Your Questions

Q: Dr. Eppley, I was wondering if metal wires was used to stabilize the bone after a cheekbone reduction, can this cause a systemic body rash or highly unlikely? If so, can the wires be removed? What are the risks? Thank you.

A: Wires used in facial skeletal bone fixation are highly unlikely to cause a systemic reaction like a body rash or other tissue reactions. They are made of stainless steel which, unlike titanium plate screws which are now more commonly used in the face for such procedures as cheekbone reduction, do not a higher risk of allergic reactions. However, I have never heard of or read of such reactions occurring in facial bone fixation with stainless steel wires.

Regardless wire ligatures can usually be removed in any facial bone where they are located. They would be removed through the same incision by which they were put in. As long as the  bones are well healed they should be no risk in doing so other than the temporary swelling that results from the removal procedure. Most cheek bone reductions heal very quickly, as do most facial bone fractures/osteotomies, so I would not think that cheekbone positioning would be affected.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in having a custom jaw implant to have a wider, more symmetrical and defined jawline. 

I however don’t live in Indianapolis so am unsure as to the process of getting this done. Do I need to come to Indianapolis more than once? Or can I just send the CT scan that I have already done, have Skype consults and only come in once?

In terms of timing I have a tight schedule with uni. Ideally I would be hoping to get this done in January but am unsure if this is realistic with your schedule and time required for everything to be ready? How long does it take for the designing and the printing of the implants? When would your next availability for such surgery be?

I understand that the price of custom implants can vary considerably but what would be an estimate for the total cost (including your fee, the implant production, the GA fee, hospital fee etc..)?

A: In answer to your questions:

1) You only need to come here once for the surgery. You send the 3D CT scan to me from which your custom jaw implant will be designed. All preoperative consultations will be done by Skype.

2) The design and fabrication of a custom jaw implant takes from 4 to 6 weeks to complete. So January surgery is very possible.

3) My assistant will pass along the cost of the surgery to you next week.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin ptosis surgery. Three years ago I had a chin implant placed through the mouth and then it was removed a few weeks later because it was causing dynamic ptosis. My chin and lower lip are lower than they were before and my oral vestibule seems really low in my mouth. My doctor said it was because of scar tissue and there was nothing he could do. I realize now that my mentalis muscle needed to be resuspended. Have I waited too long to have this done and have any chance of success?

A: The timing from the onset of the implant removal/chin ptosis does not really affect the success of the surgery when it is performed. The success of the surgery depends on many technical factors, one of which it is higher when a small chin implant is placed to support the uplifted chin tissues. Besides resuspending the mentalis muscle, the other very effective technique in my experience is to raise the height of the vestibule. This would be of particular benefit in your case as you have already described that it seems too low since the original chin implant surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin ptosis correction. Part of the reason I’ve put off having the surgery is because the success rate seems really low. I haven’t found anyone who has had this done sucessfully. I’ve read everything about mentalis resuspension that you’ve posted on your website and some of the information is conflicting. In an older article you state that everyone who undergoes the procedure has some degree of improvement, But elsewear you state that the surgery completely fails more times that it is successful. I’d like to know what your opinion is now, I don’t what my expections to be unrealistic.

A: Chin ptosis correction surgery can incorporate one or several techniques. Mentalis muscle resuspension alone, while initially effective, often disappoints with more healing time. When multiple techniques are done (muscle suspension, V-Y mucosal closure, elevating vestibulopasty and a chin implant) the results are much better and more sustained.

But you undergo the surgery with the knowledge that chin ptosis is a difficult problem to correct and results are far from assured. Usually the actual chin ptosis ends up corrected but the more visible issue, the sagging lower lip, can prove to be the challenge for sustained improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q:Dr. Eppley, I am a 28 year old male and i have a question about forehead bone reduction procedure. I’ve had these two lumps on my forehead for as long as i can remember. I always thought I got them from hitting my head when I was a kid. Recently these lumps started to bother me more and more so I decided to see a plastic surgeon that specializes in reconstructive plastic surgery in my home country and ask what he thinks about it. 

