Forehead Grooves

Q: Dr. Eppley, I would like your opinion on something. Over the past few months I have noticed deep ridges in my forehead which run a long the forehead veins. I went to see a dermatologist for fear it was en coup de sabre, but was told the skin didn’t seem like that. I’m 46 years old, thin and female. I am extremely depressed about it as it looks like I’m a Klingon when I look at myself in shadowy light. in bright light it is OK. I was thinking of having a face lift in the UK later in the years so don’t know if anything could be done about it then. Is this something you could address? I was wondering whether maybe forehead cement but then would that be possible with the veins where the ridges are and would that push the veins up to make them bulging instead. Yours desperately.

A: Thank you for your inquiry. I would have to see pictures of them but most likely it is forehead veins and not linear scleroderma. I have seen this quite a few times. These veins, when deflated, can leave long vertical grooves in the forehead which is often paired. How to treat them is challenging. The concept of bone cement on the surface makes sense but would likely leave raised ridges and may likely cause its own aesthetic problem. The other alternative is fat injections placed around them. Since fat is injected with blunt cannulas there is little risk of entering the veins or disrupting them.

The key issue is what these forehead grooves look like in three positions, when standing up, laying down and then with your head bent over. (head lower than your heart) This will make the diagnosis that this is indeed forehead veins. Those three pictures would be very helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Rhinoplasty For Tip and Nostril Changes

Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing? 

A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.

One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.

The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.

The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Female Chin Implant

Q: Dr. Eppley, I got a 7mm Medpor Chin Implant put in on January 20, and I want it removed ASAP. Its too bulky and makes my face look less feminine than before. What are the chances of my face going back to the way it was before? Would another implant need to be put in? my doctor doesn’t do silicone chin implants for their tendency to drop overtime so Medpor it was. I’ve heard how difficult these implants can be to remove, what’s your experience with removing them? If I was to replace with a silicone implant, is it better to do it when removing the other or a few months later?

A: I am not surprised that a Medpor implant is too bulky for a female. While that implant needs to be removed, it is important to always remember that you had a chin implant placed for a reason and that was to correct a chin deficiency. This may be the wrong implant but that does not mean that there is no merit to having a chin implant at all. A better shaped and more feminine chin implant made from silicone would offer horizontal advancement with far less width if any at all. I would strongly consider replacing the implant rather than merely removing it. I have to see you throw away the complete effort.

I have removed many Medpor implants. While they are not as easy to remove as silicone it can be done. I have never heard of silicone implants ‘dropping over time’. There jus no biologic explanation for that and something I have never seen. It is better to remove and replace at the same time (with screw fixation of the new silicone implant) than to delay. The only reason to delay/stage it is if you are uncertain that you really want an implant at all. But that will change what is done during the implant removal. If you are just removing then you need to do a submental tightening of tissues since the tissues have been expanded to avoid a chin pad drop/ptosis.That ail not be necessary with a chin implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Calf Implants for Lower Leg Asymmetry?

Q: Dr. Eppley, I contracted polio when I was an infant from a vaccination, which resulted in atrophy of my left leg. Would fat grafting or thigh and calf implants help to make my legs more symmetrical? I know the discrepancy looks severe so I don’t have expectations of perfection but I’m hoping something may be done to lessen..  possibly with the combination of both procedures. 

A: Thank you for sending your pictures The easiest and less severe component of your leg asymmetry is that of the calf. One calf implant placed on the inner half would go a long way to improve symmetry below the knee. Two calf implants would produce near symmetry inj size to the other side.

The thigh deformity is the bigger part of the leg asymmetry and the more challenging to improve due to its magnitude. Injectable fat grafting would be the only treatment that can be done and its success is partially dependent on how much fat you have to harvest. This combined with how much fat survives determines that outcome. Based on the performance of the first procedure (and how much fat you have to harvest) you may need a second fat grafting session to get the best possible outcome.

Dr. Barry Eppley

Indianapolis, Indiana

Cleft Chin Implant

Q: Dr. Eppley, is there a chin implant that can make a cleft chin? I would like to get a cleft with my chin implant augmentation and I am told that cleft chin implants exist but do they work?

A: Contrary to popular belief, a chin implant that has a central cleft in it either manufactured that way or intraoperatively put in it will not create the appearance of an external chin cleft. It seems like that chin implant approach would work but it does not.

The key to making a vertical cleft in the chin when using an implant is to use/make a clefted chin implant but then the overlying soft tissue must be thinned out and then sewn down into the implant cleft or even all the way down to the bone. What makes it work is the suture technique down to the bone.

I wish it was as easy as putting in a cleft chin implant and creating a visible external chin cleft…but it is not.

