Your Questions

Q: Dr. Eppley, I am interested in forehead reduction and hairline lowering. I would like to know if Im a great candidate for the forehead reduction and hairline lowering. I hit a brick wall when I was younger and that is how I have bumps on my forehead. Can you please respond back to me thank you!

A: Thank you for your inquiry and sending your pictures. I can clearly see your motivation for the forehead reduction and hairline lowering procedures with a long and high forehead and a large  protrusion of the frontal bone. You are correct in making the assumption that these two procedures would be of benefit. A less protruding forehead and a lower hairline would be very aesthetically advantageous. The key procedure of these two is actually the hairline lowering as a hairline that was 2 to 3 cms lower would help disguise the forehead protrusion significantly even though it can be reduced by burring somewhat. However, your scalp skin looks fairly tight, as most high foreheads are, and no more than about 1 to 1.5 cms of advancement could be obtained by simple loosening it up and bringing it forward. You would be better served by a first-stage scalp tissue expansion to create more hair-bearing scalp to bring forward. Then the second stage could be a large scalp advancement and bony forehead reduction. This would produce a much better result than a single stage procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rhinoplasty surgery. I have always hated my nose. It has a large bump on it and it slopes down at the tip. I have always wanted a smaller and more shapely nose. What type of rhinoplasty do I need?

A: Based on a review of your pictures, you are an ideal candidate a good rhinoplasty result. This is based on your pictures which show the type of nasal anatomy which is very favorable for surgical change to get near ideal nasal proportions and shape.

Patients with nasal nasal skin have the capacity after surgery to show quite quickly and completely the changes that have been done to the cartilaginous/bony framework. In addition, thinner nasal skin does not get as much swelling after surgery and it does not take as long for most of the swelling to subside. Such is the type of nasal skin that you have.

A very common and favorable type of nasal problem is the convex dorsum which patients know as a nasal hump or bump. This overgrowth of the cartilage always makes the tip of the nose look like it is pushed downward, even if it is not. Reduction of this hump completely changes the shape of the nose and the profile, which make the nose looks smaller and more proportionate. The tip of the nose can also be narrowed at the same time. The other consideration in your rhinoplasty is the potential benefit of a small chin augmentation at the same time. Your chin is naturally shorter which is common in a nose with a hump. Reducing the size of the nose (dorsal reduction) and bringing the chin forward creates a diametric change in the facial profile which makes it more balanced overall.

Computer imaging will demonstrate these rhinoplasty and chin changes and I will get those prediction to you tomorrow.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast augmentation. After having two children I have lost all of my breast tissue, I am completely flat, the proverbial straight as a board chest look. I desperately need breast implants. What size and style of breast implant would you suggest? 

A: Based on a review of your pictures, you are an ideal candidate for breast augmentation. Let me detail what makes one an ‘ideal candidate’ . An ideal candidate for any plastic surgery procedure is the one that is most likely to get the best result based on their natural anatomy and the anticipated changes from the surgery.

The best breast augmentation results come from small breasts that have no sagging and with the nipples centered on the diminuitive breast mound. Thus when the mound gets expanded by an underlying implant the resultant shape assumes completely the shape of the implant with firm skin and a perfectly positioned nipple-areolar complex. Your pictures demonstrate that you have an ideal presurgical breast mound by this description.

When choosing a breast implant, the first thing to decide is between saline or silicone-filled. With your lack of any breast tissue, silicone would be a better choice to avoid the rippling of saline implants which would be revealed without a thick layer of breast tissue to disguise it. Implant size is a matter of personal choice but the volume of the implant should generally not exceeded your natural breast base width. The final implant decision is whether the implant should have a round or teardrop shape. That is a personal choice of whether you want an augmented breast look that is round (full upper pole) or a more natural or sloped breast shape. (lower pole fuller than the upper breast pole)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had skull reshaping with bone cement last year in South Korea as my back of head was pretty flat. Since then I wasnt told that much information and may have put pressure on the left side of the back of my head, and now the left side is flat. can you fix this and is it safe to re apply more bone cement on top? 

