Your Questions

Q: Dr. Eppley, I am interested in rhinoplasty surgery. Is it possible to to do nostril narrowing making my nostrils smaller and the tip of my bulbous nose smaller, what would you suggest ? I want a thinner and more defined nose altogether.

A: Your rhinoplasty questions are good ones and are fairly common in ethnic African-American rhinoplasty. What you have is a nose that has little underlying cartilage support with thick overlying skin. This is why it is wide, short and ‘turned up’ so to speak. It simply lacks much underlying support to hold the skin up. While it is tempting to think that just thinning out the cartilages on the nasal tip, defatting it and then narrowing the nostrils will create the desired effect, it will not. In fact, such an approach may likely end up making it look worse. What you need is an augmentative rhinoplasty (not a reductive one) that builds up the bridge of the nose and tip and pulls the skin upward (and somewhat downward at the tip or derotation) to create a thinner and more defined looking nose. If the nose is augmented then narrowing the nostrils will be more effective. I have attached some imaging of your nose to demonstrate that effect. How to achieve the augmentation is a classic debate between a rib graft or an implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is it possible to thin out my large African-American nose, add a defined bridge and still look “natural”? How long does surgery take and how long is recovery?

A: Thank you for your inquiry and sending your pictures. The African-American rhinoplasty is unique  because of the very thick overlying skin and lack of a strong bone or cartilage framework underneath it. You are correct in your description of how to approach the broader and flatter nasal structure by dorsal augmentation (usually with an implant), increasing tip projection with definition with columellar strut and tip cartilage grafts and nostril narrowing. I have done some computer imaging to show some of the potential outcomes with are highly controlled by the thickness of the overlying skin and how well it can contract down over a new supporting framework. The first  imaging prediction is based on the least amount of change (thinning) that can occur while the second imaging prediction is based on what I believe to be the maximum change that can occur in a single rhinoplasty procedure. You did not provide a side view image so how that would be affected will require a profile picture. I will let the images speak to your assessment of whether such a result would be natural in appearance.

This typical African-American rhinoplasty usually takes about 2 1/2 hours to perform under general anesthesia as an outpatient procedure. Since internal breathing work does not need to be done (I am assuming) nor do nasal osteotomies or a rib graft harvest (since an implant would be used), there should be minimal pain afterward and no bruising. Recovery is more about how you look having to wear external nasal tapes and a splint for a week after surgery. Once that comes off there are no physical restrictions and one’s appearance should be socially acceptable. While the final results of a rhinoplasty can take six months to fully appreciate (maximal skin contraction and thinning), one should be reasonably comfortable returning to work and socializing again in 10 to 14 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in cheek augmentation and an African-American rhinoplasty. I have fat cheeks and I want them smaller. I also want a more refined and less fat nose. I have attached a picture of me so you can see what needs to be done.

A: Thank you for sending your picture. This one view is not the best picture to judge the result but it is helpful. I believe you are looking for a buccal lipectomy to reduce the fullness under your relatively flat cheek bones. Or you could leave the buccal fat alone and augment the cheekbones which I think is a better alternative. (maybe just a little buccal fat removal. Your nose shows many of the typical ethnic features and that could be improved by an open rhinoplasty in which the nasal bridge is built up with an implant, the tip lengthened and narrowed and the nostril flaring/width reduced. I have just imaged the buccal lipectomy and the rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Would like to have a more defined nose tip and thinner nostrils. My nose spreads and flairs. I have a bridge and a nice profile, would life the nostrils thinned and not rounded. Not interested in keeping a so called afrocentric ethnic nose.

A: As you know, you have many nasal features that are consistent with your ethnicity that you want to change. The typical African-American nose at its tip is reflective of the underlying cartilaginous structure.  It is due to broad and widely-spaced lower alar cartilages that are inherently weak, a blunted and shorter caudal end of the septum, vertically-deficient columellar skin and a horizontally-ovoid wide nostril bases. The overlying tip skin is also very thick which blunts tip cartilage definition. Therefore, to make the change of more narrow nostrils and a better defined nasal tip, changes must be done to these structures. Through an open rhinoplasty, the lower alar cartilages need to be brought together and supported by both a septal extension and columellar strut cartilage grafts harvested from the septum. This is much like a tentpole effect raising up the tip and allowing it to push upward against the thick nasal skin for a more narrow and defined tip. The nostril width  needs to be reduced by removing skin at the sides of the nostrils bringing them inward. Depending upon how much the nostrils need to be narrowed and the location of the scar determines what nostril reduction technique is used.

While seeing your pictures is helpful, only a non-smiling front view is useful for imaging. I have cropped the one such picture that you have sent but the image quality on magnfication is not great. But this rudimentary altered image helps illustrate the rhinoplasty objectives.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I find my nose too wide. I would like to narrow it a bit. I was also interested in having a cleft chin and anything else you suggest. Thank you so much.

