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Archive for the ‘rhinoplasty’ Category

OR Snapshots – Injectable Diced Rib Graft Rhinoplasty

Sunday, October 29th, 2017


Cartilage grafting to the nose is most commonly done using anatomically convenient graft sites. This usually means the septum which offers straight graft dimensions or the ear which offer curved or shaped grafts. For many traditional rhinoplasty surgeries these graft sites are sufficient both in size and shape.

But in rhinoplasties that require larger amounts of augmentation, almost always that of the dorm, facial graft sites are too small in volume and do not have the right shape. This is where rib graft harvesting does into play if one wants avoid an implant or a cadaveric cartilage source.

While rib grafts in rhinoplasty offer plenty of volume, they usually have some shape issues. Occasionally a rib graft may actually be harvested that is straight or it can be carved to be straight. But rib graft carving must take into consideration the perichondrial lining and the ever present risk of postoperative warping.

A well known technique of avoiding rib graft warping in rhinoplasty is to change it from a solid graft to a particulated one. By dicing the rib graft into very small pieces or cubes and containing it in some form of a wrap, a very moldable cartilage graft is obtained. The debate in the use of diced rib grafts is whether it should be wrapped in autologous fascia, a very thin piece of allogeneic dermis or a bovine collagen mesh wrap (Surgicel) There is no standard consensus on the ideal wrap material.

Another method to place the diced rib cartilage graft is to not wrap it at all. The placement/containment method is a small syringe from which it can be injected. This requires a precise soft tissue pocket over the dorsum and can be done through either an open or closed rhinoplasty. The diced graft is injected and then digitally molded into the desired shape. Tapes and a metal splint are placed over it to help maintain its shape.

This injectable rhinoplasty technique allows for rapid tissue ingrowth into the diced cartilage graft. Within a few weeks it becomes very firm and maintains its shape. My and other clinical experiences show that significant graft resorption does not occur.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Female Refining Rhinoplasty

Sunday, October 15th, 2017


Background: The popularity of rhinoplasty is a combination of the prominence of the nose on the face and the successful outcomes possible from the procedure. It is hard to know the exact gender distribution that undergoes this type of facial surgery but it seems like more females than males have the surgery.

While the nose shapes in women are highly variable, there are common features of the nose that they wish to change. Almost first and foremost is that of the nasal hump or bump. At the least women prefer a straight dorsal line and some even prefer more of a saddle nose or swoop their dorsal profile. The second feature is that of the nasal tip. A wide or drooping nasal tip is not a flattering nasal shape in a female. 

Recovery from rhinoplasty its highly influenced by the thickness of the nasal skin. The thinner the skin is, the less swelling of the nose after surgery that will occur…and the sooner the final result is realized. The percentage of female noses that have thinner skin than men is not precisely known but it seems that it is so. The young thin Caucasian female that comes in for a rhinoplasty often has thinner nasal skin.

Case Study: This young female in her mid-20s presented for rhinoplasty. Her two basic nasal dislikes were the small hump and the wideness of the nasal tip. She had fairly thin nasal skin.

Under general anesthesia, she had an open rhinoplasty in which the nasal hump was reduced to a straight dorsal line and osteotomies done to make a less nasal base beneath the hump. In addition, the nasal tip was narrowed by a cephalic trim and transdomal sutures.

Her 3 month results show a smooth dorsal line and a more narrow tip. The nasal bridge still remains sensitive as expected as bony healing takes much longer for complete healing.


  1. Many women seek nose reshaping changes that are for refinement of small disproportionate features.
  2. Small hump reductions and nasal tip narrowing are two common nasal reshaping requests.
  3. Females with thin skinned noses respond quickly to nasal reshaping surgery that only takes a few months to see the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cranial Bone Graft Rhinoplasty

Sunday, September 17th, 2017


Background: Rhinoplasty surgery often entails the need for grafts. Most commonly cartilage grafts from the septum or ear are used as the volume needs are low and it is helpful to have a convenient and anatomically close harvest site. But major nasal reconstruction may need much larger graft volumes for which the rib offers a near limitless amount.

