Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing?
A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.
One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.
The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.
The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.
Dr. Barry Eppley
Q: Dr. Eppley, I am interested in getting a rhinoplasty to reshape the tip of my nose. I have attached two pictures one picture being how my nose looks now (bulbous tip, very bulky in appearance) and a second picture of how I want it to be like. ( slim and straight) Would the result I hope to achieve be possible? What would need to be done to produce the desired result in the picture?
A: What you initially have is a bulbous tip that makes it fuller and stick above the rest of your otherwise straight dorsal line. This bulbous tip is composed of the union of the paired lower alar cartilages which are both wide (cephalic to caudal direction) and long. (anteroposterior direction) A tip rhinoplasty can reshape these cartilages by a cephalic trim, cartilage length reduction by medial footplate resection and dome narrowing by suture plication. Together these nasal tip changes are very likely to achieve the desired result that you have illustrated.
A tip rhinoplasty, what I call a Type 1 rhinoplasty, is done through an open approach and is associated with a fairly quick recovery. Some prolonged nasal tip swelling can be expected.
Dr. Barry Eppley
Q: Dr. Eppley, I had mandible angel jaw reduction(removal of square bone at the posterior part/not the front or anywhere towards the frontal part of face) about 5 months ago. Dissolvable stiches were used. The stitching on the inside was fine. The stitches on the outer/upper part of the gum on both sides were dissolved in about 8 days. I had this done in Asia and had to travel back home, realising the stiches on outer/upper gum were dissolved. No infection. The problem now is that both sides of my gum have a gap/opening and I have to gargle after I eat because food bits get into these openings,flap in the gum.
1. WOULD THIS AFFECT THE SWELLING OF THE GUM TO GO DOWN COMPLETELY?( THERE’S NOW A FLAP/OPENING)
2. CAN IT BE STITCHED AGAIN? TO CLOSE THE OPENINGS ON BOTH SIDES OF SURGERY SITE.WHAT COULD BE DONE TO RESOLVE THIS PROBLEM?
Another thing I’m realising. It looks like the jowl area is protruding, it looks round? The square jaw is gone but now there is protruding of something (fat?skin?tissue? I don’t know)around the jowl area? Age is 41.I tried to suck the inside of my cheek in and I think it helps get rid of the round, bulge on jowl area. Therefore, I’m thinking that a buccal fat removal will help get rid of this bulge.
3.Please see pics attached and advise what you can do to take care of this bulge, jowl area?. ( Is it fat? skin? tissue or muscle?)
One more thing I’ve been comtemplating is the nose. Tip augmentation and trimming the fat on the tip area for better definition?
4. I’m not sure what it is that should or could be done to improve the nose. Perhaps there are other things that I am not seeing. Please let me know what you see , what you would suggest doing to improve the nose.
ALSO,LOOKS LIKE DESCENDING FAT BELOW THE EYES, AROUND THE CHEEKS AREA, CREATING A FOLD NEAR BOTTOM PART/SIDE OF NOSE.
5. Is there any method for this descending fat be removed? Im thinking I’d be better off without them.
Hope to hear from you soon.
A: In answer to your questions:
1) I am not completely sure what this issue is in regards to your gum tissue. Normally the incisions for mandibular ramus surgery are done far away from the gum line in the mandibular vestibule leaving at least 1 cm cuff of tissue from the incision to the attached gingiva. When done in this way there never is any issue with gingival (gum) retraction or healing issues. Because you have these concerns now makes me wonder if your incisions are not either very close to the gumline or actually went through the gumline for access. At point, gargling is the best way for oral hygiene and to let the tissues heal further. (although at 5 months after surgery things should be fairly well healed. Whether improvement is possible is hard for me to say as I obviously can not see where the flap is in the tissues.
2) As above. Most likely, the gingivomucosal flaps can be re-raised and closed.
3) Jowling is always an issue of loose skin and descended fat. It has nothing to do with the buccal fat pad and its removal will not be helpful for eliminating jowls. It has probably become more apparent and has ‘developed’ now that the bony jaw angles have been removed. (loss of bony support) Jowls can only be treated by either spot liposuction or a jowl lift.
4) I would agree with your assessment of your nose that further tip projection and definition would be aesthetically beneficial. A tip rhinoplasty with a columellar strut and a double stack tip graft with possible nostril narrowing is how that could be accomplished. I have attached some imaging of that potential result.
5) The fat around the nose at the level of the nasolabial fold can be treated by very small cannula liposuction if desired.
