not brought back together at the time of the intraoral mucosal closure with a V-Y advancement, then the sides of the nostrils will flare outwards. Lastly, the tip of the nose can change due to the altered position or shape of the anterior nasal spine on which the caudal end of the septum and columella resides. It appears that you now have some degree of all three of these nasal problems. All of these deformities can be corrected during a secondary septorhinoplasty procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, lastyear ago I had a septoplasty to correct a severely deviated septum that resulted from a broken nose when I was a teenager. My surgeon removed a sizeable bone spur that was obstructing my breathing and that improved it a lot. Unfortunately, it did little to correct the aesthetic appearance of my nose. The septum is still very deviated midway up the nose so it has maintained its crooked appearance. Furthermore, my right nasal bone is caved in slightly.When I consulted a plastic surgeon a recently about the possibility of a revision of the prior procedure, he said it would not be worth it considering a lot of cartilage was removed. This would make it hard to re-anchor/attach the septum and would also increase the risk of perforation. What can I do to fix this asymmetry? Is a rhinoplasty still possible?
A: A septoplasty, in and of itself, will rarely make a significant change in the correction of a deviated or asymmetric nose. This is because deviation of the nose is a multi-factorial problem that is caused by aberrant anatomy than involves more nasal structures than just the septum. While it is true that a secondary septoplasty will be difficult due to scar tissue, there is no way to really know beforehand if it will be a good source of cartilage for the rest of the rhinoplasty. I have found more times than not that there is still some cartilage to be harvested. When combined with ear cartilage, there will be enough graft to so a more complete septorhinoplasty procedure. I would still approach your nasal concerns as a correction of the entire anatomy of the nose rather than camouflage techniques such as injectable fillers.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dear Dr.Eppley, I am interested in having surgery to better my breathing through my nose. In my younger days I was hit in the nose several times and suffered much damage which makes it hard to breath through my nose. I have suffered with this for years and would like to do something soon.I do have several questions and would like to be very educated on the procedure. I was wondering how long you have been doing these types of operations and how much they would cost. Also what can I expect after the operation. As of now you can see my nose has caved in on the sides and it is extremely hard to breath through my right nostril. I look forward to hearing from you. Thank you.
A: Injury is a common cause of nasal breathing difficulties. External forces can displace both the nasal bones and the septum, causing obstruction through one’s nasal passages. While septal deviation is the most common sequelae of traumatic injury, changes in the external skeleton through nasal bone fractures and upper and lower cartilage derangements (middle vault collapse) can also be sources of the breathing problem. Such changes are also a source for visible nasal asymmetries and crookedness of the nose. Traumatic nasal injuries almost always require a full septorhinoplasty to get a complete correction. This sounds like what you need by your description. If you could send me some pictures, I can take a look at them and do some computer imaging as well if needed.
Typically, insurance will cover some of the costs of a septorhinoplasty but may not cover everything depending upon what is needed and done. This would have to be initially pre-determined through the insurance company with a letter and photos to get an answer from them in regards to coverage.
Dr. Barry Eppley
Indianapolis, Indiana