Your Questions
Your Questions
Q: Dr. Eppley, I am interested in rhinoplasty and have several specific concerns/goals I want to achieve.The only other thing about my nose that I am most uncomfortable with is the lower part of my nose. It appears that my columella is hanging or sagging. I really don’t like the way that part of my nose looks. The nostrils also appear higher than the bottom part of my nose and you can see the inside. I am not sure if this is because of natural Alar retraction or because the columella is hanging down? Both? Neither? The nostrils themselves are kind of “pinched”. They are very narrow and a lot of times I feel like they are the biggest cause of my breathing problems as they seem to collapse some even during normal breathing. Also, Is it possible to change the angle of the tip more upwards? It may just be the bottom part of my nose that makes it looks like its not angled up but I am really not sure? I know that you have said that anytime you make the nose smaller you risk making breathing problems worse. Is it possible to make the nose wider? Like the nostrils or the base itself? If so, would this help with breathing?
A: I would not call your columella a true hanging columella. This is controlled/treated by the reduction of the caudal end of the septum (which is necessary to tip rotation) and removal of any redundant columellar mucosa.
One of the hardest things to improve in any nose is nostril show. This will be potentially magnified with any degree of tip shortening/rotation that is done. Alar rim grafts are placed to combat it but there is no guarantee that it will not be a persistent issue. Pinched nostrils are treated through the use of batten grafts to provide improved lower alar cartilage support.
The best strategy to manage breasting difficulties in a rhinoplasty are middle vault spreader grafts to help open up the internal nasal valve.
The combination of extensive cartilage grafting (columellar strut, alar rims, batten and spreader grafts) is the most one can do to improve nasal tip support and open the anterior nasal airway as much as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I got a 7mm Medpor Chin Implant put in on January 20, and I want it removed ASAP. Its too bulky and makes my face look less feminine than before. What are the chances of my face going back to the way it was before? Would another implant need to be put in? my doctor doesn’t do silicone chin implants for their tendency to drop overtime so Medpor it was. I’ve heard how difficult these implants can be to remove, what’s your experience with removing them? If I was to replace with a silicone implant, is it better to do it when removing the other or a few months later?
A: I am not surprised that a Medpor implant is too bulky for a female. While that implant needs to be removed, it is important to always remember that you had a chin implant placed for a reason and that was to correct a chin deficiency. This may be the wrong implant but that does not mean that there is no merit to having a chin implant at all. A better shaped and more feminine chin implant made from silicone would offer horizontal advancement with far less width if any at all. I would strongly consider replacing the implant rather than merely removing it. I have to see you throw away the complete effort.
I have removed many Medpor implants. While they are not as easy to remove as silicone it can be done. I have never heard of silicone implants ‘dropping over time’. There jus no biologic explanation for that and something I have never seen. It is better to remove and replace at the same time (with screw fixation of the new silicone implant) than to delay. The only reason to delay/stage it is if you are uncertain that you really want an implant at all. But that will change what is done during the implant removal. If you are just removing then you need to do a submental tightening of tissues since the tissues have been expanded to avoid a chin pad drop/ptosis.That ail not be necessary with a chin implant replacement.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I contracted polio when I was an infant from a vaccination, which resulted in atrophy of my left leg. Would fat grafting or thigh and calf implants help to make my legs more symmetrical? I know the discrepancy looks severe so I don’t have expectations of perfection but I’m hoping something may be done to lessen.. possibly with the combination of both procedures.
A: Thank you for sending your pictures The easiest and less severe component of your leg asymmetry is that of the calf. One calf implant placed on the inner half would go a long way to improve symmetry below the knee. Two calf implants would produce near symmetry inj size to the other side.
The thigh deformity is the bigger part of the leg asymmetry and the more challenging to improve due to its magnitude. Injectable fat grafting would be the only treatment that can be done and its success is partially dependent on how much fat you have to harvest. This combined with how much fat survives determines that outcome. Based on the performance of the first procedure (and how much fat you have to harvest) you may need a second fat grafting session to get the best possible outcome.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, is there a chin implant that can make a cleft chin? I would like to get a cleft with my chin implant augmentation and I am told that cleft chin implants exist but do they work?
A: Contrary to popular belief, a chin implant that has a central cleft in it either manufactured that way or intraoperatively put in it will not create the appearance of an external chin cleft. It seems like that chin implant approach would work but it does not.
The key to making a vertical cleft in the chin when using an implant is to use/make a clefted chin implant but then the overlying soft tissue must be thinned out and then sewn down into the implant cleft or even all the way down to the bone. What makes it work is the suture technique down to the bone.
