Your Questions
Your Questions
Q: Hi Dr. Eppley, I am interested in nose and neck surgery. In the front view the tip of my nose is too fat. My nose profile shows that my bridge projects too much and the line from my top of forehead down through the bottom of my nose is too straight. I wish to have these things changed by a closed rhinoplasty. Also my neck and jowls is sagging and I would like liposuction to tighten them up, I am 49 years old. Additionly I don’t wear face makeup so I wish for no visible scars to show. Thank you for your time and I really enjoying reading all your info on the web and hoping you can improve my nose and neck. I have attached some pictures for you to review.
A: Thank you for sending your pictures. I have some computer imaging on them and those are attached. Here are my comments based on your stated desires and what is realistic.
Your rhinoplasty would be best done open. You have thick nasal bones and cartilages and to effect those changes you would get a better result through an open visual approach. (less chance of need for revision) You have thick nasal skin so there is no risk of having your nose ‘overdone’ or looking like it is too small or has an operated look. Thick nasal skin always make a rhinoplasty result less rather than more in appearance.
You have too much loose jowl and neck skin to just do liposuction alone. That will just make the skin look loose and have more sag. You need a tuck-up neck-jowl lift with liposuction to get the result that you are after. Again, the thickness of your skin and it looseness work against a fat removal only procedure. Your skin quality and amount in the jowl and neck area makes it necessary for a more aggressive approach to get a good result.
One additional thought is that of your chin. It is horizontally short and that works against you getting an improved jaw line and neck appearance. A chin augmentation would really complement the neck-jowl lift.
Dr. Barry Eppley
Indianapolis Indiana
Q: I had a breast reduction in October 2010, and I am thinking about getting pregnant again. I was a DDD before, and now am a B. Surgery went well, but if I gain roughly 20 lbs during pregnancy, how big do you think that the breasts will get? I had a free nipple graft, so no breast feeding. I just don’t want to go back to the “bigger” me. I love being smaller. Thanks so much!
A: The changes that will occur after pregancy from a breast reduction are fairly predictable for many patients. The breasts will, of course, enlarge during the course of your pregnancy. They will not likely become a DDD again but they will certainly get bigger than a B cup. After delivery, your breasts will almost certainly shrink back down. There are a few patients in which they do not shrink back down considerably but this is fairly rare. What will also happen in this shrinking process is that they may potentially end up even smaller than before, perhaps going all the way down to an A. This is known as breast involution (loss of breast tissue after pregnancy), and is common, but in the breast reduction patient may become more pronounced. I have seen more than one breast reduction patient who lost all of their remaining breast tissue after pregnancy and actually later went on to a have a breast augmentation to get back some breast volume and shape. What will actually happen to you, of course, can not be precisely predicted but I think the fear of ending up bigger again is unlikely.
Dr. Barry Eppley
Indianapolis Indiana
Q: I would like an opinion by a plastic surgeon. I would like to get rid of the hump on my nose and for it to be smaller and not so wide. My nose is especially wide underneath my eyes. I would like a chin implant to help with my side profile. These are the two procedures that I’m for sure ready to have done immediately. I eventually would like enhance the size of my lips. I had Juvaderm administered to my upper lip about two years ago and did not have good results. My primary focus right now is my nose and chin and would really like to see what I would generally look like after a Rhinoplasty with a chin implant. Thank you so much!
A: The combination of a rhinoplasty and chin augmentation is very common and highly successful. This is particularly true in one’s s profile view even though that is not how one usually sees themselves. (even though most of the world knows you more this way) In this what I call the ‘ying and the yang’ procedure, reducing prominent areas on the nose (hump reduction, shortening or de-lengthening the nose) and bringing a recessed chin forward can make for a significant change in one’s side view. And because two areas are being changed in different directions, it does not take large changes in either the nose or the chin to make a real visible difference. This can be demonstrated before surgery (and always should be) by computer imaging. Rhinoplasty and chin augmentation are two procedures that can be both easily and accurately demonstrated by computer imaging manipulation.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am in the beginning stages of considering the possibility of rhinoplasty procedure. A large nose runs in my family, but what I’m most unhappy with is that my nose is slightly crooked. I also wouldn’t mind some size adjustment, both length and width. I am truly unsure of what potential costs for something like this may be. I am 30, single and have limited income. Can you provide me with more information that may be helpful to me at this point in my process? I would certainly consider a consultation, and would be extremely interested in seeing photos of what you could do with me, if possible.
A: Rhinoplasty for the crooked nose is one of the more challenging nose operations. This is because a very crooked nose is the result of more than one part of the structural anatomy that accounts for why the nose is not straight. It usually involves a deviated septum, middle vault asymmetry and right down to a twisted tip. It is not usually possible to just fix a deviated septum and have the whole nose.then become straight. Crooked noses involve every cartilaginous element and often the bone as well. For these reasons, correction of a crooked nose involves a full septorhinoplasty.
While computer imaging can make a crooked nose perfectly straight, rhinoplasty surgery is not like Photoshop. It is best to think of a straighter but not perfect crooked nose result than to undergo surgery with the expectation that it will be perfectly straight. While that is the goal, there is a reason (bent and deformed cartilages) that the nose was crooked to start with. And cartilage does have memory so some relapse or recoil may occur even out to 6 months after surgery.
