Rhinoplasty surgery, in the purest sense of the term, implies changes to the external or visible parts of the nose. Since the appearance of the nose does not necessarily affect how it functions, your insurance will not cover any of the rhinoplasty procedure if the goal is to achieve an improved looking nose. For instance, your insurance will deny coverage if your primary reason for surgery is improving a nose that is unattractive, too large or crooked.

But there are circumstances where insurance will provide coverage of a nasal procedure. Notice that I did not use the term rhinoplasty. As soon as you use that term, you are talking about changes to the outside of the nose which we know is not covered…unless the source of the problem is from a birth defect, traumatic injury, or from tumor removal. To define those further, birth defect usually means cleft lip and palate or some other craniofacial deformity where the nose has not developed normally. Traumatic injury means a documented history of nasal fracture, that is relatively recent (not 20 years ago or when you were a child) and there are medical records to substantiate that it actually happened. Tumor excision almost always means some type of skin cancer where a portion of the skin on the nose has been removed All of these external nose needs will constitute a reconstructive rhinoplasty procedure and there is not usually  battle to get it approved. (most of the time)

Your insurance will not only cover for these reconstructive issues but they will also cover for breathing difficulties of the nose. A deviated septum is the classic case but there are other internal structures of the nose that can be obstructive, most notably the turbinate bones. Difficulty breathing can also cause headaches and contribute to sleep apnea. All of these are medical issues because they dysfunctional. Many times, the physician’s examination alone is sufficient to provide adequate documentation but other tests may eventually be required including nasometry, CT scans, or sleep studies. One key area that your medical insurance looks for is…what non-surgical treatments have been tried ( and failed) to prove that surgery is necessay. (and the last resort)  This usually means a trial course of steroids or other nasal swelling treatment strategies.

Documentation is key for your insurance company to consider that such symptoms exist. Regardless of whether the medical necessity reason is a structural problem due to a birth defect or trauma or a long-standing breathing problem, a pre-determination letter must first be sent from your plastic surgeon. One must then wait until you receive a written response from the insurance company before ever proceeding to surgery. If you do not see it in writing, do not assume that it is going to be covered.

Do not let the urgency of your or your surgeon’s schedule override written confirmation of medical coverage. This is a common mistake. It is much better to know the financial facts up front (and then pay if you have to) than try and sort it out later when you are receiving bills and late notices from a variety of providers because it has been denied due to a lack of the required pre-determination. Remember, once you have it done without a pre-determination, the insurance company is not really under any obligation to pay after the fact. (even if it would have been  initially qualified) Paying medical charges that are accrued at the rate of insurance billings are a lot higher than those charged for on a cosmetic fee basis. Let the insurance and pre-determination process run its course…or otherwise you may find yourself really paying through the nose.

Dr. Barry Eppley

Indianapolis Indiana

1.      How will my nose look after a rhinoplasty?

One of the most important considerations about having a rhinoplasty is to end up with a ‘new’ nose that makes you happy. While no surgery can absolutely be guaranteed as to how it will look, there should be a good understanding between the you and your plastic surgeon as to what your goals are. This is why computer imaging is so important before surgery. It serves as a method of communication so that what you would like and what is possible can be meshed into an image of a likely outcome.

As a plastic surgeon, we can reasonably predict what each patient will say bothers them about their nose. Whether it is a nasal hump, a wide tip, a downturned nose or a nose that is off center, we can quickly see what makes one’s nose out of proportion. The pupose of computer imaging is to make sure what we see is the same as you see. And it also allows us to know how to modify the changes we might do (e.g., more hump reduction, too much tip narrowing, tip up too high or still too low) so that it meets your needs better.

2.      Does rhinoplasty leave scars?

Rhinoplasty can be done two ways, open and closed. While there may be some debate and advocates for either approach, most rhinoplasties today are done through an open approach. This does leave a small horizontal scar on the strip of skin between the nostrils. (columella) The remainder of the incisions are hidden inside the nose just like a traditional closed technique.