I wish it was as easy as putting in a cleft chin implant and creating a visible external chin cleft…but it is not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had rhinoplasty (4 weeks ago) and I am extremely unhappy with the result. I asked my surgeon to remove the bump on my nose but it is still there and also my nose looks extremely wide. I was wondering if this could still be due to swelling- and if so, how much can I hope for it to go down, and if not, how soon do you think I could get a revision – I really want to be able to feel comfortable with myself before I go to back to school in September. I’ve attached some photos – as you can see my bridge is very wide and there is still a noticeable bump- could these just be caused by swelling, is there a chance they could go down completely/a lot?
A: In trying to answer your questions, I am at a significant disadvantage. I do not know what your nose looked like originally and know no details of how your rhinoplasty was done. These pieces of information are critical to know as to whether the eventual resolution of swelling will produce a favorable outcome or not.
But let us assume that the outcome of your primary rhinoplasty is not favorable, the timing of any revision rhinoplasty would depend on what needed to be done. This would not be before three months at the minimum and likely six months after the original rhinoplasty procedure. The nasal tissues need time to heal and have all the swelling fully subside.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have this terrible vertical line in the middle of my forehead and I really want it gone. Can you help me?
A: Vertical wrinkles in the forehead are a result of overactivity of the corrugator supercilii muscles. These are small muscles that run obliquely from the inner aspect of the eyebrow under the more superficial frontalis muscle and pass inward towards the central area between the eyebrows to insert to the underside of the skin. When these muscle contract they pull the inner half of the eyebrow inward. With both sides pulling inward together this creates the vertical lines between the eyebrows that many people have. This is why the name corrugator supercilii, which comes from Latin, means the ‘wrinkler of the eyebrows’.
The corrugator muscles are known as the frowning muscles and they produce a variety of vertical line patterns between the eyebrows. The most common are a pair of vertical lines, known as the 11s, and is the basis for the use of Botox injections to reduce their prominence. In some people a single deep vertical line appears, just like the one you have. They are often very deep and are the hardest of all vertical forehead lines to treat.
This is definitely not scleroderma which appears more liken shallow groove and does not appear in the midline. This is a deep expressive wrinkle (deep vertical line) which shows deep inversion. I would not think some much of fixing it as it is not that simple…but treating it to make it less noticeable. This is caused by excessive muscle action but not has become a deep etched vertical line which will not be resolved by simply weakening the muscle. (e.g., Botox injections) The hardest part of its treatment is to get the deep indentation back up and level with the surrounding skin. The simplest and most effective approach, but the least appealing, is to cut out the indentation and put it back together in a geometric closure pattern. (small running w-plasty like forehead scar revision) There is no more effective long-term skin leveling strategy than this approach but it is like trading one scar pattern (indented and vertical) for another pattern. (smooth and small irregular line) One could certainly argue that this is probably a much better ‘scar pattern’ than what you have now. The alternative non-excisional treatment would be to place something under the indented scar such as fat injections, a small dermal-fat graft or temporalis fascia. This would create less of an indentation that would not be quite as deep.
As you can see, the ‘fixing it’ strategy is not what can be achieved. It can only be improved and it is just a question of how one feels about either the options of a smoother fine line scar or simply less of a vertical indentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m wanting to do a Brazilian Butt Lift lift. Can that be done at the same time as with a Mommy Makeover?
A: A Mommy Makeover (breast and abdominal reshaping) and a BBL (Brazilian Butt Lift) can be done at the same time but it create a very difficult recovery. It would all depend on what the exact Mommy Makeover procedures need to be and whether such a combination may negatively impact the results of any of the three procedures. For example if the Mommy Makeover needs to include a full tummy tuck there will be less fat that can be harvested for the BBL to avoid compromising the healing of the tummy tuck incision. I would need to make that evaluation during an actual consultation or you can send me pictures of your body type for a preliminary evaluation.
While it is always desirous to maximize the number of operations one can do in a single setting for economy of recovery and economic resources, there are operative combinations that can ‘fight’ against each other and may even compromise their results. This needs to be looked are carefully in these type of body contouring procedures.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital rim implants. I am 23 years old with severe depressions under my eyes. I’ve had them since I can remember. I’ve tried everything. Special vitamins, creams, makeup, nothing works. I also have dark colors as well. I am more concerned with the depressions though. You can cover up color, but not hollowness. I went to see a local plastic surgeon and he basically told me nothing could be done. “Try our cream, and makeup” is basically all they said is necessary. I am tired of looking this way. How much does the implant surgery cost? I am so desperate. Thank you.