Dr. Barry Eppley
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
Q: Dr. Eppley, for the longest time I have had my heart set on rhinoplasty but didn’t want to go through a big operation. However I have recently learned that a much less complicated procedure can be preformed that involves reshaping of the nasal tip. (tip-plasty) I was wondering whether or not you feel as though tip plasty would be to my benefit or if you feel as though I should undergo full rhinoplasty. The only aspect of my nose that I have ever had an issue with is that the tip appears too bulbous from the front and 3/4 side view. I also feel as though it protrudes slightly too far from my face. I tried taking some high definition photos, but they would not upload so I had to use webcam photos. the frontal photo is extremely bright however it was the only way to show the definition of my nose from the front.
A: Rhinoplasty is very much like many other aesthetic facial operations, they are numerous versions in magnitude that are used based on the problem being treated. Simplistically, rhinoplasty can be thought of as either a full rhinoplasty or a tip rhinoplasty. The difference between the two is that a full rhinoplasty includes significant changes in the bridge of the nose and will always involve osteotomies or breaking of the nasal bones. Tip rhinoplasty usually does not include much internal work such as septal straightening and turbinate reduction. While there are many cross-overs between these two basic rhinoplasties, depending on patient need and desires, this is a very basic way to view them. More tip rhinoplasties are done in revisional surgery than in primary rhinoplasty.
While your tip is large, I would agree that the top portion of your nose looks in better proportion. I think that an isolated tip rhinoplasty would be of great benefit to you.
Dr. Barry Eppley
Q: Dr. Eppley, I am a 25 old year guy and I am really not satisfied with my looks. I am looking to improve upon my face for a more youthful look .I know it’s not wise to compare yourself to others as everyone’s face is unique but I think the most distracting feature of my face is a very big and wide lower face (mandible) that makes my face chubby and more old looking. The last time I inquired you about an outer cortex osteotomy for as such the same problem and you requested my pictures so I did attach them. Now I would be really grateful if you clarify me my following doubts:
1. Is it possible to reduce my lower jaw width and angle to make my face more slimmer and proportionate?
2. If yes, how much is it possible to reduce the bigonial distance and achieve a more ovoid looking face (Front view) in my case?
3. Would chin augmentation be helpful to achieve the same?
4. I also want to have a tip rhinoplasty that would give my nose tip more definition and sharpness. Again, how much is it possible to achieve a nose like the one in the model pictures I have attached?
5. Please suggest any additional improvements in case you notice that would be required for a more youthful appeareance such as brows,cheeks or any other.
A: In answer to your questions:
1) There is not a really good procedure to make your entire lower face more narrow. Even if one could do a lateral corticotomy (remove the outer layer of the lower jaw bone) that would just not make enough of a difference in your face.
2) Certainly the jaw angles can be removed but whether that would make a very visible difference is uncertain. Some of your facial width is soft tissue and can not be reduced. The best way to answer whether this procedyure would be worth it is frontal cephalometric x-ray or facial film to look at how much flare the angles have. If it is significant then it may be worthwhile.
3) Vertical chin lengthening is, by far, a more practical approach to facial lengthening (and narrowing) for you given the more square facial shape that you have.
4) A tip rhinoplasty will definitely help narrow your nose but trying to achieve the very slim noses in the pictures you have sent is unrealistic. You will likely end up halfway between where you are now and those type of results.
5) Some soft tissue (fat reduction) would also be helpful, removing part of the buccal fart pad and thinning out the fat outside of the corners of the mouth.
I would think that a vertical lengthening chin osteotomy, tip rhinoplasty and buccal lipectomy with perioral liposuction would be the three procedures that I would recommend that could make the greatest difference in your facial shape/appearance.
Dr. Barry Eppley
Q: Dr. Eppley, I feel my face is a little weak down around my jawline area. Iwas hoping to have a more masculine jaw with out elongating my face any more… just maybe make it more full. Also as you can see on my photographs, my face is very asymmetrical. My right temple seems sunken in so was researching your page and saw you have a temporal implant, was wondering if I good candidate for the procedure. And last but not least, my nose is also very asymmetrical. If I feel above the nostril I can feel more cartilage on the left side of the nose and my right doesn’t have any. I am open to suggestions please if you can let me know the procedure you believe I will benefit from.
A: From a jawline standpoint, there is a clear chin deficiency but with a slightly long (rotated backwards) chin as well. While an implant can be used and probably not lengthen the chin, the most ideal treatment is an osteoplastic genioplasty where the chin can be brought forward and shortened as well. I have imaged that potential change in the attached profile pictures. In addition, I have also added some small jaw angle implant in the front view to see if widening the posterior jawline is also aesthetically beneficial.