While the open approach does result in a scar, it almost always heals so well that it is virtually impossible to find when the scar matures. In some patients, you can only see that scar if you are within 10 cms or less. And it requires one to be looking from below the tip of the nose…a very unnatural viewpoint.

3.      Will rhinoplasty improve the breathing through my nose?

Nose surgery can be done to change the external appearance of the nose (aesthetic rhinoplasty) or to improve obstructed breathing through the nose. (functional rhinoplasty or septorhinoplasty) Often both are done together.

Functional nasal surgery, however, is done completely inside the nose and works on those structures that contribute to air flow. This includes the septum (straightening a deviation), turbinates (reduction or partial resection) and manipulation of the internal nasal valve. (cartilage grafting for expansion)

It is important to realize that doing the two together has many benefits. Straightening a deviated septum can help straighten a crooked nose and is a good source for cartilage grafts. Turbinate reductions help open up an airway that may be adverseloy affected by some of the external changes. Expanding the middle vault with grafts can make a pinched-looking nose wider and make the dorsal lines more symmetric.

4.      Will insurance pay for my rhinoplasty?

While we all would like health insurance to cover all of our medical needs, rhinoplasty is not usually one of them. Expenses related to improve breathing are almost always covered within the limits of your policy, any external changes to the appearance of the nose however are not. There are certain exceptions to that exclusion if there is a documented medical reason for how the nose is deformed. Birth defects (e.g., cleft lip and palate) and traumatic injuries (e.g., fractures)are the two main examples. I emphasize the word ‘documented’ as just saying that it occurred is not sufficient.

5.      What can be done if I am unhappy with how my nose looks after surgery?

For most rhinoplasties, the biggest risk or complication is that of an undesired appearance outcome. This is usually not a large cosmetic problem but more like an irregularity, a dip or deviation, or some location of asymmetry of the bridge, tip, or mostrils. As a plastic surgeon, we are very sensitive to how even a minor ‘problem’ is of a big concern to a patient, particularly when it is on their nose.

When one sees something on their nose after surgery that displeases them, one should first be patient. The nose is unique in that the skin continues to change on the nose for months after surgery, sometimes even up to a year. What may be there to day, could be gone or even more apparent months from now. Secondary or revisional surgery is not usually done for at least six months from the initial surgery. The primary reason is that we want to operate on a ‘stable target’, not a nasal feature that is in a state of evolution. Also, it is important that the stiffness of the nose tissues has had time to settle down and become softer again. Revisional surgery done too early is highly prone to fail.

The risk of the need for revisional rhinoplasty surgery is not rare. Because of the many different types of nose problems and types of surgery needed, no one can give a reliable estimate that applies to any specific patient. In my Indianapolis plastic surgery practice, I use the estimate of a 10% risk…a not insignificant number.

6.      What type of anesthesia is used for rhinoplasty surgery?

Surgery of the nose has a history of being done under local or IV sedation in many practices. While some plastic surgeons still do so, one should never compromise the ‘fear’ of anesthesia vs a good outcome. Comfort of the patient and the ability to manage any bleeding that may occur during surgery is best done under general anesthesia. Many older patients can recall having their nose done when they could hear or feel their ‘bones being broken.’

Today’s anesthesia techniques and drugs are so good, I see no reason to use anything less than a general anesthetic for almost all cases.

7.      I have heard that rhinoplasty is a difficult surgery to do, why is that so?

While the nose is a small structure in comparison to the rest of the face, there is a lot of complex anatomy packed in there. Contrast the nose to the chin, for example, which is much larger. The chin has only two pieces of important anatomy (solid piece of bone and soft tissues) while the nose has three bone and six pieces of cartilage covered by a very thin layer of skin. The interrelationship of how this anatomy comes together, what changes occur by altering parts of it, and how it responds to healing and scar contracture make rhinoplasty less predictable than almost any other facial surgery that we do.

Dr. Barry Eppley

Indianapolis, Indiana 

As the U.S. population continues to become increasingly multicultural, one of the increasing ethnic groups is that from the Middle Eastern region. This is a geographic term that does not have a true precise meaning as it can vary based on which countries one chooses to include in the region. Most commonly, many would include the countries that surround the Gulf Sea as well as that of Northern Africa.