A: Since skull reshaping bone cement is permanent and does not move or degrade, the appearance of flatness on one side of the back of your head has nothing to do with what you did. (put pressure on it) This flatness has likely reappeared because all of the swelling has finally gone done and the complete result of the skull augmentation procedure is not evident. In other words, the application of the bone cement was likely not symmetric. When correcting a total flattening of the back of the head, the hardest thing to do surgically is to get both sides even. (symmetry) This is not a rare postoperative problem.

The good news is that this is a very correctable skull problem through the application of more bone cement on the flatter side. There is no problem with placing new bone cement on top of older or pre-existing bone cement in skull reshaping surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting  breast implants. I have been wanting bigger breasts since I was 16 years old,  I am 26 years old. I am currently a very small B cup and want to be a full D cup using gummy bear breast implants. I am 5’ 4” and weigh 135 lbs. I have attached a picture. Based on my picture and height and weight, what size implant should I get?

A: From the one picture you have sent, there is no question you would be a good candidate for breast implants. Having no sagging of the breasts with good tight overlying skin and centrally positioned nipples is the definition of an ideal breast augmentation candidate. Since implants largely just take what you have and make it bigger, the better-shaped breast (small as it is ) will always create the best looking breast augmentation result. Since you are young and do not have any sagging you should be able to have your breast implants placed beneath the muscle which is the best option for a young person for the long-term.

When it comes to choosing breast implant size,m it is not as simple as looking at a picture and knowing your height and weight. What counts is what volume will create the look of a full D cup on you. That, of course, is also open to your interpretation of what that is exactly. This is why I prefer the use of volume sizers for the patient to try on and see how it looks. It is also important to know what your natural breast base width is. With that being said, an experienced estimate would be 400c to 450ccs breast implant size for you, probably of a high profile style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rib graft rhinoplasty. I am a 32 year-old Asian woman that has a bad nose problem now. I had a silicone implant rhinoplasty done severn years ago. It looked good and was fine until about six months ago when my nose got really red  and the implant got infected for no apparent reason. It had to be removed.:( Now my nose is sunken in and the tip is really short, it looks worse now than beforeI had the implant put in. Based on what I have read, it appears that a cartilage graft from the rib would be needed to get my nose back to the way I want it to look.

A: A rib graft rhinoplasty is the best choice for you now without question. The short nose of Asians can pose a real challenge when complications have occurred from a prior rhinoplasty. Unlike Caucasians rhinoplasty problems which are often the result of too much supportive cartilage removal, revisional Asian rhinoplasty problems result from augmentation problems from implants or grafts. When nasal implants get removed due to either infection or skin thinning, scar contracture will cause the tip to rotate upward as well as lower the height of the bridge due to the implant removal. This accentuates the naturally short nose of most Asians not to mention the scar tissue that has been created.

How effectively the Asian nose can be effectively built back up and lengthened is the result the result of the cartilage donor source. (an implant is obviously not a good choice when a prior implant has had to be removed) The amount of cartilage then controls what type of structural support and lengthening manuevers can be done. Rib grafts provide the most amount of cartilage one can use allows long straight grafts to be made for septal extension, columellar strut and extended spreader grafts as well as dorsal onlay grafts. No amount of tip or dorsal grafting from the ear or septum can produce the effects of what a rib graft can provide.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am possibly interested in skull reshaping surgery. I have occipital plagiocephaly.  My head is  clearly flat on the back left side of my head. I am 67 years old and losing my hair which makes it more noticeable. Can surgery correct this at my age or is it too late?

A: Age is not a physical issue for this skull reshaping procedure as long as one is in good health for the surgery. Since the procedure is an extra cranial procedure (onlay augmentation), it is no more complicated to go through than many other cosmetic facial surgeries. Age is only a limitation if one decides that they are too old to care about it…then it is too late.

I would be happy to look at any pictures that show the flatness on the left side of the back of your head.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting buttock implants and fat grafting to my hips and butt. I know I don’t have much fat but I really want a much bigger butt. I have attached some pictures of me and a picture of my dream butt. How possible is this result?

