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Archive for the ‘rhinoplasty’ Category

Managing the Soft Tissue Triangle in Rhinoplasty

Monday, July 10th, 2017


Rhinoplasty is most commonly done today through an open approach. The wide exposure offered through the devolving of the nose offers many advantages, particularly in complex and revision noses. But there is a ‘price’ to pay for such open exposure and is not primarily the scar that it creates. (usually the transcolumellar scar truly heals in an inconspicuous manner.

Notching of the alar rim, or asymmetry of the nostrils, is not an uncommon adverse sequeale from an open rhinoplasty. Such notching or asymmetries occur most commonly in the soft triangle area of the alar rim. The soft triangle is the one area along the top of the nostril between the tip and the nasal base that does not have cartilage support. Since the open approach causing scarring and also requires incisional closure across this area of the nostril which inherently is a bit concave, notching deformities of the alar rim can occur.

In the July 2017 issue of the journal Plastic and Reconstructive Surgery, an article in this topic was published entitled ‘Preventing Soft-Tissue Triangle Collapse in Modern Rhinoplasty’. In this paper the authors review the anatomy of this small area of the nose, the common causes of alar notching in rhinoplasty and methods for its prevention and correction.Prevention is done initially by placing the margin rim incision far enough back from the alar rim during the opening of the nose. This is harder to do than placing it closer to the rim but is worth the extra effort. During closure of the rhinoplasty elimination of the dead space can be done with soft tissue grafts tucked behind the incision line. If one seems any slight nostril asymmetry or suspects that alar notching will happen, cartilage grafts can be placed into the soft triangle area. (alar contour or alar rim grafts)

Secondary correction of alar notching always involves cartilage grafts. The question is whether cartilage grafts alone or a combined cartilage-skin (chondrocutaneous) graft is needed. An alternative approach is to also use injectable fillers. While it may temporary in many cases, repeated injections can result in more sustained results int some patients.

Dr. Barry Eppley

Indianapolis, Indiana

ePTFE Nasal Implants in Correction of Binder’s Syndrome

Wednesday, July 5th, 2017


Binder’s syndrome or maxillonasal dysplasia is a rare facial development disorder that affects the middle part of the face. It occurs as a result of underdevelopment of the nasal septum (microform achondrodysplasia)which is a driving force of midfacial growth. This results in a small premaxillary jaw segment with a flat midface, short nose with a low nasal bridge and an edge-to-edge or class III malocclusion. The remainder of the surrounding face is usually normal.

The usual aesthetic treatment for Binders’s syndrome is to increase the projection of the nose through serial surgeries up through the final growth years in late teens. Rib cartilage is typically used in a L-configuration to stretch out the nose as one grows. Orthodontics and possible surgery (maxillary advancement) may be needed in the teenage years based on the severity of the deformity. But

In the July 2014 issue of the Journal of Aesthetic Plastic and Reconstructive Surgery, an article was published entitled ‘A Simple Technique for the Correction of Maxillonasal Dysplasia using Customized Expanded Polytetrafluoroethylene (ePTFE) Implants’. Over a fifteen year period the authors treated 58 patients who had Binder’s Syndrome with ePTFE implants. The nasal bridge was implanted with an L-shaped implant while the pyriform aperture was implanted with a smaller M-shaped implant. They results were assessed by pictures, a patient satisfaction surgery and measurements of the nasolabial and facial convexity angles.

Their results show improved nasal shapes with a nasolabial angle increase from an average of 74 degrees to 94 degrees six months after the surgery. Complications included five patients (9%)  including implant migration (3.5%), implant exposure (2%) and implant infection. (3.5%) The overwhelming majority of patients rated their results as much improved and were satisfied. Typical but self-resolving after surgery symptoms were stiff of the smile and upper lip movement.

This study is clinically relevant due to the sheer number of patients treated with a rare facial disorder. Such a large number of patients with tight nasal skin envelopes that were stretched out with an implant reconstruction is impressive as is their alloplastic outcomes. Whether further complications will be seen with longer followups can not be predicted but likely there will be some. This notwithstanding this clinical study shows that ePTFE nasal reconstructions can be successful.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Rib Graft Tip Rhinoplasty

Thursday, June 22nd, 2017


While many rhinoplasties are reductive in their overall reshaping effect, some require the addition of support or structure through the use of autologous tissue grafts. Most noses can be satisfactorily augmented or rebuilt through the use of septal, ear or combining septal and ear cartilage grafts. But when such local and regional cartilages harvest sites are depleted or inadequate for the amount of augmentation needed, the rib is the remaining ‘go to’ cartilage donor site.