He gave me a diagnosis of ’eminenta frontalis’, which I interpret as just a bone shape that is somehow normal but just a bit more prominent. He did not think this is something that should be bothering me nor could it be fixed due to the underlying sinus cavity and relatively thin bone thickness (no xrays were taken) 

The thing is, this is bothering me and I would like to know what are my options.

A: If I am interpreting correctly as to what your foreheads concerns are based on the pictures you have sent, I see a pair of forehead prominences that are often called forehead horns. They are a natural development of the forehead that does occur in some males. They are not located over the frontal sinus but above it. These forehead bone humps can be very safely burred down. This would be done through a frontal hairline incisional approach. Forehead horn reduction is a procedure in my experience that exclusively occurs in men much like large or overdeveloped frontal sinuses/brow bones.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a female with a cleft chin and overactive/large mentalis muscle which creates pitting or orange peel texture in the chin area. If I have my cleft chin surgery to get it corrected, can it also correct the orange peel texture so I don’t have to keep getting Botox injections every 2 months? I am missing a little piece of bone at bottom of my chin due to the cleft chin. So I wouldn’t want a regular chin implant, but just something to fill in this dent. I don’t want to have to keep getting Botox or filler injections. I want something permanent.

A: You have two chin issues which are independent of each other. Cleft chin surgery for removing the cleft is not really based on putting a modified chin implant onto the bone. That is just a minor part of the correction. Most of the chin cleft resides in the overlying soft tissue which requires fat injections in addition to the bone implant.

The mentalis muscle irregularities/dimpling are a different issue which is not going to be improved by a chin cleft surgery. Short of Botox injections they are few other effective treatments. Fat injections into the dynamic dimpled areas would be the only other treatment option whose effectiveness can not be assured.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have several custom facial implants questions. I would like to visit you later this year for a custom midface implant and custom chin implant. Is it possible that I can have both surgeries at the same visit or would I have to wait for the first one to recover? Also what is the recovery time of a custom midface implant that covers the areas from the infraorbital rims to the ears?

A: It would be very common to have more than one area of the face augmented with implants during the same surgery. This is just as true with custom facial implants as standard facial implants.  The most common such combination would be custom jawline and custom midface or forehead/skull implants, treating distinctly different craniofacial regions.

The recovery time for just about any custom facial implants procedure is primarily related to the swelling that occurs in the face. One usually starts to look ‘reasonable’ in about 10 to 14 days after surgery. But full recovery to see the final results of the facial implant surgery can take up to six weeks after the procedure. As a general rule there his always more facial swelling that one expects and it will last longer than one wants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had three forehead contouring procedures starting with a PMMA forehead augmentation ten years ago. After some time a ridge across my forehead became more pronounced and I had two more procedures which involved removal of the PMMA implant and some adding of hydroxyapatite cement. I am lnow eft with strong indents in both sides of upper forehead, a lack of any real brow bones, and eyebrows became more propped up in corners. I would like to fill in and smooth the upper forehead and possibly build up the brows, which I think would improve/flatten eyebrows by getting them closer to their original position. I am wondering with three procedures done, and scar tissue removed, would I have enough elasticity to attempt to do this. I would love to not open the coronal scar and try to utilize less invasive methods. However, I understand the need to do this for better access to the forehead and brow bones. It has been five years since the last procedure. (second and third procedure were performed over a 6 month period with the same surgeon)

A: With having multiple forehead contouring procedures done you are correct in being suspect of how your forehead tissues would respond to further efforts at augmentation/expansion. That tissue issue is overcome, should it exist, with galeal releases done on the underside of the scalp flap. Between the need to very specifically apply further forehead augmentation materials and to potentially need to release the galea, an open approach using your existing coronal incision would be required. Limited incisional techniques in the face of your forehead circumstances is a setup for additional forehead contour issues. In essence the result will only be as good as what the surgeon can see. As you have observed in forehead augmentation even the slightest contour issue is eventually seen as the forehead tissues contract around it. It is surprising that even thick forehead tissues eventually reveal even the slightest irregularity beneath it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, f a person would like to reduce the brow bone and the nose size, wouldn’t it be best to have them done on the same day of surgery? I ask this because if a brow bone surgery is performed and them the nose after, it is possible that the brow has to be reduced again . i think I’m not explaining very well. Anyway my question is can you perform rhinoplasty and brow bone reduction together ? I’m also interested in chin reduction.