A: Thank you for sending your pictures. You clearly have little fat to contribute to your buttock or hip augmentation. Your buttock augmentation result will come largely (95%) from the effect of the buttock implants. The ideal picture you have shown is not a realistic result. That is not going to be achievable no matter what implant size is placed. With an intramuscular implant approach with a maximal volume  of 300 to 350cc, that result will be about 33% to 40% of your ideal buttock size result. If the implant is placed above the muscle (subfascial) with a maximal volume of 500 to 550ccs, you will get about 60% to 65% of your ideal result. Any addition of a small amount of fat will add little to the implant-created result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am quite determined to have temporal reduction surgery done (head width reduction), but there is still a couple of lingering question I need answered. I have attached several CT scans of my head to get a better visualization on the width of my muscle as well as my skull. I was born with positional plagiocephaly. This has caused my head to be misshaped and one side of my face is wider than the other side. Initially, I was thinking about getting the head width reduction for both side of my face, however, after a careful consideration I want to focus the head width reduction on just the right side of the face on the wider side.  If the result of the reduction is significant, I might consider a reduction on the other side of face as well as jaw and chin bone reduction on the wider side of the face. One of my main concern of the reduction is how much the width can be reduced. I recently took a CT scan of my head and I found that the size of the temporalis muscle at the widest area of my head isn’t very thick being about 6mm. Thus I felt through only muscle reduction there might not be as significance of reduction compare to when if both muscle and bone reduction is performed at some region of my head. Also I recalled last time we talked that you told me that you are not gonna remove a lot of muscle you simply reattach it and let it shrink. Since the temporalis muscle at some of widest regions of my head is only  6mm, I felt the shrinkage of muscle won’t likely achieve my desire width of reduction which is between 5mm to 7mm on the right side. Thus, I wanted to see if I can completely remove the temporalis muscle on that side above the ear.

A: It appears you have misinterpreted how I do the temporal reduction surgery. I initially detach and remove the posterior muscle in its entirety, then detach the rest from the temporal crest, shorten it and reattach it lower. So the entire posterior muscle is removed. That is critical to get a very visible width reduction from 5 to 7mms based on the thickness of the muscle present. Bone reduction is done based on what the CT scan shows although it is never as significant usually as the muscle reduction, but it is an additive component to the overall width reduction. Certainly only one side can be done if desired and, in cases of asymmetry, met be the best initial approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If I went with buttock implants under the muscle what is the largest size  I could go?Here are a few photos I would like to know your thoughts about the previous question and what would get me to my dream buttocks. I know my butt is very flat. But is there anyway to see how different sizes would look with out coming to the office since I do live out of town?What would you think the safe option is? I don’t have to have a butt like the pictures but I do want one that I can be proud of and wear certain clothes and feel good about myself. But I also want it to look natural and be a size that fits my body and my new additions up top.

A: When buttock implants are placed intramuscular (inside the muscle, not under it), the largest size for most patients is usually in the 300 to 350cc range. (which is likely not what you are demonstrating in these pictures) From your pictures, I can certainly see why you seek buttock augmentation given that your buttocks has no projection. (flat) There is no question intramuscular implants (you’re only choice since you have no real fat to harvest) will make a significant difference just not to the degree of projection like the pictures of celebrities you are demonstrating. That can more likely be obtained with buttock implants above the muscle where implants of much larger size can be placed (up to 600ccs) but there is the potential for a higher risk of complications in that location. (although an easier recovery) When it comes to intramuscular buttock augmentation, the rule of thumb is you just put in the biggest size implant possible. (e.g., 350 – 400ccs) Why?…because it will never be too big as that is the limitation of that buttock augmentation approach. The intramuscular pocket will only allow so much volume. In some cases, and you might be one, you can also inject some fat in the subcutaneous space under the buttock skin at the same time. That adds a little extra volume (50cc to 100ccs) and gets one a little body contouring as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in one of the facial procedures (cheek augmentation I think) to improve my smile. I make an effort to smile only to find out that people don’t find it compelling. I am confused and this makes my self-esteem very low. I have small(weak) cheek bones which some how make me look like I am frowning all the time. It was after me noticing my self-consciousness that I started being aware of all the people I found very approachable or had friendly faces, in other words their cheek bones were gently protruding and noticeable from a profile(side view of the face). This, them having strong cheek bones, really made them appear to be ‘ever smiling’ and smile effortlessly even when it is just a grin their evoking. I looked at myself talking in the mirror lately and was evidently stunned, because I would say things but my facial expression was not corresponding with what I say or the way in which I respond to things I said to myself. For instance, when I am surprised my eyebrows don’t rise and no lines on my forehead show, because my eyebrow bone is also flat and I seem not to send my messages across to others other than verbally. A stronger cheek bone with lines on the corners of my lips and bigger eyebrow bones will make my smile sensible. 