Dr. Barry Eppley
Indianapolis Indiana
Q: I’m a little self-concious about my lower face. I am now 48 years old and feel lilke the sides of my jaw are lacking. When I was a teenager, I had orthodontics which included removal of four permanent teeth to make room for other teeth. This moved by front teeth and my back teeth forward to close the space. Now that I’m older, I’ve come to believe that I have a shallow jaw because of this earlier orthodontic treatment. I would like some jaw angles as I think my jawline is too steep. From my chin, my jawline just goes straight back and up towards my ears without any definition to the back part of my jawline.
A: For what it is worth, your prior orthodontic treatment (which was and still is standard in many patients) is not the source of a steep jawline. A steep jawline is when the angulation from the jaw angle down along the inferior border of the mandible to the chin is greater than 15 to 20 degrees, often approximating 35 to 40 degrees. As long as the teeth satisfactorily come together, this is an aesthetic issue that is the result of high or underdeveloped jaw angles.
Jaw angle implants can make a big difference in the aesthetics of the jaw angle and jawline. but it has to be the right type of jaw angle implant. It needs to be the type that will lower the jaw angle and not just simply make it wider. In general, jaw angle implants can lower the prominence of the jaw angle by 1 to 2cms with standard off-the-shelf implants.
Dr. Barry Eppley
Indianapolis Indiana
Q: Is there no way to bringing out the midface with dermal fillers? Are the results not so good as with implants? What is the material of which midface implants are made of? What the advantages and disadvantages of injectable fillers vs implants for midface deficiencies?
A: For midfacial deficiency, albeit of the cheeks, maxilla, or paranasal region, synthetic implants are the preferred treatment. They are far superior to injectable fillers in both results and cost effectiveness. Injectable fillers are intended to treat small soft tissue deficiencies of the facial skin such as wrinkles or folds. They were never intended to be used for more significant bone-based facial deficiencies but rather to be placed into or just under the skin. The sheer cost of placing large volumes of injectable fillers down at the bone level would quickly equal or come close to the cost of implant surgery. When you factor in that they are all temporary, the value proposition of injectable treatments for facial skeletal deficiencies becomes quite poor.
Most facial implants, including those of the midface region, are primarily composed of solid silicone. Silicone is one of the most biocompatible of all implant materials and also offers the largest array of facial implant designs. All midfacial implants are introduced and placed through incisions inside the mouth so there is no external scarring with their use.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, it was so interesting reading your thoughts on cheekbone reduction surgery after a facial injury. I have some questions about almost the same problem. My right cheekbone is bigger than the left one and it is growing bigger. When I look at two year old photos you can see a big difference. I was in a car accident about 15 years ago and hit the right side of face on the dashboard of the car. Is it possible to have some sort of surgery?
A: While cheek bone injuries are common from many types of trauma, they are largely that of fractures and displacement. Secondary reconstruction is often needed to bring out a cheek bone that is too flat or has inadequate projection. The reverse problem, overgrowth or too much projection of a cheek bone is very rare. The presumed cause is that a hematoma has developed above or around the bone, stimulating some bone deposition or ‘growth’. Depending upon the dimension of the cheek bone overgrowth, surgery can be done to reduce. Shaving of the cheekbone is always possible but is not usually my preferred technique unless the overgrowth area can be precisely identified. It is far more common to do a cheek osteotomy and remove a vertical wedge of bone to allow it to move inward. A very helpful diagnostic tool is a 3-D CT scan. This allows one to study the shape of the cheekbones on both sides and determine the exact location of what is making the bigger cheek bone look the way it does. This allows for a precise surgical procedure for bone reduction to be planned.
Dr. Barry Eppley
Indianapolis Indiana
Q: Dr. Eppley, I want to get your opinion. I want to get rid of some body fat. I am not obese but need some help getting rid of some fat areas. I really don’t want to get liposuction and am interested in trying the Zerona. What has been your experience with its use? Do you think it is worthwhile to do? Or should I just go ahead and get liposuction?
A: As you have read about it and probably seen it in magazines or on TV, Zerona is a non-surgical device for circumferential fat reduction most commonly used for the waist, hips, and thighs. (although it can be used anywhere) It works by emitting a low-level laser energy that targets fat cells through a photochemical process. This causes the fat cells to temporarily open up and release fat which is then safely removed and broken down without side effects or downtime.
Its manufacturer has done a considerable amount of marketing largely based on his clinical study that was used to get FDA approval. In this study, they showed an average inch loss reduction of 3.65 inches across patient’s waist, hips, and thighs in as little as two weeks.
While this sounds great, I decided in my Indianapolis plastic surgery practice to do my own study. We studied our first 10 patients who underwent a full series of Zerona body slimming treatments. Our results were an average circumferential measurement reduction of over 6 inches. On a patient satisfaction scale, seven (70%) were extremely satisfied and saw significant improvement, two (20%) were satisfied as they saw improvement but had hoped for more, and one (10%) saw little change or improvement and was not satisfied.
Our first Indianapolis results were better than expected. When it comes to the measurements, know how they are derived. When you have an average of 6 inches lost, this does not mean it comes from the waistline or from one single body area measurement. Rather it is the collective number of inches lost from a combined number of cirumcumferential measurements including the waist, hips and thighs.