While the Middle Eastern region is a blend of many cultures, there are certain nasal characteristics that are commonly seen. The overlying skin is almost always thick and heavy, a large dorsal hump is present, the nasal tip is ill-defined and bulbous, and the columella is frequently short. These characteristics give the appearance of a long and plunging nose with an acute nasolabial angle.

The Middle Eastern nose, like all ethnic rhinoplasties, poses challenges based its thick skin and cartilaginous make-up. But beyond the anatomy of the nose, it is important to have clear communication with the patient about their nasal goals. When the plastic surgeon and the patient have different ethnic and cultural backgrounds, it is easy to have objectives that are unintentionally different. Computer imaging and multiple consults can help to prevent this communication gap.

The open approach should almost always be used. To rework the cartilage framework in a way that will make a significant change in nasal appearance requires optimal visualization. Some plastic surgeons may be able to achieve a great rhinoplasty result in the Middle Eastern patient through a closed approach, but that has not been my experience in my Indianapolis plastic surgery practice. While there is always a concern about the columellar scar in patients with increased skin pigmentation, that has not been a problem. That is not a surprise given the known experience with other ethnicities.

Structural support to the tip and the middle vault is essential. The thick skin of the nasal tip can make it challenging to achieve definition and a more upright position with an increased nasolabial angle. Septal grafts to the columella are always needed to support the large and heavy skin sleeve. Tip grafts are usually beneficial to create more definition through tip skin which has been slightly defatted. The septum can provide more than enough graft material and almost always needs work anyway as it is frequently deviated and off midline.

The dorsal hump must be looked at and analyzed carefully during surgery. While it can appear to be high, it may not need to be as significantly reduced as one initially thinks. In some cases, this is an illusion due to the downturned tip and decreased nasolabial angle. Rasping and radix grafts may be all that is needed. In other cases, however, a large bony hump does exist and full osteotomies are needed to bring down the dorsal line.

Alar and nostril narrowing  by excising skin at the sill or base is often needed. One should not hesitate to do so when indicated as adverse scarring is rarely seen.

Rhinoplasty in the Middle Eastern patient is challenging but successful results and a happy patient can usually be achieved. The use of well known structural support principles through an open approach are important intraoperative maneuvers. Preoperative planning with an understanding of the patients aesthetic objectives is just as important in any form of ethnic rhinoplasty.   

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty is one the most challenging and unforgiving operations of all facial plastic surgery operations. Due to the complexity of nasal anatomy and how its multiple parts interrelate, many different surgical maneuvers and changes are possible. Some of these changes are more significant while others are more subtle. But they all can make a difference in the final result, whether it be how the nose looks or how well it breathes.

Because of the importance of the nose to one’s facial appearance and the many different maneuvers that can be done in rhinoplasty, communication between patient and plastic surgeon is absolutely critical. In my Indianapolis plastic surgery practice, I use paper diagrams of the anatomy of the nose during a rhinoplasty consultation and computer imaging forwarded to the patient after the appointment. Both visual methods are essential in having the patient understand what the problems are and what is surgically possible.

In the course of this communication, some appreciation by the patient of the anatomy of the nose and the terms we use in rhinoplasty surgery are necessary to make sure we are really communicating.

Most people underestimate the complexity of the nose because they are thinking only about its visible external appearance. But beneath the skin lies an intricate arrangement of cartilaginous- and bone-based structures that give the nose both its form and function.

The surface of the nose features a number of distinct regions and structures.

·  The root  or radix of the nose is the area between and just below the eyebrows. It is the uppermost part of the bridge.

·  The bridge lies below the root and forms the upper one-third of the nose.

·   The middle vault lies between the bridge and the tip of  the nose.

·  The dorsum (roofline) is the shape and height of the nose as it runs between the root and the tip of the nose.

·  The tip of the nose is where the dorsal line of the nose meets the columella.

·  The columella is the strip of skin between the nostrils which extends down from the tip to the upper lip.