A: When it comes to infraorbital hollowness/tear troughs, this is an anatomic problem of either lack of soft tissue volume or inadequate bone projection. These are most commonly treated today through the use of temporary injectable fillers. In my opinion, however, these should only be used a trial method to see if soft tissue voluminazation would be effective. They are certainly not a long term strategy particularly when ine is very young and this is a congenital anatomic issue.
Longer-term surgical treatment options would be either the use of injectable fat grafting or infraorbital rim implants. (sometimes called tear trough implants although these are not necessarily the same) Each has their role and the choice between the two would depend on what your depressions under the eyes look like. I would need to see some pictures of your eyes to make a more definitive recommendation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in breast reduction surgery. I am 24 years old, 5 feet tall and pregnant. I was a 32C before and am currently a 32G. You have high reviews on Real Self. I struggle with stretch marks on my breasts and have no faith in my breasts shrinking after because of them. I am interested in a combined breast reduction and lift.
A: While you may ultimately need some combination of a breast reduction/lift, it would be important that you wait a full six months after delivery before having the procedure. You want your breasts to fully shrink down and be a stable size with whatever sagging may ensue. In essence you want to have a ‘stable target’ to operate on so the breast reduction result does not change appreciably afterwards due to still evolving changes in your breasts.
You may also be surprised how much your breasts will shrink after delivery. What seems like a breast size that can never go down adequately can actually even end up too small later. The sagging will not improve with time and a breast lift may ultimately be needed but it is way too early to say that you need a breast reduction as of yet.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, We are interested in chin reduction for our daughter. She is now 17 years of age. Through her orthodontist we have been told that she wiuld need a chin reduction. We have been to visit a plastic surgeon in our local area who is willing to operate on her but we would like to find someone with your level of expertise. We would like to what your thoughts are on what type of chin reduction surgery should be done. I have attached some pictures of her for your assessment. Many thanks.
A: That you for sending your daughter’s pictures which is extremely helpful. She has an unusual excessive chin problem as it is very horizontally protrusive but also vertically short. This creates a prominent chin ‘knob’ deformity. While I don’t know what the bone looks like underneath (it would be helpful to see a lateral cephalometric x-rays from her orthodontist who undoubtably has one) her excessive chin problem is both a bone and soft tissue issue. Both have to be addressed to produce a satisfactory chin reduction result, removing soft tissue alone will not work. While the bone may be horizontally excessive, her chin is also vertically short. Her entire lower face is actually vertically short compared to the rest of her face. Ideally you would want to convert the excessive horizontal bone to increased vertical chin height. This would stretch out some of the horizontally excessive soft tissue which is just following where the bone is. Then any excessive soft tissue could be removed. While this may be the ideal approach, it would entail two stages to do so. The other approach would be a one-stage submental chin reduction with removal of excessive horizontal bone which would then allow some of the excessive soft tissue chin pad to be removed and tucked under. This would still leave the chin vertically short but would offer significant improvement in a single surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I recently had scalp expansion (last surgery two weeks ago) and it looked great. Now two weeks later, I am losing most of my hair next to the suture line and where the expander at the top of my scalp was. Is this normal or will I now need yet another surgery to repair this damage?
A: Le me explain the infrequent phenomenon of scalp expansion hair loss. It is not rare to have hair ‘shedding’ (temporary condition) from the stress of a tissue expander if the amount of scalp expansion is large or is being done in the presence of existing scalp scars and tissue loss. This should to be confused, which is an understandable confusion, with actual hair follicle loss. (permanent condition) Hair is very sensitive to stress since it easily be changed into the telogen phase where the hair shaft separates from the hair follicle. Once the stress period is over (after the scalp surgery is complete) the hair follicles will resume growth at some point and new external hair will begin to appear. There may or may to be some scar widening from the tissue expander insertion site.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two chin reductions, a sliding genioplasty and bone burring and a chin lipectomy. Now my chin has collapsed, please help me to know what to do for a chin reduction revision?
A: Based on your history of two intraoral bony chin reductions, the overlying soft tissue appears to have ‘collapsed’ or become completely balled up over the chin. This is what can happen when intraoral approaches are done for horizontal chin excess. Intraoral bony chin reduction relies on the excess soft tissue chin pad to somehow shrink down and become less over a reduced bony chin prominence. While that may work for a very small horizontal chin excess, larger reductions result in the chin soft tissues just contracting down into a mass of distorted and indented soft tissue. This is why a submental approach which reduces bony and soft tissue is the better choice as it prevents what appears to have happened in your case by reducing the soft tissue as well as the bone.