Should you get Zerona treatments? It is reasonable to do of you understand that Zerona is not magic nor is it equivalent to liposuction surgery. And it may not work well for everyone. But most patients do end up see some visible body changes and were happy that they had the treatments. Because I want to have happy and satisfied patients, and do not want to see patients waste money if avoidable, we credit much of what patients pay for Zerona towards the cost of liposuction surgery should they decide to go that route after a Zerona treatment program.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I am considering liposuction of my stomach. I am not fat but just want to thin it out further than I can do on my own. What is the best liposuction method to avoid any uneven or irregular areas on my stomach area afterwards. Since I am thinner to begin with I think it is more likely on someone like me. Would Smartlipo be best?
A: While highly effective at removing abdominal fat, irregularities after abdominal liposuction are not rare. Since the outer contour of an abdominal liposuction result is a direct reflection of the evenness of fat removal underneath the skin, it is important to have as even removal of fat as possible. While many new technologies have emerged for performing liposuction, they have not necessarily resulted in a lower incidence of contour problems. This is because the technique for performing liposuction is more important than the device.
No matter what liposuction method is used, the tracks or tunnels that are made under the skin by different types of cannulas in the fat layer is ultimately important for the final contour. This has lead to the use of smaller cannulas for fat removal and this has definitely decreased irregularity problems. But small cannula size alone is not enough to guarantee no contour irregularities…and it is probably not the most important.
Superceding cannula size is the precision of the underlying tunnels that are made. This is the in and out pattern of the liposuction cannula that most people associate with the procedure. While this movement may look random, it is not. Rather it should be a deliberate and evenly distributed method of cross-tunneling.
Cross-tunneling, when possible, during liposuction is still one of the most important concepts in liposuction to avoid abdominal irregularities. By cutting tunnels in the fat from multiple directions in any given area, fat is removed in a more even fashion. This is especially important in the abdomen where the cross-tunneling method can be most effectively used.
In short, the operator and not the device is the most important consideration when performing liposuction and avoiding postoperative irregularities.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I have consulted Dr. Eppley before about jaw implants and noticed in a recent article that he is using Kryptonite Bone Cement that is injectable. Could this be used to augment the jaw or cheeks and chin instead of having a full blown surgery? Just curious if it can’t because if it can be used in skull recontouring the use for facial recontouring seems like a logical extension of its use. After all, bone is bone and why would it not adhere to the jaw/cheeks/chin as well?
A: Currently, the use of Kryptonite Bone Cement as an injectable method is for skull recontouring only. While in theory it could be used for facial augmentation (cheek and chin implants) as well, there are two major problems with this application. First, the material must be injected and then shaped by external molding. Making a flat shape on a skull by using external digital molding can easily be done, trying to make a more complex shape like a cheek or a chin is another material.Whatever shape you get after four minutes after injection is what it will permanently be. To adhere to bone the periosteum must first be raised just like an implant. Injecting onto the bone does not make go under the periosteum alone. If he material does not completely go under the persiosteum and adhere to the bone, it will rock and be mobile. Secondly, the cost of Kryptionite is 10 to 20X what a facial implant will cost. For the skull, all competitive materials cost thousands of dollars in material cost as well. For the face, however, facial implants are far less expensive and have established shapes that work. It simply is not cost effective for the patient to use Kryptonite for facial bone augmentation, even if it worked just as well.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr. Eppley I am a 25 year old male who has been through several extensive surgeries due to craniosynostosis as a child. The last reconstruction surgery done was when I was 18. Unfortunately my Dr. wasn’t as concerned with the cosmetic outcome as I was. I feel that my head is to narrow both from ear to ear and back to the forehead. Additionally my forehead has irregularities and is not proportional. I feel that I need to widen my entire skull, giving it more girth. Augmenting the back of my skull, as well as the sides, starting in my temple regions, then along the front of the forehead so that my eyebrow line is defined rather than flat.
Also during surgery they left me with a 1.5″ wide scar from ear to ear. Towards the top of my head it actually creates a deep groove. Last but not least, I feel that my hairline is extremely close to my eyebrow line, and my left temple area of hair grows too far in towards the middle of my forehead. What would need to be done to improve all my skull imperfections and correct the proportions of it? Is there a way to make my scar smaller or vanish possibly by cutting along onside and folding my scalp over it? Finally, can I bring back my hairline and fix the side area as well? Since these are all things cause by a brith defect/disease what if any could possibly be covered under insurance?
A: Based on your concerns and objectives, I think it is possible to provide improvement for some but not all of them. Nor could whatever can be maximally done occur all in one surgery. Adding material to your skull (cranioplasty) is often best done for the forehead and front of the skull which is the most aesthetically visible. This should be your primary focus. While material can be added to the back of your skull, you can do not both front and back at the same time. Your coronal scalp scar may be able to be reduced depending upon how tight your scalp tissues are. It can certainly be narrowed, it is just a question of how much. Your concept of de-epithelization of the scar and advancing the other portions of the scalp over it for closure is the correct approach. Changing the position of your frontal and temporal hairlines, however, is not realistic as there is no procedure to really make that happen other than how the hairline may change slightly with the scalp scar excision and closure may cause.