Rib grafts offer an unlimited supply of cartilage graft material when it comes to what is needed in the nose. Regardless of where it is harvested (inframammary or subcostal incisions), the amount of donor material is more than adequate. Issues such as curved cartilage shapes (ribs are rarely perfectly straight) and whether full-thickness or in situ harvesting methods are used may pose some graft limitations But these are overcome by experienced harvesting techniques.

In the tip of the nose, rib grafts are needed when considerable tip lengthening or derotation changes are needed.  (rib graft tip rhinoplasty) Placing an L-shaped cartilage construct at the end of the nose has a powerful tip augmentation effect which is only limited by the ability of the skin to stretch over it and still have adequate perfusion after surgery.

Rib grafting to the nasal tip is often an onlay technique where the grafts are placed over the existing medial footplates and dome cartilages. A pocket is made under the columellar skin below the incision down to the anterior nasal spine into which one carved piece of the tip graft is placed. (vertical graft component) A lower dorsal-dome cartilage graft (horizontal component) is fashioned and placed on top of the existing dome cartilages to be united at 90 degrees to the columellar piece. Suturing the two rib grafts together creates the new tip defining point.

Dr. Barry Eppley

Indianapolis, Indiana

A Clinical Outcome Study of Nasal Implants (Alloplastic Rhinoplasty)

Sunday, June 18th, 2017


There is an inevitable need in rhinoplasty surgery in some patients for augmentation. Whether it is for smaller defect corrections or for an overall major dorsocolumellar increase, volume addition to the nose is not infrequently needed. There is no question that cartilage grafting is the best tolerated form of nasal augmentation with the lowest risk of infection. But they are not perfect and cartilage grafts have their own issues from donor site harvesting, structural and shape constraints and an increased technical skill for their use.

As a result, the use of a variety of implant materials in the nose will always persist. Despite their often negative perception implants do have a role to play in the nose and any clinical series ion substantial volume and follow-up is always worthy of review.

In the April 2017 issue of the journal Aesthetic Plastic Surgery, an article was published entitled ‘Soft and Firm Alloplastic Implants in Rhinoplasty: Why, When and How to Use Them: A Review of 311 Cases’. In this paper the authors  report on their experience in over 300 cases of nasal implants. It is important to distinguish what they mean by soft and firm nasal implants. The ‘soft’ nasal implants they used were synthetic polyester sheets (mersilene mesh) which is used for other surgical applications as its origins. These are sheets of monofilament fibers whose structure permits soft tissue ingrowth. These mesh implants were used in the tip, dorsal and side walls of the nose in varying thicknesses. Such soft implants were used in the majority of their cases. (87%, 269/311) The average implant thicknesses were 1.5mm or less. The firm implants were solid silicone L-shaped nasal implants. The thickness of these implants were 5mms or less. In some cases the tip of the nasal implant was covered by fascia or morselized cartilage. Such firm implants were used in the remainder of their cases. (13%, 42/311)

The infection rate in the soft implants occurred in 6% of cases (15 patients) Revisions for aesthetic purposes was done in 3% of the patients. (7 in number) Conversely no infections occurred with firm silicone implants. Aesthetic revisions were done in 7% of the cases. (3 in number)

The use of implants in the nose, known as alloplastic rhinoplasty, has its share of detractors. For some rhinoplasty surgeons the use of synthetic materials in the nose is never done while other surgeons use them routinely as is the case in this paper. Implants do have their unique set of advantages including volume stability, lack of the need for a donor site, versatility in shaping of the implant and often shorter operative times.

In this paper the authors show a very acceptable and low rate of implant infections as well as the need for revisions. In my opinion this was not due to the implant material but in how it was used. The key to their success is that they did not ask the implants to ‘do too much’. The implants usually had low thicknesses even in the solid silicone implant group. While one can get away with a lot of soft tissue stretching or even mucosal perforations with cartilage grafts, implants are much less tolerant of these soft tissue issues. Probably the greatest contribution this paper makes to the rhinoplasty literature is that implants can work fairly well in the nose when judiciously and selectively used.

Dr. Barry Eppley

Indianapolis, Indiana

The Anterior Septal Angle in Rhinoplasty

Sunday, June 11th, 2017


The open approach is the most commonly used technique in contemporary rhinoplasty. Whether it is a primary nose or a secondary revision, the open approach provides wide access and visualization of all nasal structures. But once inside how does the plastic surgeon decide to proceed?.