A: It sounds like you have a good grasp on how to improve your facial appearance. By your own description you know that cheek augmentation by implants, possibly combined with brow bone augmentation, would help your smile both outside and in.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in abdominal scar revision. I had a panniculectomy done six years ago and an original tummy tuck approximately 11 years ago.  I’ve been unhappy that the scar is so high. As you can see in the photos there are 2 scars. The one on the bottom was from my first tummy tuck. Do you think another surgery to lower the top scar could be done? There’s not a whole lot of skin to work with but low cut bathing suits are what I like to wear. I’m very self-conscious about my scar. Your thoughts are appreciated.

A: My first reaction is that I am stunned that the intervening skin between the two abdominal scars actually lived and not died. That was a very risky procedure from a skin necrosis standpoint. But it did work although the logic of two such displaced scars remains a mystery.

If the goal is to lower the upper abdominal scar (via an upper abdominal skin flap elevation) and bring it down to the lower one, that is not going to be possible. There likely is not enough skin looseness to allow that much downward mobility after having had two excisional abdominal procedures. I do think it is possible that the skin between the two scars can be removed and made into one scar, but that will only happen because some of the closure will come from the lower pubic tissue being elevated. This will then place the new scar about halfway between where the two scars are now. That will not meet your low cut bathing suit criteria. Unfortunately I do not believe your abdominal scar situation can be improved to meet your aesthetic criteria.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, will a buccal lipectomy make a noticeable difference in the shape of my face? I am trying to get a shadowing effect below my cheek bones so I will have more of a male model look.

A: While the buccal lipectomy procedure has a controversial side as to its long-term facial aging effects (creation of the gaunt face), it is also importanbt to look at their upfront effectiveness as well. In most cases, a buccal lipectomy is a complementary facial reshaping procedure whose magnitude of effects differ based on one’s facial make-up. In a thinner and more skeletonized face, its effects are more visible but this is also the patient who is most predisposed to have sunken in cheeks later in life. In a heavier rounder face, buccal lipectomies often have a more minor effect and other procedures must be done around it to create a more visible facial reshaping effect. These are also the same patients that will not have a sunken in cheek look later in life. Opting for buccal lipectomies in facial reshaping must take into consideration the balance of early facial shape improvement versus potential detrimental long-term facial shape changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in knee lifts. I am 50 years old and am very active but my knees look like an 80 year old women. I need a knee lift to regain my KNEE self-esteem. I am in disbelief as active as I am that my knees have aged so horribly. I have an adverse reaction to most anesthetics so hopefully this is a procedure which could be done under a local anesthetic. 

A: The knees, like any other structure on the body, are not immune to the aging process. the constant motion across the knee joint requires moveable flexible skin. But for some people (usually thinner and very active ones) that constant motion results in the development of loose skin. This loose skin appears as folds above the knees, often having two or three small skin folds that have ‘piled up’ above the knee cap.

The procedure of a knee lift can remove these skin folds by excising a crescent of skin above the patella. It must be marked and removed carefully so that enough skin is left for the knee to bend 90 degrees of greater without undue pulling on the wound closure/scar. It is a fairly simple outpatient procedure that for the very motivated could be done under local anesthesia. It does result in a fine line scar above the knee and this must be considered carefully as a worthwhile aesthetic trade-off for the removal of the suprapatellar skin folds.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get a buried penis repair done. How exactly is it done?

A: When you use the term ‘buried penis’ that unfortunately does not tell me what type of tissue problem there is and what needs to be done to make it better. Is it a short penis only, an isolated large suprapubic mound, is there an abdominal overhang or some combination of two or all of them? There are different plastic surgery techniques that are done for the buried penis problem with varying degrees of success. These could include pubic liposuction, a pubic lift, penile release and lengthening or some combination of all of them. Having a picture of the pubic area, ideally from the front and side views, would help me understand the buried penis problem and give you some recommendations on whether plastic surgery would provide a positive improvement. (increased penile show)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I know I need rhinoplasty but am not sure what else I need. I would like you to analyze the attached photos in order to determine the ideal procedures to bring better balance to my face. These are my own assumptions about my facial appearance, both what I see as out of proportion and how to go about fixing it along with the objectives I hope to achieve

1. Droopy asymmetrical nose – It would be optimal to both straighten the entire nose and strengthen the tip (add cartilage). The tip would look best projecting forward more. I would still want to keep a high strong nasal bridge, so little shaving should be done there. Tip should still be turned down slightly a few degrees further than perpendicular to the face.