·  The ala are the sidewalls of the nose forming the roof of the nostrils

·  The nasal base extends from one side of the nostril to the other along where the nose meets the upper lip.

Beneath this surface topography lies the bone and cartilage structures which give it both shape and support. Some of these important structures are:

·  The paired nasal bones (root and bridge)

·  Two upper lateral cartilages (middle vault)

·  The septum which runs between the upper lateral cartilages

·  Two lower lateral cartilages (tip and nostrils)

·  The medial crural footplates (columella)

Contemporary rhinoplasty is focused on conservative and subtle anatomical changes accomplished by preservation, reconstruction and modification of the osseo-cartilaginous framework of the nose. There are two surgical approaches to these structures – the open and the closed approach.

The open approach is performed by making a trans-columellar skin incision combined with internal incisions, followed by skin envelope dissection and elevation. The open approach offers full exposure to the nasal framework, allowing for accurate diagnosis and precise manipulation of its external structures. If extensive changes are needed in a first rhinoplasty or if a secondary rhinoplasty is needed, the open approach is usually better.

The closed approach does not require any skin incision and does not leave external scar since all the incisions are made inside the nose. The lower lateral cartilages can be dissected and freed from the surrounding tissues and “delivered” outside. This approach is best suited for isolated hump deformities or minimal tip changes.

Armed with this basic nose anatomy and surgical terminology, may your rhinoplasty consultation and discussion make you a better educated patient! 

Dr. Barry Eppley

Indianapolis, Indiana

‘For the most part I like my nose, but I have a slightly rounded, bulbous tip. I don’t really want to change my nose… just tweak it a little bit and give the tip of my nose slightly more definition.’

‘I have a decent nose. However, as I’ve gotten a little older, I noticed the tip of my nose has became more rounded and less defined. I wanted a “tweak” to refine the nose.’

These are common statements that I have heard in my Indianapolis plastic surgery practice from patients seeking nose changing surgery. Often in rhinoplasty, patients are concerned about one specific feature of their nose that they don’t like. As a plastic surgeon, I am trained and experienced to see the entire nose and how it relates to the rest of their face. This perspective allows me to offer suggestions about other changes to the nose that may also be beneficial. However, it is important to respect a patient’s concerns, particularly if they are concrete about one specific change. After all, patient’s know their own nose the best and they have to live with the result.

The tip may be the smallest third of the external nose by surface area but it is the complex. Its shape and angulation has a profound impact on nasal and facial appearance. It is the one feature of the nose that is the most unique between every person.

A tip rhinoplasty is a variety of operative manuevers that seeks to change the volume, angle, or height of the nasal tip. Alterations can range from simple to complex, depending on the degree and scope of an individual patient’s problem. Many different outcomes are possible, depending on both the patient’s desires and the plastic surgeon’s aesthetic sense.

Anatomically, a tip rhinoplasty involves changing the relationship of the lower lateral (alar cartilages) with the upper lateral cartilages and the caudal (end) of the  septum. It can be as ‘simple’ as a cephalic trim,  a reduction of the upper part of the bulbous tip cartilage, or more involved with adjustment of the septum at its base and grafts placed between the nasal ala to enhance and rotate the tip. Various types of techniques, including suture modification, cartilage excision, or structural grafting may be used to achieve the desired aesthetic outcome.

Most commonly when a patient refers to tweaking the nose, they usually mean making it a little narrower (more refined) or lifting it just a bit… or both narrowing and a little lift combined. Such changes can be done through either an open or closed approach. When the changes are small, I prefer a closed or endonasal approach to lessen the duration of time that the patient has to endure the surgical swelling.

When modifying the tip of the nose, it is critical to not ‘over tweak’ it. This means to not make the tip into a single point (too narrow) or lift it too high or short. When this happens one will have an operated look which is synonymous with having had one’s nose done…exactly what patients are trying to avoid.

Barry L. Eppley, M.D., D.M.D.

Indianapolis, Indiana

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 – 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the very popular topic of rhinoplasty (nose job) was discussed.