A: There would be no technical or medical reason why rhinoplasty, brow bone reduction and chin reduction surgery could not all be performed at the same time as a single surgery. The combination of these procedures is not all that uncommon. I think the origin of your question is the concern that one procedure may aesthetically affect the other. This doing them together would allow for a more harmonious result. While this concept is not as relevant as one may think, there is a relationship between a brow bone reduction and rhinoplasty at the radix where the two procedures ‘meet’. Depending upon the type of rhinoplasty performed and how much dorsal hump reduction may be done there can be a real impact of how one procedure affects the other and how the details of it would be performed. Such a relationship at the upper nose and central brow bone area, and how much reduction should be done, would be determined before surgery using computer imaging.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a scrotal reduction procedure. I have a testicular implant on my right side. There is a lot more scrotal skin on the left side than the right. I need it reduced using I think a lateral incision. Would you also if I wanted put in an incision on the right side just for aesthetics, so that it looks as if both sides have been reduced? Do you ever do that. Just create a scar for aesthetics? For symmetry?

A: A scrotal reduction can be done on the larger left side. Your unique situation of having a testicular implant on the opposite has created this unilateral need. If you prefer to have a scar made on the right side, without any skin incision for the sake of scar symmetry, that can be done as well. Usually a scrotal reduction or scrotal lift is done by making a midline excision of skin along the natural raphe between the two sides of the scrotum. But there is no reason that the reduction approach can not be down on the side as opposed to the midline. In your case this would likely create a better and more symmetric scrotal reduction result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Botox injections for migraines. My son has had persistent migraine headaches for the past two years. I can tell you his headaches/migraines are always in his forehead area above his eyebrows.  He never has pain in the back of his head.  I have done extensive research and it seems that neurologists always do shots over the entire head and neck, like 31 injections!  That just doesn’t seem right to me.  His current neurologist recommended another neurologist, but I am hesitant to use him for this reason, even though it would probably be covered with insurance. Any information you can provide is greatly appreciated.

A: The migraines types that respond best to either Botox injections or surgery are those that are focal. This means there is one specific focus or location where the origin of the migraine can be identified. There are four well known extracranial foci of migraines, one of which is the supraorbital region of the brows where the nerve exits the bone. This sounds precisely as to what type of migraine your son has.

Botox injections for frontal-based migraines should be directly around the supraorbital nerve….and not anywhere else. I would agree that neurologists tend to use a shotgun approach and put it all around the head. This is not the injection approach for your son to determine the effect of chemodenervation and it is certainly not a cost-effective one either.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in buttock implants. I have an incredibly small butt given my body size. I don’t really have that much fat so a BBL procedure is probably out. I would also like to get rid of my hip indents. Will buttock implants take care of that as well?

A: Thank you for sending your pictures. I can see your buttock concerns as their size is very small compared to the rest of your body. The traditional placement of buttock implants inside the muscle allows for only a small size of implant to be placed (around 300cc) which is about the size of your hand. I believe this would be inadequate for you. Buttock implants that are placed above the muscle allow for much larger implant sizes but have a higher rate of potential complications because they are not in the muscle and your buttock fat layer is thin under the skin.

Putting these two buttock implant issues together for you means that ideally you should have a two-stage buttock augmentation procedure., Your first stage should be fat transfer to your buttocks. While the amount of fat you have to transfer is not enough to make a big difference it will thicken up the fat layer under the skin and help get rid of your hip dimples. (which implants will not) This will then allow buttock implants to be placed more safely above the muscle as a second stage procedure 3 to 4 months later.