2. My eyes are too prominent relative to my other features and I would like a stronger, masculine look to eyes. I have looked at everything from malar to inferior, lateral, and superior orbital rim implants. I am less sure what would prove ideal for this issue, so your own suggestions here would be much appreciated (though if you think it is a bad area for me to augment please let me know as I want your complete objective opinion). Be as specific as possible, referencing both the individual anatomy and procedures that are possible.

A: Based on the one side view picture that you have provided, I did some imaging for the rhinoplasty based exclusively on tip rotation and elongation with minimal reduction of the middle vault height and no reduction of the nasal bridge bone. With this change I see no reason for chin augmentation which is the first other facial feature to think of when the nose becomes derotated.

From an eye standpoint, the only consideration you want to make is for infraorbital rim-malar augmentation. While superior and lateral orbital rim augmentation can be done, the effort to do does not justify the minimal benefits and risks. The focus for making the eyes less prominent should be on the recessed infraorbital-malar complex. I have factored this into the imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to possibly get temporal zone migraine surgery or Botox injections.  I have been diagnosed with chronic daily headache (migraine) and believe this would be beneficial.  I have had it for approximately 3 1/2 years and normal medications and treatments do not correct the issue. The issue developed approximately 2 to 3 months after returning home from overseas.  I do wear a TMJ mouth guard for bruxism and have daily muscle tension type headaches in both temples and above the ears.  Since medications and the mouth guard do not fix the problem I believe that this procedure may provide some more permanent relief. Please feel free to email or send any additional information. Thank you.

A: By your description, it appears you have symptoms that involved both temporal and masseteric muscles. This, to me, more likely suggests myofascial pain syndrome of these muscles and fascia rather than a specific trigeminal nerve compression issue. The first place to start is with Botox injections into either the temporal or masseter muscles or both. Then see what the response is which, in my experience, I have yet to see a patient who does not get some significant reduction in their symptoms. Migraine surgery is reserved for those patients in which a specific peripheral neurovascular trigger can be found rather than overall masticatory muscle pain/headaches. That is the first place to start and is what should be done during the first visit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in skull reshaping to reduce the width of my head. I have a large head and I’m embarrassed about it. I have to buy larger hats than everybody else and it’s a hassle to wear sunglasses or prescription glasses because my head is so large that it squeezes and gives me a headache. I have to order special made ones if I want them to be comfortable. I understand that it’s not really a problem, but I’ve been self conscious about it for years and I want something done to stop constantly thinking about it. I would like a procedure that would make my head smaller in width. What could you do?

A: Skull reshaping can provide numerous skull shape changes and one of those is in the reduction of its width. In looking at your head shape, it easy to see your concerns with a fair amount of temporal convexity, bulging of the anterior temporal lines and a general side to side large cranial outline. While there are limits to how much the skull be reduced, there are some visible changes that can be achieved. The bulging on the sides of your head (temporal area above the ears) can be reduced by temporal muscle reduction/shortening and the anterior temporal lines (transition between the sides of the head and the top) can be reduced by about 5 to 7mms. These manuevers will never make your head width as small as you would like but they can make a visible difference.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw implants to give me a more defined jawline. I can see from your computer imaging that adding the chin implant to the jaw angle implants really does make a difference. I have a couple questions. Are the implants silicone? Do the size and type of the implants determine how chiseled my face would look? I’m trying to get as close to the ‘male model’ look as possible. I’m not sure if any other procedures would make as much of a difference as these.

A: Chin and jaw angle implants (jaw implants) are made of either Medpor or silicone material and I have used both extensively. However I much prefer silicone because implants made of this material can inserted much easier, shaped intraoperatively much better if needed and are far easier to revise/remove if needed. A good saying about silicone facial implants is…easy in, easy out and easy back in if needed.