As for your nose, I can see a slight retraction of the alar rim upward creating nostril asymmetry. That would also account for the differences you feel in the lower alar cartilages in the tip of your nose. This could be improved by the addition of an alar rim/onlay graft to the right side of the tip of the nose.
As for the temple areas, I am having a hard time to seeing the amount of asymmetry between the two sides. This may be a function of the photograph. For temple asymmetry, a small subfascial temporal implant can provide a moderate amount of augmentation to the more depressed side.
Dr. Barry Eppley
Q: Dr. Eppley, I have concerns about my nose and I focus on it all the time. I think (know) my nose is too pointy at the tip and people confuse me as if I am Native American. I could see why. What can be done to make my nose less pointy?
A: In looking at your pictures, the pointiness of your nose is the direct result of the alar cartilages which make up the tip. Your alar cartilages show rim retraction (an acute alar angle backwards) and a narrow dome area. Together this makes your nose tip come to a point. Since the overlying skin just follows the underlying cartilages, this gives you a sharp and pointy nose appearance. This could be improved through a tip rhinoplasty with cartilage grafting. In some cases of a pointy nose, the tip is both narrow and very long. This requires tip cartilage shortening. But your tip is not too long, it is just too narrow. Cartilage grafts would be harvested from your septum and used to augment the alar rims combined with a tip shield and dome spreading grafts. The objective is to change the shape of the dome and lower alar cartilages to make the tip more round and drop the rim of the nostrils down. This should help make a substantial change in the way the tip of your nose looks.
Dr. Barry Eppley
Q: Dr Eppley, I would like the fat tip of my nose made slimmer and the size of my nostrils reduced. While I like the shape of the upper part of my nose, the lower part is too big and disproportionate to how small the rest of my face is. Is this something that rhinoplasty can do, just change one part of the nose without affecting anything else? I do not want to change the shape or height of my bridge. I don’t know how difficult it is to just change the shape of the tip. I also fear that the tip could become too small and give me a reverse problem than what I have now. I do not want a petite nose with a pinched tip, just one still looks like me only in better balance. Thanks
A: Tip rhinoplasty is a very common nose procedure and only changes the shape and size of the lower third of the nose. Whether that will look more balanced without the need to alter any other part of the nose is best determined before surgery through computer imaging. You may very well be right but it can be surprising sometimes other areas look when one part of the nose is changed. Just be certain beforehand by some computer imaging work. It would be rare to take a big tip of the nose and make it too thin. (discounting Michael Jackson who had many nose procedures and is a result that should not be seen as the norm) Usually the question is whether as much tip refinement can be achieved as the patient hopes, particularly if the nasal skin is thick.
Dr. Barry Eppley
Q: Dr. Eppley, I want a rhinoplasty to change the shape of my nose. I have attached a picture of the type of changes that I want done to my nose. This is my effort at a little computer imaging with Photoshop. The first plastic surgeon I saw told me that all I need is tip work while another plastic surgeon told me I have to do a complete rhinoplasty to get that look. Please let me know what you think as I am confused.
A: The first thing I would say is to not get confused trying to decide whether you need a limited or full rhinoplasty. There are fee and recovery differences between a tip rhinoplasty and a full rhinoplasty but the most important issue is what rhinoplasty techniques will give you the best result. The fundamental difference that separates the two rhinoplasties is that a more complete technique involves osteotomies or the narrowing of the nasal bones due to significant hump reduction. When you have a difference of opinion between two board-certified plastic surgeons on a limited vs a full technique it is usually because you could go either way. This is computer imaging can be so useful. Imaging allows discussion about different changes and how they might affect the overall look. The techniques used to achieve those goals are up to the surgeon at that point. You have shown only one photo of your nose from an oblique angle. It is impossible to say for sure what you may need from just this one angle. A front and side view would also be very helpful as the nose must be considered from numerous angles when considering a rhinoplasty change.
Dr. Barry Eppley
Q : My issue is about my nose. It is a bit big and has a round ball at end. I have always dreamed of having a princess nose. Can rhinoplasty make this dream come true?
A: Rhinoplasty can make some significant differences in the shape of one’s nose. The three primary areas that can be reshaped are the bridge (upper 1/3), the middle vault (central 1/3) and the tip. (lower 1/3) Most patients are focused on changes in the bridge and tip as common areas of concern.
The tip of the nose is its most projecting point and, like a peninsula of land, its shape is out there for all to see. The most common tip complaints are its width, shape, and its projection. (too high or too low). A wide tip, often called a fat tip or a round ball, is caused by large amounts of lower alar cartlilages. The width of these cartilages and how the two come together to make the dome (tip) is the most indivualistic part of anyone’s nose. The tip of the nose is like fingerprints, it is uniquely shaped for everyone.