You have a very challenging buttock size problem that is not easily remedied by more traditional one-stage buttock augmentation procedures.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a deltoid implant. I am a 22 years old son and had a nerve injury from high school football that atrophied my left shoulder and deltoid muscle. I would like to explore an implant that could give back some muscle bulk and maybe a more natural look back. I am very sensitive to the appearance of my shoulder now. Although I have insurance, I’m certain a cosmetic surgery would not be covered. Could you give me an idea of the cost, how quickly I could get an appointment for surgery, the recovery time, and the physical therapy needs. (if any)

A: I will have my assistant pass along the cost of deltoid implant augmentation surgery. Presumably because you are young and thin, injectable fat grafting is probably not an option due to low body weight. Thus a deltoid implant implant offers the most reliable method of long-term shoulder augmentation. The only question in that regard is whether this is best done by a standard or custom made deltoid implant. I would need to see pictures of his shoulder from different angles to make a better assessment in that regard. Recovery from a one-sided deltoid implant is fairly rapid since the muscle is atrophied. There is no need for postoperative physical therapy.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a church choir singer. Would a tracheal shave operation affect my voice?

A: The concern about the impact of tracheal shave surgery on one’s voice is common. Whether it be a singer or radio announcer this is an understandable concern as air passes through the voice  box. Everyone knows what their own voice ounds like and no one really wants to have their voice changed if it is integral to their profession.

Tracheal shave surgery should not and has not affected patient’s voices in my experience in the voice-sensitive patient population. But it is one of the known risks of the procedure because one is operating on the voice box. (thyroid cartilage) The key to avoiding that risk is to not get too aggressive. Too much cartilage reduction could theoretically weaken the paired thyroid cartilages thus theoretically changing the tension on the vocal cords. This is avoided by being more conservative and not trying to make the prominence of the Adam’s Apple completely flat. The thyroid cartilages need to maintain some integrity to support the internal attachments of the vocal cords. The risk is not of voice cord avulsion but of loss of cartilaginous support.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Due to the risk of nerve damage with sliding genioplasty, I have decided a chin implant is likely more viable to me. It turns out, my mandible is incorrectly rotated in all 3 axes. (see picture + morph of close to ideal, ignore other changes made). Combined with lack of projection, this makes it even look less projecting from certain angles. Unfortunately I can only upload 2 images. My idea was to make the chin broader, to simply fill in for the incorrect rotation. Do you think this is a viable thing to do with a custom jawline implant?

A: I think you are absolutely correct in that only a custom jawline implant can correct your overall jawline asymmetry You have a 3D problem for which any 2D solution (e.g., sliding genioplasty, standard sized chin and jaw angle implants) would be inadequate and may actually exacerbate the jawline problem. The custom implant should be a total wrap around implant that encompasses the chin and the two jaw angloes. It does not have to be big but it needs to ‘fill in’ the jawline deficiencies and desired areas of aesthetic augmentation. You have a chin problem that is actually a total jawline problem.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have scoured the internet to find a solution to my lip incompetence, but can’t get answers. My lips are apart at rest and my chin dimples and strains when I put my lips together. This also makes my chin look receded. My nose to top lip measures 18mm and my chin to bottom lip measures 36mm. The gap between my lips measures 11mm. It would mean so much to me if you’d take a few minutes to review my measurements and photos and determine if you think you might be able to help me. Thank you so much!

A: Thank you for your inquiry and sending your lip/chin pictures. When I first looked at your amount of lip incompetence from the front view I thought there is nothing that really could be done as that was just ‘the way you were made to be.’ But when I saw your side view I knew instantly why you would have such a degree of lip incompetence and chin muscle strain…you have a major chin/jaw deficiency. Your chin looks receded when you close your lips because it ireally is. You have a major chin bone deficiency. What you need is a sliding genioplasty to move the chin bone forward . This will reduce your chin muscle strain and will go a long way to helping your lip incompetence.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, my objective is to reduce fat and tighten the skin in the inner thigh area, front, and back of thigh. I have decided to do this procedure but am searching to find the right surgeon and recommended procedure – inner thigh lift vs. Smart lipo. Please let me know if I can provide more information as I have attached some pictures. Thank you very much for the information and timely responses.