The size and the shape of the implants play a major role in the look of the final jawline result, provided one has a fairly lean facial look to start. The thicker the overlying soft tissues are, the less defined the outline of the implants becomes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in orbital floor augmentation to raise up my eye which is about 2 to 3mms lower than the other side. Regarding the graft material, I’d prefer to go with natural ear cartilage if that’s something you’re comfortable using. Have you used ear cartilage for orbital floor augmentations before? I also have several more questions about this procedure…

1. Could raising the eyeball via the orbital floor (as opposed to reconstructing the entire orbit in a different position) result in pressure on the upper part of my eye?

2. Is there any chance of this procedure affecting my vision?

3. How long would I have to abstain from wearing my contact lenses?

4. Could this result in unintentional horizontal movement, in addition to vertical movement? Is there any chance of ending up with a cross-eyed look?

5. Approximately how long will it take for my eye to settle in its final position, about 2mm higher than where it is now?

6. Approximately how long will the procedure take and how long will I be under anesthesia for?

7. Is there any way to do before/after 3-D imaging for this procedure? I think what I’m seeing in my head is a complete relocation of my entire eye – I’m having some trouble visualizing what it would look like just to have my left eyeball raised, while my eyelids, lashes, etc. remain in the same position.

A: Cartilage can be used for orbital floor augmentation and certainly would be a natural material. I am all for using a natural material when possible. Cartilage has the advantage somewhat similar to a synthetic implants in that it should not undergo any resorption. The only issue with ear cartilage is that the amount of graft material is fairly limited. Ear cartilage is great for the nose but the front part of the orbital floor is much bigger. Thus the only caveat is that the ear graft size may be somewhat insufficient for its intended purpose. In answer to other questions:

1. This amount of orbital floor augmentation will not put any undue pressure on the eye.
2. There is no risk of vision loss with this procedure.
3. You can wear your contacts as soon as you feel comfortable and can get them in.
4. The procedure will not result in any unintended horizontal movement.
5. The final results from orbital floor augmentation can be critically judged 6 weeks later. Always the eye will look a little higher than the ‘normal’ eye for awhile.
6. This is a one hour procedure done under general anesthesia.
7. Computer imaging can be done of the eye moving up but it will create a distorted view. Computer imaging can only show more or less of what is already present. Thus moving the eye up should show a similar amount of iris exposure but it will look elongated and will not show a natural iris to lower lid margin relationship. I am happy to do it but you will probably not find it helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of facial freshaping.  I have some issues regarding a long face, and more importantly a long midface. It’s just been seriously bothering me for years to the point where it is causing problems. If you could take a look at these pics and just figure out what is so wrong with it, i would really appreciate it.

A: While I would not disagree that your face is a little long and the guilty component is your midface, there are other facial structural issues that are magnifing that impression. A horizontally short chin and a long nose with an acute nasolabial angle make the midface loo longer than it already. When you combine that with a very skeletonized face (little facial fat), the effect becomes even more so. There really are no true midface shortening procedures other than a maxillary impaction which is only used for vertical maxillary excess that has a gumkmy smile. (which does not apply to you) But what you can do is change some of the other factors that are accentuating the midface elongation effect. This includes a sliding genioplasty to bring the chin forward, a rhinoplasty to rotate the tip and decrease its length and submalar cheek augmentation to procide some more width to the midface. Together, these facial structural procedures can help shorten a long midface appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been wanting to get a rhinoplasty for awhile to augment my radix and glabella. My goals are to widen and raise the radix so that there’s a smoother transition between the nose and the brow ridge. Anyway, I have two questions:

1) Will I be able to achieve this through cartilage grafting, and if so, how long a recovery should I expect?

2) I’m hoping to get it done next year. As such, could fillers be injected into the radix and glabella in the interim? It would also serve the purpose of giving me an idea of the kind of augmentation that can be achieved. Also. if fillers can be used, how much filler will actually be required? Thanks!

A: The long-term solution to a deep radix is augmentation, albeit done with a synthetic implant or a cartilage graft. There are arguments to be made for either an implant or a graft but I will leave that subject alone for now. If that is the only thing that is being done to the nose, there is a very short recovery since such augmentation can be done through a closed rhinoplasty technique.  If one is uncertain as to how one would look with radix augmentation, one could do either computer imaging or place injectable fillers as a ‘surgical test’. Usually most injectable radix augmentations take about .3 to .4cc of material to create the desired effect. While there are many different type of injectable fillers, one should use those that are composed of hyaluronic acid as these can be placed in the smoothest fashion and the timing of their resorbability can be adjusted based on the specific product used.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. Do yout have experience in removing medpor L shaped implants? This nose has become tight and hard.