Whether insurance will cover such a procedure must be determined by a process known as pre-determination.
Indianapolis Indiana
Q: Hi Dr. Eppley I just had a combined breast lift with implants less than three days ago. I have several concerns at this point and want your opinion. My left breast seems to currently have a different shape than my right (more fullness to the top and more stiff on the top). I don’t know if it’s usual for them to have different shapes at the beginning of recovery if they were different sizes to begin with (my right was bigger than my left before surgery).
A: It is very common with any type of cosmetic breast surgery at this early postoperative period (48 hours) to have breasts that have some differences. This is a function of many factors including peak swelling that occurs 48 to 72 hours after surgery, the fact that no two breasts swell the same afterwards even if they had the identical operation, the fact that they are heavily taped which distorts them, and your pre-existing asymmetry (which will be improved but not cured).
For all of these reasons, I would not even try to look at them and come away with any assessment. It simply is way too early and substantial changes will take place over the next 4 to 6 weeks in both breasts as swelling subsides and the breast implants and tissues settles.The time to get more critical is 6 to 8 weeks after surgery but certainly not now.
In the end, I believe there will be some mild asymmetry in shape and the nipple position as this always occurs after major breast recontouring. (combined breast augmentation and breast lifts) But there is no way to get idea about that at this point. I know it is hard but my best advice is to stop looking at them for now.
Dr. Barry Eppley
Indianapolis Indiana
It has been over a decade since a landmark study was published on identical twins and how their appearance changed as they aged. It showed how you live your life impacts how fast you age, and how old you look, more than the genes that are flowing through your bloodstream or camped out in your skin.
In this plastic surgery research that studied twins, it was observed that often one twin would look considerably older then the other. Since their gene make-up was obviously identical, how does one account for these differences? After studying hundreds of adult identical twins, the researchers discovered that how we nurture our skin has a huge influence on how well or poorly our skin ages. Three lifestyle factors came up consistently as accelerants of wrinkles and droopy skin; sun, smoking and stress.
So for this New Year if you want to slow down the clock on how you look as you age, here is another set of resolutions to consider. Limit the number of S’s in your lifestyle, adopt an S-free lifestyle as possible. Limit sun exposure, quit smoking and reduce the stress in your life as much as possible.
Everyone knows of the damaging effects caused by too much sun exposure on your skin. There are great examples that are not more than a person or two away most of the time. But not getting as burnt as toast at the beach is not what ages most people, it is the daily innocuous exposure that we don’t even feel. Lack of adequate daily UV protection in your moisturizer will add a few years and wrinkles than might otherwise have occurred.
The horrific effect of smoking on our heart and lungs is well chronicled since C Everett Koop was our Surgeon General. And most people recognize that it is not good for the skin either. Its impact is more than just those pesky lip lines from embracing that cylinder (and we have yet in plastic surgery come up with a good way to get rid of them), but it causes more and deeper wrinkles to occur, thins the skin, and creates a lot of dark spots and pigmentation irregularities. By reducing the blood supply to the skin, proper nutrients can not be delivered creating a state of skin malnutrition. A significant smoking habit can easily make a person look five to ten years older.
Stress is the wild card. It is bad for your skin and definitely causes more wrinkles. But treating stress is not as easy as applying a topical cream or not flicking a match or lighter. Maybe don’t sweat the small stuff (and it is all small stuff) approach is one antidote to adopt.
So if you’ve got wrinkled skin, age spots or a turkey neck, don’t blame your family tree. Blame those Ss in your life and make this the year you resolve to reduce them.
Dr. Barry Eppley
Indianapolis, Indiana
It has been over a decade since a landmark study was published on identical twins and how their appearance changed as they aged. It showed how you live your life impacts how fast you age, and how old you look, more than the genes that are flowing through your bloodstream or camped out in your skin.
In this plastic surgery research that studied twins, it was observed that often one twin would look considerably older then the other. Since their gene make-up was obviously identical, how does one account for these differences? After studying hundreds of adult identical twins, the researchers discovered that how we nurture our skin has a huge influence on how well or poorly our skin ages. Three lifestyle factors came up consistently as accelerants of wrinkles and droopy skin; sun, smoking and stress.
So for this New Year if you want to slow down the clock on how you look as you age, here is another set of resolutions to consider. Limit the number of S’s in your lifestyle, adopt an S-free lifestyle as possible. Limit sun exposure, quit smoking and reduce the stress in your life as much as possible.
Everyone knows of the damaging effects caused by too much sun exposure on your skin. There are great examples that are not more than a person or two away most of the time. But not getting as burnt as toast at the beach is not what ages most people, it is the daily innocuous exposure that we don’t even feel. Lack of adequate daily UV protection in your moisturizer will add a few years and wrinkles than might otherwise have occurred.
The horrific effect of smoking on our heart and lungs is well chronicled since C Everett Koop was our Surgeon General. And most people recognize that it is not good for the skin either. Its impact is more than just those pesky lip lines from embracing that cylinder (and we have yet in plastic surgery come up with a good way to get rid of them), but it causes more and deeper wrinkles to occur, thins the skin, and creates a lot of dark spots and pigmentation irregularities. By reducing the blood supply to the skin, proper nutrients can not be delivered creating a state of skin malnutrition. A significant smoking habit can easily make a person look five to ten years older.