Maybe you have been unhappy with your nose for a long time or perhaps you are having difficulty breathing through your nose. Either way, a rhinoplasty or nose reshaping may be an option for you.

A rhinoplasty can change many things about your nose, including your nose size (in relation to your face), nose width at the bridge, the size and position of the nostrils, and nose profile (by downsizing visible humps, bumps or depressions on the bridge).

A rhinoplasty can also reshape the nasal tip, improve the appearance of large, wide or upturned nostrils and correct nasal asymmetry. From a functional standpoint, a rhinoplasty can correct certain breathing difficulties such as those due to a deviated septum. Rhinoplasty is also an option for certain birth defects or noses that have been injured in car or sports accidents.

A rhinoplasty or nose job is a surgical procedure designed to reshape the nose. It can be done to correct a structural deformity (such as a bump or hook), provide subtle changes to nose size and shape to improve your appearance or to correct a functional problem (such as difficulty breathing due to a deviated septum).

Plastic Surgery and Rhinoplasty consultations with Dr. Eppley can be arranged by calling his Indianapolis suburban area facilities at IU Health North or IU Health West Hospitals at 317-706-4444 or sending an e-mail inquiry to: info@eppleyplasticsurgery.com

Rhinoplasty continues to be a popular facial procedure and is one operation that is almost synonymous with plastic surgery. The central position of the nose on the face makes the need for any rhinoplasty surgery to be very precise. Good results in rhinoplasty are largely dependent upon a detailed understanding of the anatomy of the nose. Whether it is a small area of nasal change or an entire nose restructuring,  how the anatomical framework is altered will eventually be revealed through the overlying skin.

What makes your nose look like it does? Think of the shape of your nose like a single level house. The roof covering is the overlying skin, the framework of the roof is the nasal bones and upper and lower alar cartilages, the central support beam is the septum, and the walls are the nasal lining. The look of one’s nose, like the shape of the roof on the house, is directly influenced by how the framework of the roof is shaped. A hump or bump on the nose  occurs, for example, because the central beam is arched (too long), raising up a normally smooth roof line. The tip of the nose is too long, for example, because the legs of the tripod support on the roof edges is too long. Deviated noses occur because the central support beam is deviated or the tripod edge supports are longer or shorter on one side.

As an Indianapolis plastic surgeon, I think of changing the nose in terms of four areas, three outer framework and one inner framework support. The upper outer one-third is the nasal bones, the middle third (also known as the middle vault) is the upper cartilages, and the lower one-third is known as the lower cartilages or the tip of the nose.  The septum is the central internal support.  One important nose area is the thickness of the outer skin which, although we can not change, definitely influences how the changed framework will eventually be seen.

Rhinoplasty surgery  is about changing the way these framework parts are joined and in how they are shaped and inter-relate. Taking down a hump on the nose, for example, is a matter of lowering the roof line by reducing the nasal bones and septum heights and usually allowing the roof sides to fall back in together once shortened. Reshaping the tip of the nose is by changing how the sides of the lower cartilages come together in the middle and changing their unified angulation to the underlying septum. Building up the nose is by adding some form of graft to the top of the roofline along its entire length.

Due to the complexity of how all of these framework structures come together, many rhinoplasties today are done through an open approach to best view how the parts come together. For minor changes, however, a closed or endonasal approach still works well and is associated with a quicker recovery time and less nasal tip swelling after.

Dr. Barry Eppley
Indianapolis, Indiana

One of the potential complaints of rhinoplasty patients is that their nose is too long. This should be differentiated from someone who feels that their nose is too big. While big may mean long when it comes to the nose, most of the time patients use the term big in reference to the size of the nasal tip or to a nose with a large hump and plunging tip that is also too long.

From a rhinoplasty standpoint, the length of the nose refers to a measurement from the top of the bridge down to the most forward point of the nasal tip. There are some anthropometric assessments as to what the most pleasing nasal length should be…the classic one being that the nasal length should only be as long as the height of one’s ear. There are also some specific measurements and proportionate relationships that also define ideal nasal length but suffice it to say if you think it is too long…it is probably too long. The most common feeling is that the length of the nose does not appear to be in proportion with the rest of your face.