In the March 2017 issue of the journal Plastic and Reconstructive Surgery, an article was published entitled ‘The Importance of the Anterior Septal Angle in the Open Dorsal Approach in Rhinoplasty’. In this review paper the authors discuss the importance of the anterior septal angle as it contributes to nasal tip support and length as well as internal nasal valve anatomy and airway function. There are many important nasal maneuvers that can be from the anterior septal angle from spreader grafts, septal angle reduction, septoplasty and cartilage harvest to caudal septal resection and the placement of columellar strut grafts.

The importance of the anterior septal angle is described using the four gateways. The dorsal gateway allows for dorsal aesthetic line creation/restoration, septal reduction and spreader grafts and correction of the deviated noise with spreader grafts. The posterior gateway allows for airway obstruction improvement by septal correction back to the vomer as well as cartilage harvest with emphasis on maintaining 10 to 15mms of L-shaped septal construct. The nasal tip gateway looks at the role that the anterior septal angle plays in tip support, specifically the use of septal extension grafts to control tip projection and shape. Anterior septal angle reduction can also be done in the tension nose to help widen the external and internal valves. The caudal gateway allows for the placement of columellar strut grafts and depressor septa muscle transection.

What has become apparent after decades of performing open rhinoplasty surgery is that the identification of the anterior septal angle is the first step after exposure or degloving of the nose is done. From this anatomic point all structural changes can be initiated.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Teenage Cleft Rhinoplasty

Wednesday, June 7th, 2017


Background: A cleft through the upper lip always affects more than just the lip. As the cleft cuts through the nasal sill on its way back through the alveolus and palate, the nasal structures above it are altered in very predictable ways. The internal septum deviates towards cleft side, the contralateral inferior turbinate enlarges, the ipsilateral lower alar cartilage slumps, the nostril base widens and retracts inward, and the columella and tip of the nose tilts to the cleft side. Even high up above the cleft the nasal bone on the cleft side  is affected, being wider and lower.

A cleft rhinoplasty to be successful must address many of these structural disturbances. Supporting the tip of the nose and nostrils against overlying skin which has historically been distorted, and even deficient, requires the creation of cartilaginous structures to push out on the skin and resists its memory. Cartilage grafting is paramount and the best grafts as possible need to be obtained. A septum that has never been operated on is ideal but this is not always the case. When in doubt a small rib graft is always the go to graft in cleft rhinoplasty.

Cartilage grafting in the nose has a variety of well known graft locations and names. But in the end the tripod construct is what is needed ensuring that a columellar strut, spreader/dorsal grafts and batten or alar rim grafts are needed to help create a better shaped and projecting nasal tip. Even with the creation of the best underlying cartilage framnework, cleft rhinoplasty results can be very humbling.

Case Study: This 15 year-old female was born with a right complete cleft lip and palate deformity. She has been through primary lip and palate repairs as an jnfant  as well as secondary alveolar bone grafting and tip rhinoplasty as a young child. As a teenager she sought a more definitive nose reshaping procedure.

Under general anesthesia and through an open rhinoplasty approach, the septal deviation and cartilages were obtained coming down through the anterior septal angle.  The contralateral inferior turbinate was also reduced. Spreader, columellar strut and cleft- sided batten cartilage grafts were used. The right nasal base was also moved down and inward.

Her longer-term results shows definite improvement in the shape of the nasal tip and nostrils. But her thicker nasal skin precludes as much refinement as one would have hoped.


  1. A more formal cleft rhinoplasty can be done as easily as the mid-teens.
  2. Most cleft rhinoplasties need cartilage grafts and the septum is the best source of strong straights grafts if possible.
  1. Rebuilding/add support to the cleft nostril is the cornerstone to rhinoplasty in most cleft patients.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – The Female Swoop Rhinoplasty

Tuesday, April 25th, 2017


Background: The nose is made up of many angles, lines and shapes and represents the most aesthetically complex structure on the face…despite its proportionately small size. How all of these various geometries (subunits) fit together changes based on what view or angle that the nose is being assessed. The most basic of all these nasal aesthetic considerations is that of the  dorsum and is one of the most commonly manipulated and requested nasal features.

The dorsum is a central subunit of the nose that extends from the frontonasal angle superiorly down to the tip. In the front view it has aesthetic or side lines that create a smooth flow, or lack of the flow, down the length of the nose connecting the inner brows into the tip. In the side view, and a view that is of highest significance to patients, is the dorsal line. This profile line of the nose is a dominant aesthetic feature and has long been one of the most basic motivations for having rhinoplasty surgery as well as how the result is judged.