A: Thank you for sending your thigh pictures. What you are seeking is common, a reduced in size firmer inner thigh region. But the solution to it is anything but common or easy. The reality is that the inner thigh region is very difficult to get satisfactory results from an aesthetic standpoint, It will always leave one wanting better.

You have correctly identified the only two treatment options that exist for the inner thigh…fat reduction or an inner thigh lift. (removal of skin and fat) Neither is perfect, each one has their own advantage and disadvantages. Liposuction is a ‘scarless method’ that removes fat and relies on creating its results by skin contraction. The inner thigh skin is one of the poorest tissues to contract in the body so such results are usually only a modest reduction. (less than you want). Do not get hung up or enthralled with such liposuction technologies as Smartlipo which promote better skin retraction. I have the device and have failed to see any difference between it and other forms of liposuction. Also one must avoid being too aggressive with liposuction in the inner thigh as such efforts can result in very visible skin irregularities. The inner thigh is the number one area of dissatisfaction of the entire body with liposuction because of this very issue. This it pays to be more conservative but that also means less of a result.

Inner thigh lifts (which are combined with liposuction) produce a better result but does so at the price of a scar in the groin crease. That scar has a tendency in non-bariatric patients to end up drifting below the groin line due to tension and risks wider scarring.

You are a classic case of what you want you simply can’t get it the way you want it. (aka the best result with the least amount of scarring) You would be best off to initially do liposuction and let the results prove to you that any further efforts such as a lift would be worth it. Liposuction will provide some improvement and, as long as no substantial skin irregularities develop, it will be somewhat better but with no negative consequences. The risk of adverse and irreversible scarring makes the inner thigh best left for the bariatric patient.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had occipital skull augmentation craniofacial surgery two years ago for the back of my head. However, i noticed after healing that the lower portion of my head is still very flat. The surgeon had only augmented the upper portion of my skull with bone cement. I am wondering if anything can be done about the bottom area, making my head appear more round. I always tie my hair back to make the middle/lower portion appear less flat. Thanks for your time.

A: Not knowing exactly where the full extent of the bone cement was placed I can not answer your question with certainty. While it is most likely that only the upper half of the occiput was augmented (because this is the easiest area to augment on the back of the head), it is also important to realize that the bottom end of the occipital bone is much higher than most people think. It is usually at the horizontal level of the upper ear. The best way to really answer the question if more occipital skull augmentation can be done lower to make the back of the head rounder is to get a 3D CT scan of your skull and see exactly where the bone cement is and what its shape is at its lower extent. Unless your surgery was done with you in the prone position (face down) during surgery, then the entire bottom half was probably not augmented. and you have a surgical augmentation that probably looks like the Bumpit hair volumizer device. That may work when placed on top of the scalp but does not have the same effect when placed on the bone.

Dr. Eppley

Q: Dr. Eppley, I am interested in a brow bone reduction. Given the strong prominence of my forehead, and based on everything I have seen on your website, my brow bone will probably need to be removed, reshaped, and reattached. If this is the case, how many days will I need to take off work and approximately how long will it take before there are little to no visual signs of surgery? I have decided I want to go through with this, I simply need to schedule time off work. Email is the best way to get in touch with me, given my schedule. Thank you

A: Thank you for your brow bone reduction inquiry. The recovery from brow bone reduction is largely that of appearance. I(swelling of the eyes and forehead)  It probably takes about 10 days to 14 days after surgery until one looks fairly reasonable and a full three weeks until one appears visually completely normal and does not have any signs of having had the surgery. There are other physical issues that take longer to recover from such as forehead numbness and incisional healing but that is not an externally seen recovery issue

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, For my projected rhinoplasty resultsI have redone the computer imaging superposition to represent a lesser overall nasal reduction. I would still be very happy with this result, perhaps even happier.