The most common cause of a long nose is that the septum is overgrown, driving the tip cartilages forward and often down as well. In my Indianapolis plastic surgery practice, I approach this nasal problem through an open rhinoplasty. This enables one under direct vision to remove the end of the septum and reposition the tip cartilages up and back. In some cases, both of these maneuvers are needed. In others, only tip repositioning is needed. Precision and accurate placement of sutures are needed to get a satisfactory result.

The application of tapes are placed at the end of the rhinoplasty which helps control swelling and support the nasal tip in its new position. The use of tapes may give the appearance that the nose is too short or uplifted too much. This is a temporary distortion caused by the tapes which passes when the tapes are removed a week or so later.

The biggest concern with long nose correction is that the nose may appear too short or uplifted after. This is avoided by not removing too much septum or overlifting the tip cartilages by sutures that are too tight.

Dr. Barry Eppley
Indianapolis, Indiana

On this week’s Doc Chat Radio show on WXNT 1430AM in Indianapolis from 1:00 – 2:00PM on Saturday afternoon, hosted by Dr. Barry Eppley Indianapolis plastic surgeon,  the popular plastic surgery topic of Rhinoplasty was discussed. Rhinoplasty, also known as nose job surgery, is one of the top five cosmetic procedures performed in the United States.  Dr. Eppley discussed what rhinoplasty is, where the name comes from, and what nose job surgery really is. He interviewed several patients who have had recent rhinoplasty surgery and reviewed why they had surgery, what the recovery from rhinoplasty was like, and how their appearance and nasal breathing has been improved. Rhinoplasty is often combined with other facial plastic surgery procedures, most commonly chin augmentation. Patients go through computer imaging before surgery so they can have a good idea as to what realistic changes in their nose can be done.

Free Rhinoplasty and nasal surgery consultations with Dr. Eppley can be arranged by calling his Indianapolis suburban area facilities at IU Health North or IU Health West Hospitals at 317-706-4444 or sending an inquiry by email to: info@eppleyplasticsurgery.com.

Rhinoplasty surgery is capable of making a number of different changes to the shape of the nose. One of these potential changes is in the length of the nose. A nose’s length is measured from a point between the eyebrows at the top of the nose (an anthropometric point known as rhinion) down the bridge to the end of the tip of the nose. In theory, the proper length of the nose is supposed to be the same length as your ear. And there are a variety of mathematical ratios that also calculate what one’s nose length should be. However, you either feel your nose is too long or you don’t…as that is more pertinent than any other analysis.

While the length of the nose is a result of every structure down its entire length, what occurs at the tip is most pertinent. The nasal tip and its position is how you judge how long or short your nose is and it is the only area where length can be adjusted.

A long nose is usually caused by an overgrown or long underlying septum. Like the central pole in a tent, the septum is the driving force behind the support and position of the lower alar cartilages which make up the nasal tip known as the dome. If the septum is long, it will drive the tip out and down increasing the length of the nose. Externally, this is apparent by more of a downturned tip or an acute nasolabial angle. (angle between the columella of the nose and the upper lip)

A long  nose can be shortened primarily by resecting part of the end of the septum where it sits behind the columella. (strip of skin between the nostrils) By shortening it and changing the angle of its end, the tip cartilages of the nasal tip can be moved back. As the nasal tip moves back and up, it opens up the nasolabial angle. This creates both a true and an illusionary shortening of the nose.

Because accuracy and proper repositioning of the septal-alar cartilage relationship is needed when shortening a nose, an open rhinoplasty approach is best used. When the long nose is shortened, the hump on a nose (if it exists) will become less apparent as the dorsal line is changed. For some, this may mean that hump modification is not needed. For others, less aggressive hump reduction techniques may be used.

Shortening a nose and changing the tip angle can have a significant change in one’s facial appearance. It can change how other facial structures look as well, particularly that of the chin.

Dr. Barry Eppley

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Clarian North Medical Center, Carmel, Indiana
Clarian West Medical Center, Avon, Indiana
Indianapolis