The question is how best to release the contracted chin tissues and restore their volume. There are two basic approaches. First, if one is happy with the horizontal chin projection fat injections can be done to expand out the soft tissue a bit and try to soften it. The second approach is if one can tolerate a little more horizontal chin projection, the soft tissues can be released through a submental approach and a small chin implant can be used possibly with a little bit of fat injections.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a custom occipital implant three months ago. While I was initially thrilled with the results, I now feel that I wish it was bigger. Do you think it is too soon to consider a revision? Also my scalp is still somewhat numb, less numb than right after surgery, but somewhat still numb. Is this normal?
A: First, it really takes a good six months to have all normal feelings return to the scalp and to really ‘forget’ that one has a custom occipital implant on top of their head. It also takes one about the same amount of time to psychologically adjust to an extended body part and to put it in perspective. Thus you really are not there yet and what one feels today may or may not change later. So in the interim the following comments may be helpful to gain some further perspective.
It is extremely common, and almost expected, that every occipital implant augmentation patient eventually feels that they could have used more of an augmentation or some change in the augmentation location. They may feel that maybe the implant should have been designed bigger or placed differently or may even consider having a second implant done. This is known in the plastic surgery world as another ‘spin at the roulette table’ or ‘another bite of the apple’ to use a few common American phrases. I sum it up more psychologically as ‘cosmetic accommodation’.
This is common in this type of surgery because the reality is that a one stage approach can usually only achieve about 60% to 70% of the ideal augmentation one wants due to the limits of the scalp’s ability to stretch. The most ideal results always come from a two stage approach with a much larger implant. This is a discussion to have up front as one has to choose between the more efficient one stage approach that produces less than one ultimately probably wants or a more costly two stage approach for the ideal result. Besides the initial expansion phase, a two-stage also requires a change in the incision to across the top of the head rather than low in the occipital hairline.
Your preoperative situation with an already existing occipital scar throws a variable into the occipital augmentation planning….as it becomes the only way to place an implant as any incision across the top of the head places the stretched and/or expanded skin between the two incisions at risk for skin or hair loss. You always only had the option of the use of your existing occipital scar whether you had tissue expansion or not.
From the occipital scar location, it would have never been possible to get an implant any further forward than where it is right now. You simply can’t get around the curve of the skull to make a pocket from an incision that low in the hairline. You should take some solace in that you have had the maximum thickness of implant placed as far forward as was possible given the constraints of the incisional access. (15mm height)
In a few cases I have had occipital implant patients who really want to go for a second implant to get an even greater result. Without tissue expansion this is usually not possible. But even it were I would caution any implant patient to resist the temptation to take an initial uncomplicated surgical result that is good, but perhaps not perfect, and try to make it better. The next time around they may not be so fortunate.
Hopefully these comments will provide some additional perspective on your recovery process and the final result as you eventually gain full perspective on it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 2 questions about a custom jawline implant. Recently I tried to find photos of celebrities with similar skull width and face shape as me, but I noticed that among people with similar midface width, the shape of the jawline can be very different. I can basically tell 2 different types, and what I’m trying to achieve is the Type I effect. That is the “long sharp chin” effect while the jawline still looks 3-dimensional. My current chin implant is sharp, but the size of it is too small and still short and the weight of the entire lower face looks very unbalanced (jaw body vertically short and flat). Also my jawline looks very 2-dimensional.
I really don’t like an over-masculine jawline like a “squared jaw” that protrudes in lateral direction like a lot of bodybuilders might request…). I prefer a neutral but a little more “boyish” one as type I. But almost all results of jaw implants I’ve seen are sort of similar to Type II (it’s big and wide), so
1. I just want to ask whether it is possible to achieve Type I effect with a wrapped-around vertical custom jawline implant?
2. Although it’s obvious that they are different, but I can’t tell exactly what contributed to the differences… Can you tell me some differences between Type I and Type II jawlines?
A: The short answer to your question is that the ONLY way to achieve a more vertical jawline enhancement is with a custom implant approach. No standard or preformed off-the-shelf are designed for that effect, they are all width based implants because they are all sitting completely on the bone. That is why you see many ‘type II’ jawline enhancement results and not your desired ‘type I’ jawline augmentation result.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a 33 year old male and am interested in skull reshaping of the back of my head. (occipital bone reduction) My occipital bone has always been really noticeable. Now I am quite bald it’s even more noticeable now. I often get remarks about it, people tend to touch the back of head to feel it, and I’ve heard people talking about it behind my back. Is it possible to reduce it? I’ve seen a similar case on your webpage.