But in some nasal reconstruction cases where other craniofacial work is being performed, the most convenient donor site is one in which it is already open…the skull. Split-thickness cranial bone grafts have a long history of use in facial reconstruction including for reconstruction of the nose.

In reality, cranial bone is not the best graft for use in the nose because it is rigid and has to be made straight by either burring or controlled bending through partial osteotomy cuts.  One must also be careful that it does not put a lot of pressure on the nasal tip skin to prevent soft tissue breakdown. But if careful graft shaping is done, as well as bone fixation if needed, successful outcomes can be obtained with its use.

Case Study: This young female has been involved in a motor vehicle accident and sustained multiple craniofacial fractures of the forehead and midface. While these fractures underwent primary repair she remained with numerous residual brow bone, orbital and nasal deformities.

Under general anesthesia she had her original coronal scalp incision reopened for exposure and cranial grafts harvested to rebuild the frontal sinus and right orbital floor. Medial canthoplasties were also performed from this approach to improve her traumatic telecanthus. Her nasal dorsal had been impacted inward giving her a saddle nose appearance. A long 4 cm cranial bone graft was harvested and reshaped to be straight by partial thickness osteotomies and sutures. The dorsal bone graft was secured by screw fixation at the frontonasal junction. It was combined with a septal columellar strut graft through an open rhinoplasty approach to ensure adequate nasal tip projection.

A satisfactory nasal profile was achieved with good tip projection. The bone grafts has maintained its volume and structural integrity at a there year followup.

Cranial bone is not a primary source for nasal reconstruction grafting due to the limitations of its rigid structure. But if open access to the skull is already present for other procedures, it can make be used successfully.


  1. Cranial bone is one secondary option for dorsal grafting in rhinoplasty.
  2. The curved nature of cranial bone requires graft bending techniques for a straight dorm.
  3. A dorsal bone graft often needs to be combined with a columellar strut for an L-shaped nasal reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Free Diced Cartilage Grafts in Rhinoplasty

Thursday, September 7th, 2017


The use of cartilage grafts in the nose is common and is the most frequently used tissue graft in the nose. This is not surprising given that 2/3s of the nose is made up of cartilage. Harvesting adequate cartilage for use in rhinoplasty can be done from a variety of sites from the septum, ear or ribs. Donor quantity is not usually a problem but getting a good graft shape for its nasal purpose is often the challenge.

Cartilages grafts in the nose have several basic structural demands. Most commonly they need to be straight with some rigidity such as in use as a columellar strut, alar batten grafts etc. The most demanding structural requirement in the nose for cartilage is in dorsal augmentation. Not only is the most graft volume needed for this use but it must be straight and not change shape after surgery.  Rib grafts often are ideal in volume for dorsal augmentation but such grafts are rarely straight and are prone to postoperative warping. This has led to their use as a diced cartilage construct, usually wrapped in fascia or Surgicel as a containment method.

In the September 2017 issue of the journal Plastic and Reconstructive Surgery an article entitled ‘Free Diced Cartilage: A New Application of Diced Cartilage Grafts in Primary and Secondary Rhinoplasty’. In this paper the authors looked at the use of free (injectable) diced cartilage grafts to augment the nasal dorsum in 446 patients over a one year period. In the majority of the patients (73%) free diced cartilage was the only dorsal augmentation method used. In the remainder of the patients it was either combined with fascial wraps or done exclusively with fascial wrapping of the grafts. The study period was under one year (average 7 months). Revision rates for dorsal irregularities were 25% collectively with the free diced grafts along having a 5% revision rate.