A: Thank you for your inquiry. Your picture shows many of the features of the African-American nose, which is largely a broad and wide tip with lower alar cartilage flaccidity, flared nostrils and a low dorsum. Rhinoplasty changes would include dorsal augmentation, columellar strut graft, tip lifting and narrowing and lateral nostril flare reduction. Unfortunately the one picture that you have provided is not of good enough quality for computer imaging to show how these changes might look on you. Pictures should be better quality (not fuzzy), taken from the front and side view and be non-smiling.

Chin dimples are central round indentations on the central of the soft tissue chin pad. Chin clefts are vertical grooves that run from the center of the chin pad down to the lower border of the jaw. Either one made from an incision inside the mouth where a core of soft tissue (muscle and fat) is removed below the desired location of the external location of the chin dimple or a wedge of tissue removed along the underlying location of the desired chin cleft.. The underside of the chin skin is then sutured down inward to make the dimple or cleft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a dorsal hump on my nose. I had a consult with another doctor who mentioned using fillers or if electing surgery breaking my nose. I do have breathing problems in my nasal area which we discussed also. But, I am concerned about dramatically breaking my nose. I am African American. I do not want a slender Jackson Family nose. I want to look like myself, just better 🙂

A: While the African-American nose typically has a low and wide nasal bridge, it can still have a dorsal hump. Or in the low nasal bridge a pseudo dorsal hump, a dorsal hump that appears to be there because of a low nasofrontal junction or radix area. There are two approaches to your dorsal hump removal , augmentation or reduction, which has already been discussed with you. Augmentation may be a better approach for you since you already have a breathing problem and you fear too slender of a nose. The only role that fillers would play in my hands for your nose is to determine whether augmentation above the hump produces the desired effect. This is a good simple and reversible test using the non-surgical rhinoplasty concept. If filling above the hump produces a good look, then you can proceed with a rhinoplasty doing dorsal augmentation using either a cartilage graft or an implant. Each has their own advantages and disadvantages which needs to be discussed in detail.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Hi, I have hated my nose for a long time and I have finally decided to get a nose job. I am African-American and I don’t like the lower third of my nose. My nose is too wide and big when I smile. My nostrils flare really wide. I just want to get rid of some of the wideness but don’t want to change the whole nose. Is that possible?

A: One of the many distinguishing features of the African-American nose can be its unique tip and nostril shape. The tip is often more flat and less well-defined and the nasal base is wide, often with nostrils that have a larger size that also flare. Many African-American rhinoplasties involves reduction of the wide and flaring nostrils. This can be done by removing skin from the inside of the nostrils for some minor reduction or by repositioning the entire nostril base for a more major change. Nostril and nasal base reduction can be done by itself but it is important to see how this may change the overall look to the nose. This is where computer imaging is absolutely essential. Most likely changing the size of the nostrils will affect how the tip of the nose looks and will make it look even more flat and shorter. Some tip changes through columellar strut grafting may be needed with nostril reduction to keep the lower third of the nose in balance. Dr. Barry Eppley Indianapolis, Indiana

Q: What is best way to build up an African-American nose that is short and small?

A: The overall shape of the African-American nose is often that of being broader and less projecting than that of a more Roman or aquiline nose shape. As a result, one of the key considerations in the rhinoplasty management of this nasal shape is to build up the bridge or dorsal line of the nose and improve tip projection and definition. Such an approach is most likely what is meant by having a nose that is ‘short and small’.

An type of augmentative rhinoplasty requires the addition of some form of graft or internal support structure to lift up the roof (skin) and reshape it. How much graft volume is needed determines the best way to do it. Each patient will be different in this regard. But this discussion always comes down to whether one wants to use a synthetic implant vs. cartilage.

The historic debate between allograft vs. autograft in rhinoplasty is an old one. Each has their own advantages and disadvantages with surgeon advocates on both sides. But the differences between the two are always the same. An implant is a lot easier to do (off-the-shelf) for both patient and surgeon and comes in a variety of ready-made shapes to create small or big ghraft needs. The price that is paid for this ease is the increased risks of infection and long-term implant extrusion and problems. Cartilage grafting is much harder to do, necessitates a donor site and require more surgical skill and experience to do well. But the risk of infection is much lower and there is no risk of any long-term extrusion or rejection problems.

Which is best must be determined with the patient through a thorough consultation and educational session. Both methods can be successful but the patient with the plastic surgeon must weigh the benefits and risks of each approach. When possible and acceptable, I prefer cartilage grafting because of its long-term benefits.

Dr. Barry Eppley