Stress is the wild card. It is bad for your skin and definitely causes more wrinkles. But treating stress is not as easy as applying a topical cream or not flicking a match or lighter. Maybe don’t sweat the small stuff (and it is all small stuff) approach is one antidote to adopt.
So if you’ve got wrinkled skin, age spots or a turkey neck, don’t blame your family tree. Blame those Ss in your life and make this the year you resolve to reduce them.
Dr. Barry Eppley
Indianapolis, Indiana
Q: I’m writing to you from after reading your article on temporal hollowing. I’ve been trying to find a recommendation on how to treat the temporal hollowing on the left side of my face that developed several years ago. I have yet to be satisfied that any surgeon I have seen truly understands the problem and how to treat it. Those that have seen it recommended some form of fat injection to mask it. Most of the surgeons wouldn’t speculate what might have happened that caused the hollowing, but I recently found out what it was. One surgeon asked for a CT scan and it was quite obvious that the temporalis muscle and the fat pad behind it was sitting around 1 inch lower, at the temple, on the left side than the right. In addition, the collapsed fat was bunching up behind the zygomatic arch causing the soft tissue to bulge above the zygomatic arch.
Several years ago, I was involved in a cycling accident that left me with facial fractures on the left. One bicoronal scalp incision and multple plates and screws later I was quite well put back together. Within a year though, I had developed a droop in my brow, one of the plates was loose along my left orbit and I had developed a minor protrusion on the zygomatic arch. The surgeon I saw opened the bicoronal scar up, lifted the brow a bit, remove the loose plate and burred the left zygomatic arch a bit. When I saw him a month later with hollowing in the temporal fascia, he had no idea what might have caused it.
You’re the first surgeon anywhere in the world that I’ve found who has experience in treating this problem. As you’ve mentioned that different filler materials may be used depending on the case, I’d be really interested from hearing from you about what you believe to be the best treatment in my case. Also I am interested in reducing the bulge over the zygomatic arch. To date, only the surgeon has made any recommendation in that regard. He suggested that a small amount of Lipodissolve might be used along the top of the arch in order to reduce the fat along it prior to applying the filler treatment. The same doctor suggested Aquamid as the filler, but after researching this, I have decided against it as there are a large number of reports on the Internet referring to negative side effects.
A: Thank you for sending me your photos and providing your history. I think it is quite clear as to what the origin of the temporal hollowing is. In your first bicoronal craniofacial fracture repair, little or no temporalis muscle was lifted up to do the primary fracture fixation. But in the second procedure, the zygomatic arch was burred down. The only way to safely approach the zygomatic arch to do any burring, without risking injury to the frontal branch of the facial nerve, would be to do some elevation of the temporalis fascia near the zygomatic arch and come at it from underneath the fascia. With this approach, some temporalis atrophy (aka temporal hollowing) can be one of the side effects to doing so. Your temporal hollowing is not major compared to many other patients, but it is noticeable.
The correction of your temporal hollowing could be done by subfascial implant placement. While there are a variety of materials to use, I would place a allogeneic dermal graft if it was an isolated procedure. However, that approach MAY change if you are trying to get the arch prominence reduced. I do not think (until proven otherwise) that the prominent area over the zygomatic arch is fat. More likely, it is bowing of the zygomatic arch bone. Fat does not cause that bulge unless the zygomatic arch is no longer present. If it is indeed the arch, burring will not work for it. The bone is too thin. A more effective approach would be to osteotomize the arch’s front and posterior attachments and let the entire arch complex settle in a bit. This is a modification of a technique that I use for cheekbone reduction.
The combination of temporal augmentation and arch reduction should get you close to your intended aesthetic temporal/cheek goals.
Dr. Barry Eppley
Indianapolis Indiana
Q: Please help me out. I’m so tired of being called Mrs Leno and hiding my lower face. I have been married for 6 years to a great man but to this day I cover my face when sleeping so he can’t see me and hide my face when we are in a car or at home. I can’t take this anymore. I just want to feel beautiful for once. Can my big chin be made smaller and more proportionate to the rest of my face? I have attached some photos for you to see my chin concerns.
A: Thank you for sending your photos. I can quite clearly see your concerns. You do indeed have a very large lower jaw which is most manifest in the strong chin protrusion. In studying your photos, I think the best method of chin reduction would be an intraoral vertical reduction osteotomy. That would give the greatest amount of vertical reduction and some horizontal reduction as well. There is always some concern about what will happen to the ‘extra’ skin under the chin area when the bone is reduced by this approach. Which is why I would think about doing a simultaneous submentoplasty (skin removal and tightening of the skin) at the same time. Normally this would not be necessary but your very large chin area poses an uncommon problem even in those who seek chin reduction.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi Dr. I have a large adam’s apple that I want reduced…I am not a transgender, just a regular guy who doesn’t want a big adams apple sticking out, I get tired of people mentioning it too. I was wondering what the approximate cost would be for this procedure! Thanks!