A: The occipital bone prominence can definitely be reduced. It is only a question of how much and that would be based on the bilaminar thickness of the occipital bone.This is best determined by a simple lateral skull x-ray which will show its entire thickness and the thickness of the outer cortical table of the bone. A tracing of the occipital profile can be done on the x-rays to show what the realistic outcome would be from the procedure in the profile view.
The horizontal prominence of the occipital bone is a very common skull reshaping surgery in my experience. It involves making a small horizontal incision on the back of the head from which the occipital bone is burred down as much as possible. It is usually not possible to over reduce or due too much of an occipital bone reduction.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in some form of breast reshaping surgery I am torn as to whether a breast lift or a breast reduction is the right option for me. I have attached some pictures so you can help me decide between the two options.
A: Thank you for sending your pictures. In regards to your breasts it is important to remember that every breast reduction involves a breast lift and the associated breast lift is always a full anchor pattern lift. Thus the breast lift part does not change, the only variable in breast reduction surgery is in how much breast tissue should be removed (reduced) if at all.
Also every breast lift when done alone will reduce the size of the breast by almost one cup…and this is without taking out any breast tissue. (the removed skin is to lift and reshape the breast mound) In looking at your breasts I really see largely a breast lift with only enough breast tissue removed to ‘fit’ the remaining breast tissue into the lifted and reshaped overlying breast mound skin. Most likely you could get away with a full breast lift with no breast tissue removed at all.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I met with you for a breast augmentation consultation last week. Before I schedule my surgery, I have a few more questions about specific brands of implants. I believe you recommended Sientra, but I’ve been looking into Mentor implants. Specifically, the Mentor MemoryGel Siltex round implants. I’ m interested in the textured surface versus the smooth because the (perhaps dubious) Internet research done suggests textured surfaces lead to a lower rate of capsular contracture. And, Mentor appeals to me because of the enhanced warranty available for purchase. If my logic and/or research are wrong, please do correct me. If I did choose to go with Mentor, would there be a price difference from the original quote I received?
A: Thank you for the additional questions about breast augmentation and specifically about breast implants. Let me preface my comments with the understanding that it does not make any difference to me what brand of breast implants a patient uses. From my perspective, the three major breast implant manufacturers offer comparable devices for surgical implantation. The manufacturers, of course, see it differently and often promote and advertise relatively miniscule purported advantages to their devices.
When it comes to smooth and textured breast implants, it is important to understand what their advantages as well as their disadvantages are …as you will pay more to use them. (they are more expensive because it takes an extra step in their manufacture to add the textured surface onto the implant) Textured breast implants have only been shown to reduce the risk of capsular contracture when the implants are placed above the muscle. There has never been shown any differences in capsular contracture rates when they are placed below the muscle. The greatest reduction in capsular contracture, what was once a common breast augmentation problem, was the change in implant location from above to below the muscle. The type or surface of the implant is irrelevant when placed in the submuscular position. In my breast augmentation experience, which spans over 20 years and over 800 breast augmentations, I had yet to see a capsular contracture from a primary breast augmentation. In that time I have only performed a single above the muscle breast augmentation. All the surgeries have been done using smooth breast implant devices. This is a testament to the value and importance of the submuscular (technically the partial submuscuar or dual plane location.
It is also important to be aware that textured breast implants, besides costing more, require a slightly bigger incision to place and have a slightly higher risk of infection as any textured surfaced implant does. (the rough surface offers greater opportunity for bacterial adhesion than a smooth surface does) Due to their thicker shells they will feel more firm and will move less freely (due to tissue adhesion) than smooth breast implants.
Today, all breast implant manufacturers offer the identical warranty…lifelong implant replacement and a 10 year for surgery warranty of new implants plus $3500 towards the cost of surgery to replace them. (technically Sientra offers $3600 towards the surgery cost on the first ten years and also has a capaulat contarcture warranty so one could argue their warranty is better than Mentor and Allergan)
Again, it does not matter to me what breast implant manufacturer, style or size any patient desires. I will surgically place whatever they want. The only thing I do care about is that patients make an educated choice and that they understand the advantages and disadvantages of those choices.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had 3 syringes of Restylane Silk and 1 syringe of Radiesse over the past year placed under my eyes and on the cheeks. The injections were placed down deep on the bone. When these fillers dissolve would there be any side effects? The reason I am emailing you is because I was so impressed by your answers on many plastic surgery boards. Is there no risk of underlying tissue or muscle becoming ‘lax’ from fillers especially with four ccs. of injectable fillers in just 12 months? I appreciate your time in answering my concerns.
