Will Rhinoplasty Help Reduce Nostril Flaring When Smiling?

Q: Dr. Eppley, I am interested in rhinoplasty but have one major question. My appearance changes greatly when I smile, my nose really flattens out and I would like it to be more defined when I smile. When my face is at rest, my appearance is satisfactory. My recent pics show no definition. Will rhinoplasty help solve this concern?

A: The concern about nostril flare with smiling is actually a fairly common question from patients considering rhinoplasty. It is important to realize that rhinoplasty is a static operation, not a dynamic one. It changes the nose structures based on their natural non-moving state. While it will give the nose more definition, particularly of the tip, it will not necessarily prevent the nostrils from flaring when you smile. That is a natural phenomenon of all noses as the facial muscles pull on the non-fixed bases of the side of the nostrils. While the nose will become more refined with the surgery, you should not expect that it will solve the flare of the nostrils that naturally occur from smiling. You should consider to undergo rhinoplasty for the changes you may see from computer imaging with your face at rest.

Dr. Barry Eppley

Indianapolis, Indiana

Do I Need Cheek Liposuction?

Q: Dr. Eppley, I see that you are able to narrow the width of the face by osteotomy of the zygomatic arch. In addition to this, I am concerned about the roundness of my cheeks, which have fairly prominent ‘apples’. I have fairly prominent cheekbones (I am of asian descent), so I was wondering if it would be possible to somehow reduce the body of the zygoma to reduce the prominence of cheeks when smiling? Or is it more of an issue to do with the amount of soft tissue? And if so, is there any way to reduce the fat in that area. 

A: What you appear to be talking about is the soft tissue fullness of the cheek area rather than the bone. The term ‘apple cheeks’ almost always means an anterior cheek area that is not related to bone. This is an area that will not be affected by any bony repositioning. In some cases, small cannula cheek liposuction can be helpful in reducing this area of cheek fullness. It can be surprising sometimes how much fat can be extracted from the cheek and a few ccs can often be obtained. But it is not always successful and can be associated with some persistent after surgery swelling.

Dr. Barry Eppley

Indianapolis, Indiana

Why Did My Groupon Smartlipo Surgery Not Work On My Arms?

Q: Dr. Eppley, I am average build. I was a patient a few years ago from a Groupon and received an estimate at that time. I had Smart lipo on my arms last spring, by a dermatologist, but the skin still bags below short sleeve tops, I would like to find out if there is anything that can help with that.

A: Unfortunately, getting liposuction through Groupon is probably not the best way to have any form of plastic surgery. By definition of the way Groupon works, you are going to get liposuction for the problem area (whether it would be effective or not) and are going to get the fastest and cheapest way to do it. It is not really any surprise that you have found the result wanting.

In looking at your pictures, without the benefit of not knowing what you looked like initially, I would say that any form of liposuction never had a reasonable chance to work. What you really needed all along is a formal arm lift. You have too much loose hanging arm skin to think that it could possibly be tightened by laser liposuction. You may not want the scar from an arm lift but that is the only treatment that is worth undergoing if you want a real arm shape change.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Hydroxyapatite Facial Augmentation Be Revised?

Q: Dr. Eppley, I previously had hydroxyapatite added along my jawline and my cheeks enhanced via  zygomatic sandwich osteotomy. My jawline is somewhat asymmetric and some of the HA in the jaw area closer to my chin needs to be removed/remodeled. I would also like my cheeks enhanced via HA as the augmentation is not adequate and also somewhat asymmetric. 

I am not sure if you are familiar with all of these procedures and realize this is not a straightforward case. Essentially I would like the the jaw area remodelled for better symmetry by removing HA and the cheeks enhanced further by adding HA. 

I am not sure if you use HA, from reading your website it sounds like you don’t however your opinion as a long standing plastic surgeon would be invaluable to me. I am also not opposed to any ideas you might have or getting the jaw remodelling done by yourself.

Thank you very much for your time and consideration.

Hydroxyapatite Granule Facial Augmentation Dr Barry Eppley IndianapolisA: Thank you for telling your story and sending your pictures. I am very familiar with using hydroxyapatite (HA) block and granules as back in the 1980os and early 1990s that was the way much of facial augmentation was done. I still do it occasionally on patient request. HA has fallen out of favor for many surgeons as the blocks are hard to shape and stabilize and the granules are somewhat unpredictable in shape with healing.