The dorsal line of the nose is gender specific. Man desire a straight or even the persistence of a small hump at the osteocartilaginous junction. Conversely women either prefer a straight dorsal line, or more commonly, a dorsal line that has a slight concavity to it. Men almost never want such a dorsal line shape.

Case Study: This 33 year-old female wanted to change the shape of her nose. She had a slight nasal hump and a tip that had too much projection. The shape of her nose from the side profile was her most important motivation for having the surgery.

Under a general anesthesia an open rhinoplasty approach was done. The small osteocartilaginous hump was shaved down and smoothed. Her nasal tip cartilages were shortened and narrowed by excision and suturing techniques. Shortening the nasal tip also created the need for further reduction in the height of septum along the middle vault.

Her six month postoperative result showed an improved and more ‘feminine’ dorsal line with a tip that has a better length for her nose. Her dorsal line had the requested concavity or swoop between the forehead and the nasal tip. The columellar scar from the open approach had healed to the point that it could not be seen.

Why is it that women prefer such a nose shape? While fashion and celebrities help drive many a facial look, the desire for a small and perkier nose is a decided sign of femininity. It is also the antithesis of aging…it is a sign of youth and ‘cuteness’.


  1. The desired profile result for a female in rhinoplasty is almost always different than that of a male.
  2. Many women desire a dorsal line profile that has a slight concavity or swoop to it.
  3. Obtaining a swoop to the dorsal line is also highly influenced by the degree of tip rotation and/or shortening.

Dr. Barry Eppley

Indianapolis, Indiana

Techniques in Costal Harvest in Rib Graft Rhinoplasty

Thursday, April 13th, 2017


The use of rib cartilage in rhinoplasty is that it provides a virtual unlimited amount of graft material. Its use is most commonly indicated for significant nasal augmentations particularly in certain ethnic noses that lack overall nasal projection as well as in major nasal reconstructions. It is probably underutilized as a donor site as many rhinoplasty surgeons may not feel that comfortable with its harvest and patients are often not enthused about its use either.

In the March 2017 issue of the JAMA Facial Plastic Surgery Journal in the Surgical Pearls section, an article was published entitled ‘Technique to Reduce Time, Pain and Risk in Costal Cartilage Harvest’. In this paper the authors describe their technique which fundamentally involves two steps for improving costal harvest in rib graft rhinoplasty. First, don’t take a full thickness cartilage graft. It is an in situ technique where the rib is sectioned longitudinally at a partial thickness level of the rib between a proximal and distal cartilage cuts. Secondly, intercostal and soft tissue injections are done using a long-lasting local anesthetic (Exparel) to decrease postoperative pain.

The risk of pleural violation and potential pneumothorax are the dreaded complications of rib harvest. But the reality is that risk varies depending upon where on the chest wall that rib is being harvested. This is a real risk above the level of rib #6 but not down at the level of ribs #s7, 8 or 9. In smaller rib grafts any form of in situ rib harvest makes it both safer and easier to do. But in larger rib graft harvests an in situ approach may not allow for an adequate graft harvest. But, when possible, it is a good technique and I have used it many times. I usually take a triangular wedge along the graft length which can more easily be cut with a standard #15 scalpel blade.

The more recent use of Exparel injections for a prolonged time period of pain relief in the early recovery phase over the traditional use of Marcaine injections has its merits. This is one of the few areas in plastic surgery that has proven to me that Exparel is truly more effective. Having done many bony rib removals for body contouring (6 or ribs at at a time) Exparel has shown remarkable effectiveness in this ‘ultimate test’ of pain relief in aesthetic surgery. Thus it would be equally useful when just one subtotal cartilaginous rib is being harvested for rhinoplasty. It has a significant cost increase over that of Marcaine in the aesthetic patient but I have never found that to be a rate limiting step for its use in any aesthetic patient.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Tip Rhinoplasty

Sunday, April 2nd, 2017


Background: The shape of the nose is controlled completely by the shape of the osteocartilaginous framework underneath the skin. Nowhere on the nose is this more apparent than on the nasal tip. The complex scrolled shape of the lower alar cartilages and how they meet in the middle controls the shape of the lower third of the nose.