A: All of the mentioned fillers are completely resorbable and they are not known to cause any long-term problems because of their relatively short duration of effects. Your question, however, is a good one but I am not aware of such injectable filler volumes causing lax skin or muscle tissues. That is because, while the injection volume creation process is acute, the resorption process is very slow giving the tissues time to recover due to its natural elasticity. Once the tissues deflate after such volume, however, I could understand how one could believe they are more lax because of the getting used to the volume that had been present.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m interested in cheeckbone reduction and maybe jaw reduction to make my face smaller and oval shape. My question is, do I need a jaw reduction or the cheeckbone reduction is enough to slimmer my face? Also, I had a rhinoplasty done about ten years ago. The tip is very visible. It looks like a small pimple on my nose, probably because my skin was thin. I’d like to have a revision. Please let me know what you recommend.
A: When it come to narrowing the wide Asian face, one procedure or changing one facial area is rarely enough to have a significant effect. Combining cheekbone reduction with jawline reduction (jaw angle, masseter muscle and chin elongation) is the most effective approach. Of course each patient must be individually assessed to determine if one of these facial changes would be the most dominant and, in your case, there most certainly is. The width of your cheek bones is by far the widest part of your face and would be the one procedure (cheekbone reduction) you would absolutely do if there was only one procedure you wanted to do.
From a visible nasal tip standpoint, which I assume may be from prior tip graft or implant,the tip can be either modified (tip point reduced) or over grafted. (cartlage graft on top of the tip) It would be helpful to know what exactly was done from your rhinoplasty now 10 years ago.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I read on your website that you are able to perform Adam’s Apple Augmentation (as opposed to the usual reduction) and I was wondering what the approximate cost would be for this surgery, and what the cost and recovery differences would be if the patient opts to use the intercostal cartilage rather than synthetic materials?
A: Adam’s apple augmentation or tracheal sugmentation can be done used either a Medpor nasal shell style implant or carved rib cartilage. There are advantages and disadvantages with either approach. An implant is preformed, requires no donor site harvest and easily shaped to overlay on top of the existing thyroid cartilages. Because the implant is performed, the operative time is shorter and this costs less. It is an implant, however, so theoretically the risk of potential infection is higher. (although I have not seen that occur) Rib cartilage requites a donor site harvest, is harder to shape and adapt to the existing thyroid cartilages and costs more to perform. It is, however, a natural material and this would suffer a lower risk of infection.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal augmentation but I have questions regarding it and how it may be used for hollowed temples and cheeks on one side of the face. It appears to myself that the areas where the buccal fat pad would sit on one side of the face is abnormally thin. This contributes to a visibly old-like or sick appearance one one side of the face, but the other half looks healthy and normal for a young adult. My concern is more so on the temples than the cheeks. Is there enough protection of the temples on that side? (are there concerns regarding temple injuries) It also concerns me that I look “unhealthy” and abnormal because of it. What do you suggest for my temporal augmentation? Thank you for your time.
A: Temporal augmentation surgery is very safe and there are no concerns about ‘temple injuries’. Temple augmentation is about developing an increased muscular appearance using either implants placed in the subfascial location or fat injections directly into the muscle. Each temporal augmentation method has advantages and disadvantages with the primary difference being one has an assured permanence (temporal implant) while the long-term fate of fat injections can be more variable.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about implant rhinoplasty for my Asian nose. The original surgeon who performed my first rhinoplasty knew that I did not want an implant initially but sold me on the implant because the only thing that he offered that would be equivalent in terms of withstanding the test of time is fascia. He described it as a thin piece of skin from the scalp area that would show little difference. He never mentioned anything about rib grafts or diced cartilage wrapped in fascia. I feel that I was mislead purposely. Is it common for plastic surgeons in the United States to do this to make a buck and is this medically ethical?
A: There are numerous approaches to augmentation of the Asian nose including implants and rib cartilage grafts as you have mentioned. It is certainly true that fascia alone would provide no nasal augmentation at all due to its very thin and pliable tissue characteristics. It is good to encase a diced cartilage graft but is not an augmentation material per se.