Dr. Barry Eppley

Indianapolis, Indiana

Early Rhinoplasty Recovery

Q: Dr. Eppley, I recently had rhinoplasty (4 weeks ago) and I am extremely unhappy with the result. I asked my surgeon to remove the bump on my nose but it is still there and also my nose looks extremely wide. I was wondering if this could still be due to swelling- and if so, how much can I hope for it to go down, and if not, how soon do you think I could get a revision – I really want to be able to feel comfortable with myself before I go to back to school in September. I’ve attached some photos – as you can see my bridge is very wide and there is still a noticeable bump- could these just be caused by swelling, is there a chance they could go down completely/a lot?

A: In trying to answer your questions, I am at a significant disadvantage. I do not know what your nose looked like originally and know no details of how your rhinoplasty was done. These pieces of information are critical to know as to whether the eventual resolution of swelling will produce a favorable outcome or not.

But let us assume that the outcome of your primary rhinoplasty is not favorable, the timing of any revision rhinoplasty would depend on what needed to be done. This would not be before three months at the minimum and likely six months after the original rhinoplasty procedure. The nasal tissues need time to heal and have all the swelling fully subside.

Dr. Barry Eppley

Indianapolis, Indiana

Midline Vertical Forehead Line (Scar)

Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?

A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.

The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.

This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.

As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.

Dr. Barry Eppley

Indianapolis, Indiana

Mommy Makeover and Brazilian Butt Lift

Q: Dr. Eppley, I’m wanting to do a Brazilian Butt Lift lift. Can that be done at the same time as with a Mommy Makeover?

A: A Mommy Makeover (breast and abdominal reshaping) and a BBL (Brazilian Butt Lift) can be done at the same time but it create a very difficult recovery. It would all depend on what the exact Mommy Makeover procedures need to be and whether such a combination may negatively impact the results of any of the three procedures. For example if the Mommy Makeover needs to include a full tummy tuck there will be less fat that can be harvested for the BBL to avoid compromising the healing of the tummy tuck incision. I would need to make that evaluation during an actual consultation or you can send me pictures of your body type for a preliminary evaluation.

While it is always desirous to maximize the number of operations one can do in a single setting for economy of recovery and economic resources, there are operative combinations that can ‘fight’ against each other and may even compromise their results. This needs to be looked are carefully in these type of body contouring procedures.

Dr. Barry Eppley

Indianapolis, Indiana

Orbital Rim Implants?

Q: Dr. Eppley, I am interested in orbital rim implants. I am 23 years old with severe depressions under my eyes. I’ve had them since I can remember. I’ve tried everything. Special vitamins, creams, makeup, nothing works. I also have dark colors as well. I am more concerned with the depressions though. You can cover up color, but not hollowness. I went to see a local plastic surgeon and he basically told me nothing could be done. “Try our cream, and makeup” is basically all they said is necessary. I am tired of looking this way. How much does the implant surgery cost? I am so desperate. Thank you.

A: When it comes to infraorbital hollowness/tear troughs, this is an anatomic problem of either lack of soft tissue volume or inadequate bone projection.  These are most commonly treated today through the use of temporary injectable fillers. In my opinion, however, these should only be used a trial method to see if soft tissue voluminazation would be effective. They are certainly not a long term strategy particularly when ine is very young and this is a congenital anatomic issue.

Longer-term surgical treatment options would be either the use of injectable fat grafting or infraorbital rim implants. (sometimes called tear trough implants although these are not necessarily the same) Each has their role and the choice between the two would depend on what your depressions under the eyes look like. I would need to see some pictures of your eyes to make a more definitive recommendation.

Dr. Barry Eppley

Indianapolis, Indiana

Breast Reduction After Pregnancy?

Q: Dr. Eppley, I am interested in breast reduction surgery. I am 24 years old, 5 feet tall and pregnant. I was a 32C before and am currently a 32G. You have high reviews on Real Self. I struggle with stretch marks on my breasts and have no faith in my breasts shrinking after because of them. I am interested in a combined breast reduction and lift. 

A: While you may ultimately need some combination of a breast reduction/lift, it would be important that you wait a full six months after delivery before having the procedure. You want your breasts to fully shrink down and be a stable size with whatever sagging may ensue. In essence you want to have a ‘stable target’ to operate on so the breast reduction result does not change appreciably afterwards due to still evolving changes in your breasts.

You may also be surprised how much your breasts will shrink after delivery. What seems like a breast size that can never go down adequately can actually even end up too small later. The sagging will not improve with time and a breast lift may ultimately be needed but it is way too early to say that you need a breast reduction as of yet.

Dr. Barry Eppley

Indianapolis, Indiana