While the size of the lower alar cartilages controls how big the tip of the nose is, their symmetry influences how uniform it looks. Tip asymmetry is one of the most common aesthetic nasal deformities. It can be caused by a variety of anatomic derangements from a caudal septal deviation, buckling of the medial footplates, dome width asymmetry and alar length discrepancy to name a few.

While many rhinoplasty surgeries treat the whole nose, it is not always necessary. A tip rhinoplasty treats just the lower third of the nose and always involves some manipulation of the lower alar cartilages. Whether it is decreasing its size, changing its projection or degree of rotation, or just correcting asymmetry, the tip rhinoplasty leaves the bony structure of the nose alone. It a cartilaginous rhinoplasty as opposed to a more complete osteocartilaginous rhinoplasty.

Case Study: This young female was bothered by the shape of her nasal tip. It was bulbous as well as was asymmetric with a noticeable bump on the left side of the done. She was happy with her bridge and the nasal profile above the tip area.

Under general anesthesia and through an open rhinoplasty approach, the lower alar cartilages underwent an asymmetric cephalic trim and was reshaped with transdomal and lateral crural spanning sutures

Her three months after surgery results showed better tip symmetry and shape and a tip profile that fit better her the rest of her nose.

Some nose reshaping procedures only need an isolated tip rhinoplasty. If the rest of the nasal profile and frontal shape of the bridge and middle vault is satisfactory then only tip work is necessary. Preoperative planning has to take into account on the patient’s profile what happens if tip deprojection is planned as this create a need to lower the entire profile up through the nasal bones.


  1. The cartilages of the nasal tip have the most complex anatomy of the nose.
  2. Nasal tip asymmetry occurs as a result of a discrepancy in the size or shape of the lower alar cartilages.
  3. An open rhinoplasty allows the best visual assessment and manipulation of nasal tip cartilages.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Bilateral Cleft Rhinoplasty

Friday, March 24th, 2017


Background: The bilateral cleft lip and palate deformity poses major reconstructive challenges. At its root cause is the shortage of tissue that has resulted from the cleft as well as scar tissue that has occurred from prior surgeries.

The bilateral cleft nose has many typical features from a wide and blunt nasal tip, an underdeveloped underlying septal support, a columellar shortage of skin and wide flaring nostrils.

A more complete rhinoplasty is done in the bilateral cleft patient during their teenage years when they are past puberty. There is some debate as to whether it should be done before or after an upper jaw advancement which is eventually needed in more than half of bilateral cleft patients. That would depend on when the jaw advancement is planned and how much forward movement is needed. But in most cases it is best done six months or longer after the LeFort I osteotomy has been done.

Case Study: This 17 year-old teenage male had multiple previous surgeries for a bilateral complete cleft lip and palate birth defect. He had completed his upper jaw surgery one year previously. He had a good occlusion and adequate upper lip support. His nose showed a strong and high dorsal line, wide nasal bones and a blunted and ill-defined nasal tip.

Bllateral Cleft Septorhinoplasty result side view Dr Barry Eppley IndianapolisUnder general anesthesia he had an open septorhinoplasty performed. The nasal bridge was lowered slightly and the nasal bones narrowed. A septal cartilage graft was used to create a strong columellar strut onto which the tip cartilages could be reshaped. The nostrils were also brought inward.

Bilateral Cleft Septorhinoplasty result oblique view Dr Barry Eppley IndianapolisBilateral Cleft Septorhinoplasty result front view Dr Barry Eppley IndianapoliosHis after surgery results show definite improvement in his overall nasal shape. But like mamy cleft rhinoplasty surgeries the result always leaves one hoping for more.


  1. The bilateral cleft nose poses a reconstructive challenge due to both tissue hypoplasia and tissue scar.
  2. The bilateral cleft rhinoplasty should be done after an upper jaw advancement =has been completed and healed to provide good skeletal support.
  3. The most important reconstructive element in the bilateral cleft nose is to achieve a strong columellar support onto which the nasal tip can be built.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Barry EppleyDr. Barry Eppley

Dr. Barry Eppley is an extensively trained plastic and cosmetic surgeon with more than 20 years of surgical experience. He is both a licensed physician and dentist as well as double board-certified in both Plastic and Reconstructive Surgery and Oral and Maxillofacial Surgery. This training allows him to perform the most complex surgical procedures from cosmetic changes to the face and body to craniofacial surgery. Dr. Eppley has made extensive contributions to plastic surgery starting with the development of several advanced surgical techniques. He is a revered author, lecturer and educator in the field of plastic and cosmetic surgery.

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