The main objective for me is to reduce nasofrontal angle and get a proper ‘break’ in the forehead-nose junction, as well raise the tip to an obtuse angle with respect to 90 degrees, somewhere between 95-105 degrees, and ofcourse get a straight nose with perhaps the slightest outward curve. I have a preference for feminine leaning noses (even on males) rather than masculine, and of course my nose at the moment is very masculine! 

Regarding the chin, is there any way to get that added projection and reduce the dimple? Perhaps with a filler such as radiesse or can fat grafting achieve both these goals? The extra projection really improves the profile to my eye. 

A: Thank you for sending your revised superimposition of a hopeful rhinoplasty result. It probably is still a bit optimistic particularly at the upper dorsal line reduction/nasofrontal angle. The nasofrontal angle is the hardest structure in the nose to reduce during a rhinoplasty because of its remote access from even an open rhinoplasty. There is no good way to get bone reducing instruments up that high although I have that a combination of a horizontal dorsal line osteotomy combined with a percutaneous vertical osteotomy can help carve out a more defined nasofrontal angle. Again probably not quite as good as you have shown on your images but a lot better. When you speak of a feminine as opposed to a masculine nose you are referring to the shape of the dorsal line. Specifically you would not mind a slightly conceive dorsal line profile as opposed to a straight or even a slightly outward curved one which is more desired by most men.

Fat grafting can be done to achieve some minimal chin augmentation and some moderate chin dimple reduction. The success of either one depends on how well the injected fat survives.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, In skull augmentation is there a way I can see how I will look with the final results in a very realistic way? (e.g. Starting out with fillers etc. at least for the forehead). And how much would it cost for forehead augmentation, back of the head, and if it makes sense the top as well? I would really like an ‘ideal’ head shape as this has been very important to me.

Thank you again for your explanations and patience!

A: While temporary injectable fillers can provide some what of an assessment of what the result of any craniofacial augmentation can do, they are practical limitations to this concept. The volume of injectable fillers needed to create a visible change, and their cost, would be prohibitive. For skull augmentation it would take many syringes of fillers at several thousand dollars of cost to get just a fraction of what implant skull augmentation can create. There is just no way to compare injectable fillers and implants in the skull because of the sheer surface area of volume needed. This is very different on the face where, for example, cheek and chin augmentation can be partially replicated by a filler effect due to their relatively small facial size. The only place on the skull where an injectable filler ‘trial’ could be worthwhile is for forehead augmentation. Depending upon one’s goes, tree or four syringes of filler may approximate a forehead augmentation effect. It is still not a very cost effective approach but it can be done.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am seeking custom jawline implant revision. I’ve been doing more reading on your answers on Real Self and your resource page regarding jaw augmentation. I recently went back into surgery to have my custom made jaw implants reduced in order to remove a bump that was sticking out on one side and to slightly bring it in along the posterior border. Although I am still mildly swollen I know for a fact that my doctor has probably made it look a bit too natural. I realized the protrusion was giving my jaw a square chiseled look and what I should have proposed is that we match the other side and enlarge that slightly instead of the other way around. I now have a balanced looking jawline. (which is a plus). However I really miss the tiny pointy bit of augmentation I once had. Is there anyway I can reverse this without having to get more custom made implants. I’m hoping some sort of material or silicone block is available or can be carved by my doctor to put back in in order to give my lower face more convexity from frontal view. Any assistance would be great!

A: My experience has been that this can be achieved by placing a small vertical lengthening jaw angle implant over the angle point of the indwelling implants. This his how to augment or accentuate a rounder jaw angle implant shape into a more defined one secondarily. Overlaying a new implant on top of the existing one usually requires screw fixation in this type of custom jawline implant revision.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, As you know, there area number of procedures I am looking to get done, and I wanted to get your opinion on one of them as I read some excellent articles you wrote on the use of rib cartilage as grafting material for Asian rhinoplasty.