Surgeons naturally present and offer to patients for any surgical procedure what they know and are comfortable performing. Presumably what they have to offer for any cosmetic condition is what they feel will work well and is in the best interest of the patient. It is also far easier for surgeons to offer implant rhinoplasty over rib grafts for nasal augmentation because it is simpler, easier to perform and costs the patient less. Even if presented with the rib graft option, many patients initially choose implants for all of those reasons also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have along protruding chin and am interested in chin reduction surgery. What is the best way to reduce/reshape it so it looks smaller and more proportionate to the rest of my face?
A: In chins that are both vertically long and horizontally protrusive, there are two surgical approaches. A submental chin reduction technique is done from an incision below the chin where the bony chin can be vertically and horizontally reduced and any excess soft tissue removed. This is the best technique for bony chin reduction but does leave a fine line scar under the chin. That is somewhat of a concern with your ethnicity and skin type. The alternative approach would be an intraoral one where a vertical wedge bony genioplasty is done with horizontal setback. This leaves the question of what happens to any soft tissue excess, which may or may not contract back down but it is an externally scarless surgery.
As you can see, each chin reduction approach as its advantages and disadvantages. It all comes down to how the patient perceives the submental scar and what the risk of a redundant chin pad is after the bone is reduced.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead reduction. I have had 3500 FUE strip harvest hair transplants done five years ago. While the grafts have taken well without hair loss I have a remaining large forehead. I still have some elasticity to the scalp and am interested in seeing what a forehead reduction can do.
Q: The key element of a successful forehead reduction (and I assume you mean hairline advancement and not bony reduction) is the scalp elasticity as you have already noted. That scalp elasticity comes from the back of our head primarily and not so much the top when the scalp is advanced. If you have had 3500 transplants that would indicate to me that you have had at least two harvests procedures and a linear scar exists across the back of your head. (unless it was done by Neograft or Artiss) That does not bode well for much scalp mobilization no matter how loose it may seem. (although I can not say for sure about the scalp elasticity just by looking at pictures) Secondly there is also the issue of needing a frontal hairline incision. This is always a little bit more risky for prominent scarring in men as opposed to women. Hair density along the frontal hairline is important so that issue also needs to be considered.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a silicone implant to build up the bridge of my nose for years. I have a few questions for you about it based on your expertise in rhinoplasty, Your feedback is extremely helpful. My skin is thin and I have a medium size implant in my bridge area. ] Do you think that I should be concerned about extrusion? If this starts to extrude later on do you think the area can be filled with fat? I’ve never seen a photo of someone with a medium sized implant removed so I have no idea how deformed it looks. I’ve also heard that revision tip surgery is more difficult with the implant due to the increased chance of infection and hardening of the tip? I’ve also heard that it can take up to 10 years for infection of an implant to show up? Thank you
A: The long-term effects of a silicone implant on the nose depend on several factors including the size and shape of the implant, the thickness of the nasal tissue and how long it has been in place. Many nasal implants when removed after long-term placement will leave the nose looking ‘deformed’ due to the expanded skin over a now smaller underlying framework. While fat could be used to replace a silicone implant, it is not as predictable in terms of survival and smoothness of shape as a cartilage graft replacement. Whether you should remove or keep your nasal implant is impossible for me to say since I don’t know what you look like now and how the bridge of the nose looks and feels. Signs of ominous problems with your imlpant include skin color changes, visible edges of the implant or swelling and redness over the nose. It is understandably hard to get enthusiastic about replacing a nasal implant when it is asymptomatic.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, can you elaborate on a question I have regarding the effects of Accutane on hair transplantations? I am on a pretty small prescription of Accutane right now that isnt going to end for a while. I’ m on around 30 to 40mg/week which s considered a very tiny dosage and considered “maintenance”. I actually get some medium depth Jessners chemical and Salicylic Acid peels while I’m on this medication and have had no true healing issues.
I keep hearing that Accutane shouldn’t be taken for 6 months or more after a hair transplant because it can stifle healing but since I’m on such a small dosage would it even matter? I personally would be patient if my wounds did take slightly more time to heal.
I do have other concerns though such as what other problems could arise? Would the expected graft retention outcome be less or is it just a matter of the wounds taking slightly longer to heal. The former would make me want to wait until my dosage is finished but I don’t mind if my grafts took longer to sprout as long or if my wound took slightly longer to heal, as long as the end outcome would be the same. Its the amount of grafts that I retain and the quality of them that is the most important to me and if Accutane does affect this then i would be fine with waiting. Thanks.