A: A prominent adam’s apple, medically known as a thyroid cartilage or voice box, causes a protrusion in the very visible central part of one’s neck. its size and shape can be very effectively changed through a procedure known as a reduction thyrochondroplasty or adam’s apple reduction. Using a small (one inch) incision overlying the thyroid prominence, the u-shaped protruberance can be shaved down. There is a limit as to how far it can be reduced because of the vocal cords that lie on the inside of the voice box. Most patients will not get a completely flat side neck profile but it is safe to say it can usually be reduced 50% to 75% in profile which is a significant difference.
Contrary to popular opinion, the majority of people whom I have performed this procedure on in my Indianapolis plastic surgery practice are not transgender patients. Most are men who just want their neck bulge reduced. At one time the transgender patient may have made up the bulk of whom was requesting this procedure but not of recent times. More men are becoming increasingly sensitive to a large thyroid cartilage and want it reduced for cosmetic neck contouring purposes.
The typical overall cost estimate, all fees included, is in the range of $5,000 to $ 5,500. It is a one hour procedure that can be done under Iv sedation or general anesthesia.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have been thinking about getting a rhinoplasty. I have never had any nose surgery before. I am filipino and my nose is short and too small for my face. What I would like to achieve is the following in my rhinoplasty; augment the dorsum, lengthen the columella, improve tip projection and definition, alar base reduction and show less nostril. I would like costal cartilage rhinoplasty, definitely no silicone or GoreTex implant for dorsum augmentation. Been thinking of rhinoplasty for a long time. I have attached some pictures for your review and imaging.
A: Thank you for sending the picture and your detailed analysis and goals. Given your smaller and short nose, you are absolutely correct in determining that only a rib graft rhinoplasty could achieve your goals. What you need is a combined dorso-columellar augmentation or the geometry of a L-strut configuration. Only a rib graft or a synthetic implant can possibly achieve that degree of augmentation. You have stated you want to avoid an implant and I assume you feel so because of their potential long-term problems, even though they are the ‘easiest’ to do. A rib graft would provide the best long-term graft retention without problems even though it has the short-term ‘problem’ of a donor site and resultant scar. I have attached some predictive imaging for your review. Please note that the increased columellar show in the side vie does not appear as it is not present at all in the original photo. (you can’t morph what is not there!)
Dr. Barry Eppley
Indianapolis Indiana
Q: I am looking to get my nose fixed after it has been traumatized in the past. I believe the problem is what is called the tip of the right-dorsal horn has separated or fractured from the left cartilage. In doing so, it is no longer held to symmetry as it extends away from the cartilage it separated from. Because of this it has created an appearance of a hook on the right side of my nose as well as a bumpy tip. I noticed that by pushing the cartilage in toward the fracture point the hook is no longer significant and the tip looks less bumpy. This is what my nose use to look like before the separation of the right cartilage from the left side. Is it possible to have a closed procedure where you stitch the right tip back to its natural foundation with the left tip. I am hoping to remedy this permanently with a less invasive procedure; hopefully removing the hook and smoothing out the tip of my nose. Thank you very much for your help.
A: Thank you for sending the pictures and clarifying exactly where the problem is. The problem is in the tip of the nose which is created by the union of two pieces of cartilage. It is a difference in the shape of the two domes or lower alar cartilages. They are separated and apparently the right dome or alar cartilage has been displaced to the right. You were correct in assuming that it can be fixed by a simple closed rhinoplasty using suture techniques. That is a relatively simple fix that is as close as it gets to minimally invasive for the nose.
Dr. Barry Eppley
Indianapolis Indiana
Q: My main questions are in regards to the permanent lip options available to me. I could send you my picture so you can get a better idea. I have tried a few injectables and am not really happy with results in terms of size and longevity. I understand there are also options for implants vs. v-y surgery. (most permanent?) What are the complications, risks and costs of these options. Also, do you use Alloderm or Gortex implants, or is it based on cases by case basis. What is the longevity of Allodem?
A: I choose which permanent lip enhancement option on a case to case basis. That could include lip advancement,lip lift, v-y advancement or Advanta lip implants. There are different reasons for using any of these based on the existing size and shape of one’s lip. Pictures would be of great help in determining what may be best for you. Alloderm has not proven to be a permanent lip implant material so it is no longer used.
If you have not had good success with injectable fillers, then the concept of putting in any permanent material will likewise be unsuccessful. Your lips are not big enough or have the right shape to merely be ‘inflated’. This would indicate that you need more vermilion exposure through some form of excisional procedure such as a lip advancement or possibly a tissue shifting approach with an internal V-Y advancement.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a 33 year old adult who was born with a cleft lip and palate. I have had two rhinoplasties since the original surgeries I had as an infant. One nose surgery was at the age of 14 and the other one was at the age of 23. My nose is still not straight at all. I know that I do not normal tissue and the cartilage is very stubborn, but I want to know if there is any hope for a more symmetrical nose.