I suspect you had HA blocks put in with your zygomatic osteotomies which is good for width but not so much for projection. HA granule ‘sandwiches’ can be made which helps control the material to some degree for secondary placement on the cheeks for greater projection.

Removal of the HA along the jawline is tedious but doable since it was likely injected intraorally along the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

What Male Body Contouring Procedures Do I Need After My Weight Loss?

Q: Dr. Eppley, I am interested in having an abdominoplasty performed. But a a little history…I was overweight my entire childhood, finally reaching 320 lbs by late 2011. I made some big changes and lost most of the weight very quickly, about 90 pounds in the first year. I have been hovering around 190 lbs for over a year now and am generally happy with my weight. I have completely changed my diet and know I will never go back to my old ways. The only evidence of my former self resides in my chest, stomach, and inner thighs. There is some loose skin on my upper arms as well, but I’m not too concerned with that. I’ve attached some pictures to get your opinion. What kind of procedure do you think would be best for me?

A: From an abdominal standpoint, the roll of excess skin goes all around the waistline so a tummy tuck must be a near circumferential technique to really get all the excess skin out. Male tummy tucks are unique because they never require muscle tightening since there is no rectus diastasis from prior pregnancies. So it is essentially getting out all the loose skin and that probably encompasses at least a ‘300 degree’ excision length. The chest is always the most challenging in any male weight loss patient due to the skin and nipple sag and the inability to tolerate the scar locations from traditional breast lifting procedures that women undergo. (since they are being left with a breast mound while men want the chest flat) In my experience, all such chest reshaping procedures in many male weight loss patients leave me wanting for better results than they often produce, but the key is to not have any procedure that leaves with the trade-off of unsightly scars. In your case, I would recommend a periareolar reduction technique with liposuction. Whether any more than that would be indicated would require a true frontal picture so I can better assess what degree of chest sagging you have. (your current chest picture is taken from below and that may make it look less saggy that it really is)

Dr. Barry Eppley

Indianapolis, Indiana

What Type Of Nasal Implant Also Augments The Glabella?

Q: Dr. Eppley,I  am a young African American woman. I have a larger forehead which I can live with. The problem I have is that since my forehead is wide and protrudes and my nose is stubby, it makes my glabella look flat and too wide. I would like a glabella that makes my face look more define. What do you suggest? Thank you.

A: Thank you for your inquiry and sending your pictures. What you really have is a combined glabellar (forehead) and nasal bridge ‘defect’ or recessed area. This glabellar-nasal area lacks the protrusion and dimensions that the rest of your face has so it is disproportionate.  (or as you have accurately stated…too flat) Building up this area could be done in multiple ways. The simplest would be fat injections but that carries with it the unpredictability of how well the fat would survive. The best approach is to really have a custom glabellar-nasal bridge implant made as a single piece. A standard preformed nasal implant will not augment the globular region of the forehead. Such a custom nasal implant would be placed through an open rhinoplasty approach (low) with an endoscopic technique from above. Other strategies include a preformed nasal bridge implant combined with bone cement augmentation of the glabella. As you can see there are various augmentative strategies using different materials.

Dr. Barry Eppley

Indianapolis, Indiana

What Type of Facial Asymmetry Surgery Do I Need As A Result Of Untreated Occipital Plagiocephaly?

Q: Dr. Eppley,  I would like to know what can and cannot be done about untreated plagiocephaly in terms of facial asymmetry surgery procedures. I am still young (19), which is why I want to explore my options now so I can put this ongoing struggle in the past. I have very noticeable facial assymetry, particularly evident in my cheeks and jaw angle. I also have some forehead assymetry as well due to the soft spot on the left back side if my head. Regardless of this, the area of immediate concern is my cheeks and jaw. The left side of my face is much more prominent and “fuller” due to the Plagiocephaly. My eyes are also assymetrical because of the different orbital positions making it seem as if I have a lazy eye when looking in certain directions. Another area of concern for me is my flat midface; it seems as if I need at method to someho w “pull out my face.” My face needs to gain a more 3D look so my eyes don’t seem deeper than they actually are. Also, as you can tell from the pictures, not only do both halves of my face look drastically different from the side, my head lacks length from the front of my head to the back, as well. I would like to gain your input on what would be the most effective methods to improve my facial features.