Tip reshaping is part of almost every rhinoplasty. The lower alar cartilages can be reduced in size and reshaped by sutures. The changes in one’s nasal tip can be really significant and is usually the most impressive part of most rhinoplasty results. The only limiting factor to tip reshaping is the thickness of the overlying skin. Thick-skinned noses will not show the underlying sculpting of the cartilages as well as thin skin and will hold swelling in the tip much longer.
I don’t know if a princess nose is possible for you but I am certain that the size of the can be made smaller and less round.
Dr. Barry Eppley
Q: i am interested in changing the bottom front part of my nose. i believe it is called the columella. I think this is where the skin between the nostrils meets the upper lip. In my case, that angle is too small. It should be more open. I have read that an implant can create that effect. If an implant is placed there will it also lift up the tip of my nose? I have attached pictures which show what changes I want.
A: In doing assessment of the ‘columellar implant’ in your desired image look, there are three changes I see that you have made: 1) opening up/fullness of the nasolabial angle, 2) change in the angulation of the columella to the lip, and 3) nasal tip narrowing and lifting. It is important to note that to really achieve these changes an open tip rhinoplasty with an implant needs to be done. I would use cartilage for an implant in the columella rather than a synthetic implant. The columellar skin is not very thick and less potential problems will occur from a graft from your own body. That is so for the following reasons:
1) a premaxillary implant will push out the columellar base (open up the nasolabial angle) but will not push up the tip of the nose.
2) A true columellar implant will push out the columellar skin but will not, in and out itself, narrow and lift the lip of the nose.
The concept here is that a columellar implant or strut is an adjunct to a tip rhinoplasty but not a substitute for it.
Q: Hello sir, I did my first rhinoplasty for a minor problem. Initially I had a thin and pointed nose but overall it was not too bad looking. I went to this inexperienced surgeon because me or my parents didn’t know anything about surgery at that time. He made my nose shorter with a round tip and I got very bad dark circles under my eyes for a year. My nose is still short, fat and twisted. After three years, I have gotten the courage to consider another rhinoplasty surgery to make it look better. What do you recommend to be done?
A: Most likely what has happened is a fundamental problem that is reminiscent of rhinoplasty from days of old…removal of too much cartilage structure. This results in collapse of the nasal tip due to loss of support as well as wound contracture. Almost certainly, this rhinoplasty was done through an endonasal approach where removal is what can largely be achieved. Only the real masters of rhinoplasty can do significant restructuring that has predictable outcomes through the limited access of the endonasal approach.
For a revisional rhinoplasty such as this, the open approach needs to be done. The tip cartilages and nasal septum can be separated, cartilage grafts placed and reshaping done through suture techniques. It may also only require an onlay cartilage graft but that must be precisely placed. Only the open approach offers this degree of visibility. The cartilage grafts will likely come from the ear (conchal) due to the size and shape needed.
At three years from the initial surgery, the nasal tissues are more than soft enough to allow for good manipulation and healing.
Recovery from the short nose problem in revisional rhinoplasty is usually quite good, but access and cartilage grafting are the keys.
Dr. Barry Eppley
Q: I have a fat nose and would like it to look slimmer. It doesn’t seem to fit the rest of my face which is actually very thin. But I don’t want to have my nose broken as I like the rest of it. Are there different types of rhinoplasty surgeries?
A: Like all operations in plastic surgery, it is important to tailor it to the specifics of the problem. Most plastic surgery procedures do not use a ‘cookie-cutter’ approach but modify certain details of the operation to a patient’s specific needs. Rhinoplasty surgery is the pinnacle of this philosophy as every nose surgery is uniquely different.
Despite the many variations of rhinoplasty, they can be divided into two main types, a mini- or tip rhinoplasty and a full rhinoplasty. The fundamental difference between the two is that a full rhinoplasty treats all three sections of the nose, often breaking the nose bones (upper third) to narrow them. A tip rhinoplasty treats only the lower one-third which consists of a paired set of cartilages which meet in the middle to create the tip of the nose.
When one has a fat or wide nose, it is because the cartilages in the tip of the nose are big and protrusive and often don’t quite meet in the middle. Through a tip rhinoplasty, these cartilages can be reduced in size, reshaped and brought closer together. Using suture techniques, a remarkable change in the nose tip can be done making it thinner and more in proportion to the rest of the nose.
Dr. Barry Eppley