A: One of the most difficult of all rhinoplasties in which to get a good result is that of the cleft nose. As you have pointed out, the tissues on the side of the cleft (if it is unilateral) are not normal. This means that the lower alar cartilages are deficient and there is scar from the lip repair into the base of the nose as well as the scar tissue that you would have from your prior two rhinoplasties. But the most limiting factor, above all of that, is the skin at the tip of the nose and around the nostril. It is not only thicker than normal but it is both deficient and scarred. This is particularly true inside the nostril and in the soft triangle area near the tip. Having done many hundreds of cleft rhinoplasties, I find this issue to be the really problematic one that limits how good a cleft rhinoplasty result can be. To answer your question specifically, please send me some photos of your nose and I can provide a good answer if any further efforts at rhinoplasty are worth it.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hello Dr Eppley, I’m just writing to thank you for the great information you have posted on vertical chin reduction. I’ve always had a long chin and had liposuction on my neck 3 years ago. Afterwards it made my chin longer. I don’t know if it just looks that way or something was done to actually make my chin longer if that makes sense. In any event I’m too afraid to do anything about it, but thank you so very much for providing the great information on your site.
A: The neck liposuction did its job by making the neck less full and improving the neck-chin (cervicomental) angle. But having a long chin to start with by your admission, the improved neck shape has unmasked the chin area and made it look longer. That is actually an optical illusion. But an illusion that aesthetically does not work in your favor. When considering neck changes, it is always important to not overlook the chin area as the two work together to contribute significantly to one’s facial profile. Doing computer imaging would have revealed what neck liposuction alone would look like. It likely would have shown that vertical chin reduction was just as important to an improved facial profile as was the neck fat removal.
Dr. Barry Eppley
Indianapolis Indiana
Q: All my life I have had depressions under my eyes. It’s a hereditary thing as I have no cheekbones at all. It makes me extremely self-conscious. Although I don’t need glasses, I wear them all the time to hide this problem. I have been thinking about getting cheek implants. Do you think that will help me? I have seen some cheek implant results and they look really fake to me. How do you avoid cheek implants from looking unnatural and even making my eyes look too sunken in?
A: There is no doubt that well-defined cheekbones are an important facial component of what can make a man or a women good looking. Cheekbones help define the face by highlighting the eyes, adding balance to the other facial prominences and contributing to a look of youth and vitality.
Cheek implants can really help those whose midface is deficient. But cheek implants come in different styles and sizes. There is more to cheek implants than just choosing a size. The cheekbone is a curved structure that has dimensions of a frontal, central, posterior and inferior considerations. Different styles of cheek implants highlight these areas differently. Patients have different types of cheekbone deficiencies and that is the reason so many cheek implant styles exist. In addition, how the implant is placed along the bone and what size is chosen will influence how it will look after surgery.
Probably the biggest consideration in avoiding an unnatural cheek implant result is to not use too big of an implant. The cheek area is very aesthetically sensitive and trying to make too big of a change or use the implant to lift sagging cheek tissues can quickly make for a peculiar looking result. There are some good celebrity illustrations of this exact problem.
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi. I’m a male 34 years of age and am interested in getting liposuction done. I’m not obese, but am seriously overweight. I am around 250lbs at 6′ tall. I’m wanting to have a procedure done to have about 50 to 60 lbs removed. I’m not a professional, so I don’t even know if that’s possible. Looking forward to hearing back from you.
A: Liposuction is not a weight loss method but a body contouring procedure. While most patients do lose weight after liposuction, it is not in the order of magnitude to which you refer. For a man your size, abdominal and flank liposuction (the typical areas for male liposuction) will probably result in 10 to maybe 15 lbs of weight loss. This weight loss usually takes about 3 to 4 weeks to fully see once all the retained fluids from surgery are eliminated. Once can continue the weight loss further through their own efforts if they desire. While a weight loss of 50lbs may ultimately be achieveable, lipouction in this outome will have been the ‘kick start’ to the process. Much of the achieved weight loss will have been not from the actual procedure but from the efforts to protect and harvest the best results from their surgical investment afterwards.
In short, perceiving liposuction as a weight loss method is ill-conceived. It is better thought of as part of an overall body transformation program. Where in this process liposuction should be done requires a thoughtful discussion with a plastic surgeon.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am a male to female transsexual and need some facial changes as part of the process. My chin is too male looking with a prominent chin cleft and it is very wide. It is too wide and prominent for my face which i am trying to make more feminine and slender. I need my chin cleft removed and the width of the chin corrected by burring it down from inside the mouth.
A: In trying to achieve a more feminine looking chin, your aesthetic goals are correct but the method to get there is not the best way. Simple intraoral burring of the chin can only make a minimal narrowing effect and, if done aggressively, will like result in soft tissue sagging problems. The best approach to really narrow and taper the bony chin is through the use of an osteotomy. By doing a horizontal chin osteotomy, the downfractured segmented can be split in the middle and a center segment of chin bone removed. It can then be put back together with the entire chin significantly narrowed and with a much better tapered look to it. The chin soft tissues can then be better suspended with no risk of soft tissue sag (witch’s chin deformity) afterwards. This will also provide a better means of muscle tightening and soft tissue fill of the chin cleft to create a better chin cleft soft tissue reduction. While this sounds complicated, it is just a simple variation of the traditional chin osteotomy technique. (genioplasty without the side)
Dr. Barry Eppley
Indianapolis Indiana
Q: Hi, I have a son that is 3 and a half years old. He has plagiocephaly, the back right side of his head is flatter than the left. From a birds eye view his head appears somewhat crooked. I have read about injectable Kryptonite and was wondering if my son would be a candidate for this. At what age would he be able to have this procedure? Thank you so much for your time!