Having used diced cartilage for years for variety of dorsal augmentations, it is not surprising that others have engaged in its use. This is the largest series to date with revision rates as a non-wrapped graft construct that would rival any solid cartilage graft used in rhinoplasty. There is always the concern of how smooth the dorsal augmentation would be and whether some graft resorption would occur. The contour irregularities are the reason for the revisions which may be a reflection of either uneven graft settling or some resorption.

Dr. Barry Eppley

Indianapolis, Indiana

OR Snapshots – Batten Rib Graft Rhinoplasty

Saturday, September 2nd, 2017


The use of cartilage grafts in rhinoplasty are done for a wide variety of reasons. While all cartilage grafts add support, some of these effects are to improve the shape of the nose while others are to improve its breathing function. Of all cartilage graft placements, the nasal tip is the most common area in which they are used.

Cartilage grafts in the lower third of the nose are most frequently placed in the central tip area. Whether it is a columellar strut graft or a wide variety of tip augmentation/shaping grafts, increasing tip projection and/or support is critical to resist the potentially displacing effects of the overlying skin.

But the side walls of the nasal tip, or lateral alar regions, can occasionally need cartilage grafts as well. The lateral alar cartilages are responsible for keeping the nostrils more open for breathing and play a critical role in the shape of the nostrils as well. Extending from the tip down to the nasal base they encompass almost the full length of the nostrils like a spanning bridge. Weak lateral alar cartilages can result in their collapse when breathing in. This can often occur after a rhinoplasty when too much cartilage has been taken due to an aggressive cephalic trim.

Support to the lateral alar can be done with cartilage, known as batten grafts. As the name implies a batten graft provides support to either help the collapsed lateral alar cartilages be brought back out as in a secondary rhinoplasty or as a preventative maneuver to prevent potential collapse after surgery in a primary rhinoplasty. The most common batten grafts comes from the septum since it is straight and fairly strong. But when a rib graft is being harvested anyway, it can be cut into thin batten grafts that are even stronger than that from the septum. The stiffness of these grafts is best done in noses with thicker skin.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Cranial Bone Graft Rhinoplasty with Medial Canthoplasties

Sunday, August 20th, 2017


Background: Fractures to the nose most commonly result in nasal deviations as the direction of the force usually comes from the side. (e.g.,fists) But direct trauma to the nose results in impaction injuries which push the nose inward resulting in loss of bridge height and a collapsed nasal appearance.

The most severe type of nasal impaction injury comes from high velocity forces such as motor vehicle accidents. This not only pushes the nose in but the extension of the fracture lines and bony displacement extends to the medial orbits as well. This results in not only the nose being pushed inward but the attachments of the eyelids (medial canthi) end up being  displaced laterally. These traumatic nose and eye changes create what is known as a traumatic hypertelorism effect. (technically pseudohypertelorism) This can be very hard to correct during the initial fracture repair and often requires secondary surgery for a more complete correction.

Case Study: This teenage female was involved in an ATV accident where she sustained blunt trauma to her face at the frontonasal area by striking a tree. She sustained a severe naso-ethmoid fracture pattern as well as other facial bone fractures. She underwent primary facial fractures repair any another facility, part of which was done through a coronal scalp incision. When seen six months after her initial injury and repair, she had a telecanthic appearance with indentation of her nasal bridge.

Under general anesthesia, her original coronal scalp incision was opened and  the scalp reflected down to the nasofrontal junction. A split-thickness outer table cranial bone graft was harvested from the left posterior forehead region which had a minimal curvature to it. The graft was shaped to fit the length of the nose and inserted into a nasal pocket and secured at its superior end with a 2.0 molar screw. The graft donor site was reconstructed to contour with hydroxyapatite cement. Medial canthoplasties using 3o0 gauge wires was also done, passing it under the cranial bone graft.

At five years after her secondary nasal reconstruction, her dorsal nasal height remained stable and straight. The bone graft showed no signs of resorption.

Her eyes appears closer together which was probably as much the result of a heightened nasal bridge as the medial canthoplasties.