One of the procedures I would like to have performed is revision rhinoplasty as my implant is not completely straight, and I do not think the shape is successful. I believe it’s difficult for surgeons to really shape rib cartilage, and wanted your thoughts / opinion on shaping it for a very feminine look: a good height, generally slim bridge and width, with a curved line all the way to the tip. How can this best be done and what is your experience?

A: You are correct in rib graft rhinoplasty that shaping rib cartilage can be difficult and there is always the risk of it warping after surgery. If the rib graft can be ideally shaped as a solid piece to achieve your goals then that would be a good method to do it. But between the shape of the harvested rib and the unpredictability of whether it will warp its fashioned shape, this has led to the use of a diced cartilage graft approach. This allows it to be molded into its desired shape. This is the preferred approach in many cases of rib graft rhinoplasty today.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have spoken with you a few times about a getting a revision rhinoplasty procedure. I’m getting very close to scheduling my consultation and procedure with you. I have a question in the event I want any corrections after my procedure how long will I have to wait for a revision? I don’t want any additional surgeries after this one, but I wonder will a quick follow up procedure cause damage to my previous cartilage graft?

A: Like all rhinoplasties, whether they are primary or secondary, any efforts at revision rhinoplasty should wait a minimum of six months so the tissues have time to return to a more normal state so they can tolerate surgical manipulation. This is also an adequate amount of time for all nasal swelling to subside and one can appreciate that their concerns are stable and no new shape concerns have arisen.

Secondary revision rhinoplasty surgeries will not damage previously placed cartilage grafts. Cartilage grafts in the nose are quite hardy and are only damaged (undergo resorption) in the presence of infection. Otherwise they can be worked around, over and even removed and replaced without affect their survival and structural support.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Does tummy tuck surgery include work on the abdominal wall? I am hoping to get some relief from back pain and my chiropractor suggested I get my abs strengthened.

A: Tummy tuck surgery does tighten the abdominal muscles (vertical rectus muscles) as part of the procedure. That does not necessarily mean it makes them stronger however. It just makes them pouch out less. Whether this would improve your back pain can not be predicted with any certainty.

I think what your chiropractor was suggesting is that you work on making your abdominal muscles stronger by exercise…not necessarily by surgery. (although I was not part of that conversation so I can not say for sure) Abdominal wall muscle plication is done to provide greater structural rigidity particularly when there are defects in the abdominal wall. While a rectus diastasis is not the same as a hernia (it is a weakening of the abdominal wall not an actual defect through it), bring the muscles back together in the midline helps provide better abdominal wall support. This theoretically should help someone with chronic back pain although it is not because the abdominal muscles are stronger per se. They are simply more rigid or tighter in a vertical direction.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I would like to ask about rib removal surgery. How many ribs will be extracted if I want a thinner waist as well as a longer torso. Also, I’d like to know about post surgical pain and recovery period. Thanks.

A: Thank you for your inquiry. Rib removal surgery is a collection of procedures designed to treat various torso issues. There are ribs removed to narrow the waistline (ribs 10,11,12) or to vertically lengthen the waistline. (rib #s 7,8,9) The lower ribs are removed through incisions on the back while the upper ribs are removed through incisions on the front. If both are done at once as many as portions 12 ribs can be removed.  (ribs are not totally removed only portions of them are) I would need to see pictures of your waistline/torso to determine if either of these ribcage modification procedures are appropriate for you.

Postoperative discomfort is managed by the use of intraoperatively placed Exparel injections as nerve and muscle blocks that last as long as three days after surgery. This goes a long way in helping control what would otherwise be an uncomfortable experience.Recovery depends on what type of physical activity one is trying to recover for.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a sliding genioplasty two years ago and I’m not fully satisfied because I would like more projection. The surgeon is brilliant and he did everything very well but I just want a little more. Is it possible to repeat a sliding genioplasty and will the bone heal the same? 

Also 10 months after the operation when I visited the surgeon who performed the genioplasty he pressed quite hard on my chin with his thumbs to feel the bone. Could that have pushed it back or am I just paranoid? Is the bone, plate and screws strong enough for that kind of treatment after ten months? 