A: Thank you for your inquiry. The use of an injectable cranioplasty technique using Kryptonite Bone Cement for improving the skull contours in children and adults with plagiocephaly is new and the first cases of it are just beginning to be done. It is a very simple procedure that, just like an open cranioplasty, adds material on top of the deficient skull bone to build it out. Its advantage is not only its simplicity but that it avoids a long scalp scar and a more extensive operation. The age at which it can be done is really determined like any cosmetic procedure, when the patient (pr parent) feels that it is warranted and the effort is worth it. It really could be done any age as long as the child is healthy and the parents feels the problem is significant enough that it would be in the child’s long-term interest. Given its simplicity, there really is no significant recovery afterwards. The material within a day becomes just as hard as the surrounding skull bone and can not be displaced or deformed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I want to augment my nose from the top down to the tip of my nose. I am of Asian decent. But my question is using cartilage, how can my nose be reshaped?? Since cartilage is kind of like meat can it have a form like silicone implant ? Also I heard that cartilage can shrink or warp?? THEN WHAT HAPPENS TO MY NOSE ???
A: What you are interested is a very common treatment for the Asian type nose, that of dorsal augmentation rhinoplasty. This can be done as either dorsal (alone the bridge) augmentation only or as dorso-columellar (done the bridge and then a 90 degree turn at the tip and then down underneath the columella which is the strip of skin between the nostrils) augmentation. By far, the most common method for this type of nasal augmentation is with the use of preformed silicone implants.
But the procedure can also be done using your own cartilage. This obviously requires a cartilage graft harvest, almost always from the rib. Because of the donor scar and the temporary after surgery discomfort, most patients choose an implant. (even though from a long-term standpoint your own rib cartilage is better) Your concepts about cartilage shape and how it feels, however, is not accurate. It is not like meat but more like the consistency of a carrot stick. (as a matter of fact one is trained on how to carve cartilage using a carrot stick!) The rib (carrot stick) can be carved and then placed into the nose just like an implant. One has to be careful in harvesting the graft so that as a straight a graft as possible is taken and it must also be carved straight so it does not look crooked in the nose after it is placed.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am very unhappy with the appearence of my jaw and cheek areas. I had ptosis surgery and forehead lift ten years ago. The eyelids are not symmetric but that’s not why I refer to you now. The profile of my face is very long and in my opinion the middle of the face is too far backwards. I’m interested in what you would propose to make my appearance more harmonic.
A: In reviewing your pictures, you do indeed have a longer vertical length to our face. This is magnified by the short or more posteriorly (backward) position of your chin point and your midface. The cheek and nasal base is very flat and your chin is significantly behind the upper lip, giving your face a more convex profile.
While you can not really shorten the vertical length of your face, you can change how it appears. By bringing forward the midface and chin through bony augmentation, you can achieve better facial balance which will make it appear ‘shorter’. This can be done with cheek and paranasal implants to the midface as well as chin augmentation through either an implant or an osteotomy. I would also recommend comsidering a rhinoplasty as well. Very frequently, long faces have an increased nasal length with a small dorsal hump. This long nose contributes to making the face look longer as well. A small change in the shape of the nose through rhinoplasty can also help change the visual effect to a shorter and more balanced face.
Dr. Barry Eppley
Indianapolis Indiana
Q: I have had a couple of surgeries on my shoulder to revise an old scar I have. However, I am not quite satisfied with the results. In retrospect, while I believe my surgeon did a decent job and intended well, he did make some crucial mistakes. I fully understand that each scar is different, but do believe that my expectations are all-in-all reasonable, that is why I am looking for the right expert to perform a last try to improve the scar in a way that is satisfactory to me. I have been impressed with the scar revision results you have posted and would like to know if it would be a start to send you some pictures of the scar, maybe follow up with a call if that makes sense. It is not a problem for me come over to the states for the surgery in case we come to a consensus. Thanks.
A: Scars on the shoulders are a particularly difficult problem. Between very thick skin and relatively constant motion, scars across the shoulders will often end up fairly wide and hypertrophic. This can occur even in well done scar revisions. I would be hesitant to state that your prior surgeon made ‘some crucial mistakes’ merely because the scar did not end up significantly improved. In considering any further efforts at shoulder scar revision, it would be extremely helpful to know what was done (surgically) to determine if a different surgical technique for scar revision can be used that might have a different outcome.
Dr. Barry Eppley
Indianapolis Indiana
Q: I am interested in brow bone reduction surgery, flattening my prominent brows. I’m bald and was wondering if the incisions could be done via eye bows as I have no hairline. I was wondering a little about pricing and if there are payment options. Are there any tricks to have your health insurance assist paying for the procedure? Thanks.
A: Unfortunately, you are not a candidate for brow bone reduction surgery. You can not use your eyebrows for the incisions as this would cause unacceptable scarring, particularly across the bridge of the nose. This would also cause permanent loss of feeling of your forehead up to your scalp. The operation requires an approach from the scalp which is not possible given your lack of hair. In addition, there are not tricks for getting insurance to cover an operation that has no medical basis or symptoms.
Indianapolis Indiana