  1. One graft option in nasal reconstruction is cranial bone due to its anatomic proximity.
  2. Cranial bone grafts to the nose usually undergo minimal long-term resorption
  3. Through a coronal scalp incision, a cranial bone graft to the nose can be done with medial canthoplasties in the treatment of traumatic hypertelorism.

Dr. Barry Eppley

Indianapolis, Indiana

Case Study – Teenage Male Cleft Rhinoplasty

Friday, August 11th, 2017


Background: Of all the difficult cases in rhinoplasty surgery, the cleft  nose remains one of the most challenging. While this challenge is magnified in the bilateral cleft nose, it is only slightly less in the unilateral cleft lip and palate patient. The challenge its not in understanding the deformity but working with nasal tissues that are both deformed and often congenitally deficient.

While the cleft nasal cartilages are deformed due to the asymmetry caused by the cleft that runs up through its nasal floor, the overlying skin also poses limitations. The affected nasal alar rim is always pulled down and the skin is often restricted by a recessed nasal base. Equally importantly the internal vestibular tissues usually have a web that is both limiting in elevation and for which a satisfactory solution remains elusive.

While many cleft patients undergo limited nasal reshaping procedures as an infant or child,  the more formal septorhinoplasty awaits until after puberty. When that should be done can be debated but it is most accepted that it awaits until after any jaw surgery may be done or the determination made that it is not needed. A stable maxillary base that will  to change in the future is a prerequisite for rhinoplasty surgery.

Case Study: This teenage left cleft lip and palpate male has been through all of his primary cleft lip and palate repairs as well as secondary alveolar bone grafting. He had also had a tip rhinoplasty as a child as well.

Under general anesthesia, an open seiptorhinoplasty was performed. Septal cartilage was used for a columellar strut, left middle vault spreader graft and left alar batten graft. Bilateral subtotal inferior turbinectomies were also done.

In a cleft rhinoplasty some of the most important goals are to improve the shape of the nasal tip and cleft-sided nostril deformity. To do so requires septal correction and in the process the harvest of cartilage grafts to provide the structural rigidity that is needed to do so.


  1. The cleft nasal deformity is a combination of structural deformity and structural deficiency.
  2. Cleft septorhinioplasties almost always needs to be done with an open approach and usually requires cartilage grafting as well.
  3. The nasal tip deformity in the cleft nose can never be normalized completely but it can have major improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Technical Strategies – Rib Graft Shaping in Rhinoplasty

Saturday, July 15th, 2017


Rib grafts are the material of choice for many larger augmentative rhinoplasties and complex nasal revisions. They offer a virtually unlimited amount of cartilage graft material that can be used anywhere on the nose from the bridge down to the tip and columella. Because cartilage is softer than bone and relatively easy to carve, it is a versatile graft material that can be shaped for a wide variety of nasal reconstructive needs.

Besides the need for a donor site, the other downside to a rib graft is that it is rarely completely straight. Much of the shape of the ribs is largely curved as it bends around the side of the chest to join into the sternum. When harvesting cartilage the surgeon tries to take the straightest piece possible but, more times than not, a sizable rib graft harvest is likely to have a bit of a curve to it. Thus some form of graft manipulation/reshaping is needed.

The most common form of rib graft reshaping is to carve it like one would a bar of soap. A scalpel is use to carve it into the desired graft shape. In doing so it is well recognized to be aware of the bend of the rib and the attachments of the perichondrium. Since the perichondrium exerts a pulling force on the surface of the rib, it is important to keep the perichondrium attached on the convex side away from the curve and to remove the perichondrium and cartilage on the concave side of the curve.

Another useful or additive technique is to score the cartilage on the opposite side of the curve even though the perichondrium is left intact. Then multjple through and through sutures are placed to bend it straight or to ensure that it stays straight. This can work well in slight bends and if one is concerned about postoperative warping. Usually two to four transverse scores are needed for a long dorsal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

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

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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