I visited him again 16 months after the operation and he did the same thing again. 

I also hit my chin a little when I pulled my cover up while sleeping yesterday. I’m constantly worried that it’s shifting or lose. Do I need to be? 🙁 

Sorry for such a long message. Thank you!

A: There is no reason that you can not have a secondary bony sliding genioplasty years later that would heal just as well as the first one. While there is no good reason to be pushing on the bone, there is no risk of causing it to move backward. The plate and screw fixation is more than adequate to resist any displacing forces early after surgery and the healing of bone s more than adequate to do so months to years later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a small lipoma on my stomach that I’m interested in having removed without a scar. I found some of your posts relating to this issue and LipoDissolve (Kybella) seems like a viable alternative. Your post mentioned that it might take multiple injections, do these injections have to be within a certain amount of time? I work outside the US most of the year and only travel home to Indy a few times per year so I might have to spread the injections over a long period of time. 

A: The only non-surgical alternative to surgical excision of a lipoma is injection therapy. While one known as Lipodissolve, it is now known as Kybella injections. These are pure deocycholic acid injections which help break down the lipoma by disrupting the cell walls of the adipocyutes within the lipoma capsule. Over the years I have treated a fair number of lipomas with injections and it almost always takes ore than one injection treatment to get the maximal reduction. While I usually space these as close as 6 weeks apart, there is no harm in having much longer periods between the injection sessions. It does not adversely affect the injection’s effectiveness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The side profile shot is taken of what I consider my weaker side, though the left side has only slightly better bone and muscle definition, it is a noticeable difference. Its something I have been conscious of all my life – lowering and pushing my jaw forwards in photos etc and now as I get older, it appears to be more noticeable. 

I’m not looking for a wide angular jaw bone as I have an oval face and a fairly small head size so that would look weird. I’m relying on your aesthetic appreciation of my request based on the following considerations to hopefully provide a stronger, but normal looking, less saggy and symmetrical jaw line.

1. To gain a slight vertical lengthening of my jaw line
2. Consider the amount/effect (if any) of slight vertical lengthening of my chin with this procedure. Or will this make my face unbalanced?
3. To further enhance the weaker right hand side to correct the slight bone and muscle asymmetry to match the left side. 
4. Determine if I would benefit aesthetically by a slight chin projection to help the overall balance and proportion of my face?

Hopefully, if this can be met it will take up some of the slacker soft tissue and negate any surgical lifting and provide balance and proportion? That’s my aim anyway.

I look forward to hearing from you soon.

A: Given your multiple aesthetic needs of your lower jawline, only a custom jawline implant can come close to achieving all of your goals. The addition of vertical lengthening of the jawline as well as some horizontal chin increase can only be done by such an implant. Because the custom jawline implant adds overall bony volume it will by definition pick up some loose tissue along the jawline.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have some questions having to do with facial reshaping.

1. Is there a limitation in how many millimeters can one widen the cheekbones with a zygomatic osteotomy?

2. Since custom made cheek implants can be created as large as a patient desires, will the dimensions of the implants follow the dimensions of the widening result of the face or more specifically the soft tissue of it? For example, if a patient was to have inserted cheek implants that were about 5 mm wide each, would that lead to a total centimeter increase in bizygomatic width, or more and even less than that?

3. Aside from lip lifts, rhinoplasty and cheek implants are there any other effective ways to give an illusion of a shorter pupil to lips distance that appears long on a face? I was thinking that some work around the eyebrows could be a potentially good idea but I’m not sure how this could be done.

Thank you in advance.
A: Thank you for your inquiry. In answer to your facial reshaping questions:

1) Generally 5 to 7mms of out fracture of the anterior arch can be done before there becomes an obvious step-off externally.

2) In onlay custom cheek implants the overlying soft tissues generally follow on a near 1:1 basis.

3) Without seeing pictures of your face I can say what may or may not be effective in decreasing the pupil to lip distance.

Dr. Barry Eppley
Indianapolis, Indiana