A: What you are describing are very typical facial findings from congenital occipital plagiocephaly. While there is a long list of facial and skull changes that can be done for our facial asymmetry surgery, the question is which ones have the greatest value and are the most economically efficient. You have pointed out the most important to you currently and that is the flatter and more deficient cheek and jaw angle on the affected side. A cheek and jaw angle implant will help in that regard. But it is important to point out that the eye on the same side is also a major focal point and addressing it with orbital floor augmentation and a corner of the eye adjustment would also be important. ideally the best way to treat all three facial skeletal issues would be a 3D CT scan to make the implants match the facial structures on the opposite side the best.

Dr. Barry Eppley

Indianapolis, Indiana

Can Jaw Angle Reduction Be Done To Look Natural?

Q: Dr. Eppley, I am a woman with square jaw who just wants to have her angles rounded off, nothing extreme…so far, the people I’ve seen who have had jaw angle reduction/resection were left with no angles at all and I found it unnatural and unattractive. I saw a professor who talked to me about bone decortication, removing a little bit the angles without touching the bone or touching the muscle and that it can be done under local anesthesia with little risks and would give a natural result. But he said that asymmetries are common with that type of method. Is that all correct?

A: Jaw angle reduction/recontouring can be done by two basic methods, bicortical (amputation) or monocortical. (decortication) While the historic and still most commonly used technique is bicortical removal, you are correct in that such amount of bone removal can make the jaw angle ‘hollow’ and create a soft tissue sag or indentation over the jaw angles. For many patients, a monocortical approach may be better as it lessens jaw angle width but without losing jaw angle shape. The best candidates for this type of jaw angle reduction surgery are those that have radiographic comfirmation of an angle flare that sticks out beyond the external oblique ridge of the mandibular ramus. This makes it technically possible to reduce the jaw angle flare with the instruments that are available to do it.

But no jaw angle recontouring method can really be effectively done under local anesthesia. (nor can I imagine who would want to) It is necessary to lift the masseter muscle off the bone to provide visualization for the bone reduction. Any method of jaw angle manipulation (augmentation or reduction) run the risk of asymmetry because they can not be seen as a ‘pair’ surgically and most people do not have perfect jaw angle symmetry beforehand.

Dr. Barry Eppley

Indianapolis, Indiana

Do Forehead Implants Affect Hair Growth?

Q: Dr. Eppley, I had a silicone forehead implant placed through a scalp incision after an injury which left an indented forehead. I still have a high hairline so I want to do hair grafts or transplant. My question is can they still put hair transplants over silicone implant or will the hair not stay and grow? The implant goes from my brow bone all the way to middle of scalp. 

A: The location of any skull implant, like a forehead implant, is way down at the bone level. This is numerous tissue layers away from where the hair follicles are located which are just under the skin. Thus any forehead or skull implant will not have any negative impact on hair transplants anymore than the overlying existing hair that is there now. You can freely have hair transplants done along the frontal hairline without fear that they will not take and subsequently grow. I have had numerous patients have this done, including women, with very successful hair transplant results.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Forehead Cyst Be Removed Endoscopically?

Q: Dr. Eppley, I am a 40 year old female in good health and I have a 7mm epidermoid cyst on my forehead, just above my right eyebrow. I had an ultrasound scan which shows that it is quite deep near the skull. The report states that it is a benign looking 7mm cyst which looks subgaleal and is located in the region of the right glabella. However it is having an effect on my self-esteem and I would like to know what options I have for removal and whether a direct excision would be the best and safest option or to if it is worth getting it removed by endoscopic surgery?

In particular I am worried about what the scar will be like if I get it removed directly since I am of Asian origin and am I am concerned about the scarring. I am exploring whether having it removed endoscopically would be worth-while given my concerns over scarring.

Because my cyst is located further down near the eyebrow would this be more of a risk and more difficult to remove by endoscopic surgery? By doing an endoscopic surgery would this cause an indent or depression where the cyst was removed?
Would the benefits outweigh the risks and would there be any risks of a depression at the location after the endoscopic removal?

I would be interested in hearing your views about this and whether this is an option worth exploring. I would greatly appreciate your feedback.

A: Dermoid cysts are exceedingly common around the eye area and are often located down at the bone level. In many cases, they will even leave a little depression in the bone. While an endoscopic approach would be preferable from a scar standpoint, the question is whether this approach can technically be done given how low it is on the forehead. I can not really comment on this technical aspect without seeing a picture of where it is on the glabella region. Most likely it can be removed endoscopically having done it this way myself numerous times.

Whether its removal will leave a depression can not be predicted. But given its relatively small size, I suspect it may not. But you can always hedge that bet by placing a small fat graft in its place at the same time.

Dr. Barry Eppley

Indianapolis, Indiana