A: A hair follicle is an epithelial derived structure. Accutane impacts how epithelium regenerates and heals. Thus it is easy to see that Accutane can potentially adversely affect both the healing and potential take of FUE grafts. Whether a maintenance dose of Accutane would have any effect on hair transplantation at all is speculative. Healing from light chemical peels would suggest that it doesn’t. But given that every transplanted hair follicle is ‘valuable real estate’, why chance it? If you were my patient I would not let you do it whether you wanted to or not.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have 3 procedures I am considering. The breast reduction and/or lift is something I definitely want to do, as I’m very uncomfortable from the weight pulling on my neck. Over the past few year I have noticed facial asymmetry developing. It seems to be from an enlarged masseter muscle and I’m curious what my treatment options are for this. Lastly, regardless of how thin I am, I have always had somewhat of a double chin. My chin is not very pronounced and I’m curious if a chin implant would be a good option to fix this? Do you offer discounts when multiple procedures are done? Anything information you can provide would be greatly appreciated. I can provide pictures. Thanks for your time.
A: The breast reduction surgery is fairly straightforward and the inferior pedicle technique with the anchor scar pattern is well known. Masseter muscle hypertrophy is most commonly treated by Botox injections which can have a profound but often temporary effect. Surgical reduction through electrical cautery reduction is also an option if one happens to be undergoing another surgery. When it comes to the double chin, chin augmentation by an implant ir sliding genioplasty is often done. But often this alone may be inadequate so neck liposuction or a submentoplasty combined with it usually produces the best double chin correction. I would need to see pictures of your chin/neck to give a more educated recommendation for your double chin anatomy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a very particular question regarding cheekbone reduction fracture. I had cheekbone reduction abroad where they pushed the sides of the arch of my cheekbones in to make my face narrower. However, the posterior end of the arches somewhat move outward on and off a bit, making my face wider. I was wondering if it was possible to place plates on the posterior ends of the zygomatic arches to keep them in. Thank you.
A: When it comes to cheek bone reduction osteotomies, the posterior end of the zygomatic arch is cut and moved inward. Many times a small plate with screws is placed to keep it positioned inward. This may not be necessary if a larger plate with screws is placed on the anterior cheek osteotomy. But if there is persistent mobility and rocking of the posterior segment, it can be stabilized secondarily. The best fixation method to stabilize it inward is to make a small step plate and secure wit with a screw to the remaining temporal process of the zygomatic arch. The bent step plate is then used to push the posterior end of the zygomatic arch inward and keep it from moving back outward.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I just recieved otoplasty and earlobe reduction one month ago.I The surgeon did a wonderful job thus far but there is still some minor sweeping and obviously the ears will change shape a bit over next few months. However I don’t believe enough length was removed from the earlobes. My ears still feel long and large. (not protruding) I’ve been through multiple of your surgery photos and reviews and honestly love what you do with the ear anatomy. What I would like to know is if you could take an additional amount from my earlobe to sort of shorten the ear. I would love to do my revision with you. Please let me know if and when and I have attached pictures for your review. I would love to get out opinion. Thank you for your time and I look forward to hearing from you.
A: Earlobe reduction can be done at the same time as an otoplasty or any time afterwards. The blood supply to the earlobe is not affected by any type of otoplasty procedure or even a prior earlobe reduction. The best vertical earlobe reduction technique is the helical rim type which places no visible scar on the outer surface of the earlobe. You probably need another 5 to 7mms vertical reduction. I can not completely tell from your pictures as to what type of earlobe reduction you had done but it does not appear to be of the helical rim variety. Regardless another earlobe reduction can be still be done.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have few questions about facial implants:
1. how much will it cost approximately to get customized cheek and jaw implants done at the same time?
2. how long does it take to manufacture facial implants?
3. do you personally use screws to secure both cheek and jaw implants in place?
4. lastly, is it possible to get jaw implants just to have defined jawline without the width being added (meaning that i don`t want for my oval shaped face to change into a square shape but i definitely want the very sharp defined jawline) is it possible?
Thank you very much and I look forward to your response.
A: In answer to your questions about custom facial implants:
- My assistant will pass the cost of custom cheek and jaw implats on to you tomorrow.
- From the time of receiving the CT scan until the implants are designed, manufactured, sterilized and shipped, it would be on average about 6 weeks.
- I secure almost all facial implants with small titanium screw fixation.
- Custom implants can be designed just about any way the patient wants as long as the implants can be made to fit and secured on the bone.
Dr. Barry Eppley
Indianapolis, Indiana