A: Revision rhinoplasty often involves removal of synthetic implanted materials. I have removed more than my fair share of Medpor implants all over the face. I am assuming when you say an L-shaped Medpor implant you are referring to its use in the nose for dorso-columellar augmentation. Contrary to common perception, medpor implants can be removed without undue difficult even though they get fibrous tissue ingrowth into them and can be quite adherent. Their removal from the nose is the ‘trickiest’ area to do it because of the naturally thinner tissues of the overlying skin. The tissues may be very carefully lifted off of the implant so as not to damage the blood supply to the overlying skin. I have  removed such nasal implants numerous times over the years but the key questions is…what do you want to do to replace it? Depending upon its size, the tissues can contract and become distorted after its removal. In other words, your nasal skin and its shape is not going to return to what it was before the initial implant surgery. This is the more important concept to consider in your revisional rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of skull or face reshaping. I would like to know based on the photos/info provided what would you assume is the cause of my skull/face defects? So basically I have a protrusion of my right forehead area as well as on the scalp area (right side mainly)and extends but decreases to the left side of my top head area giving a “Gumby” appearance, slanted, lopsided wichever one. I also have a cone looking shape on the back top of my head, as well as my right jaw is sunken in slightly, my right ear is further back than the left, and my right eye slightly bulges. Hopefully this info gives you some clues to let me know what I may have. I would also like to know the best approach to fix the issue and if possible see what it could look like if corrected. Thanks a lot.

A: Everything that you are describing and demonstrating in your pictures is most likely the result of a congenital skull plagiocephaly anomaly. This is fundamentally a developmental problem with the skull base from which the skull and face shape becomes slightly twisted and asymmetric. The key question now is what can and should be done with the constellation of skull and face asymmetries that exist. While there are numerous surgical procedures for all of these issues, they are aesthetic trade-offs (scars) for doing so and these must be considered very carefully. The question that I would ask you is which one or two of these issues bothers you the most and would like to see improved/corrected?

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a non-surgical rhinoplasty. I really need my nose fixed. I’ve been so depressed about my nose for about 7 years. I’m 20 years old now. I know I can’t afford surgery so I thought hopefully I can afford this. Why stay sorry for myself when I can do something about it, please help ! I have attached a picture so you can see my nose shape problem.

A: Based on your picture, you are not a candidate for a non-surgical rhinoplasty. This very limited nose reshaping technique uses injectable fillers to build up certain parts of the nose. Almost always that is done to build up the area above a hump or bump in the upper nose. What you have is a wide or fat nasal tip due to large lower alar cartilages and how they come together…or don’t come together. Correction of the wide nasal tip requires  an open surgical approach with cartilage reduction and reshaping with sutures. That can be tremendously effective in reshaping the tip of the nose but it is a surgical procedure. Just for a tip rhinoplasty procedure done in a one hour procedure under general anesthesia the cost is around the $4,000.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some type of revisional rhinoplasty. I had a major depression on the tip of my nose for which I got fat grafted to the tip. But now I feel I have a bigger nose than before and the tip doesn’t really have any definition. What should I do now?

A: With fat grafting to the nose that kind of result would be expected given that a ‘blob of tissue (fat graft) was done. Fat grafts fill space and provide no definition as it is an amorphous graft filler. Why was this method chosen as opposed to fixing the tip depression by cartilage reshaping methods which can fix the depression and give the tip more definition?

Generally major depressions on the tip of the nose that have been present since birth are known as a bifid nasal tip. This is where the natural separation of the meeting of the lower alar cartilages (known as the dome of the nose) are too widely separated and this separation extends down into the medial footplates. (over the columella) This creates a groove or visible split down through the tip of the nose. This is repaired by cartilage suture techniques that bring the widely splayed cartilages together.

What can be done for your nose now is to remove the fat graft and repair the depression with either cartilage suture shaping techniques or crushed cartilage grafts for your revisional rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in nose reconstruction (cleft rhinoplasty) for my teenage daughter who was born with a cleft lip. She is fourteen and is looking to have surgery this coming year. I am looking for a plastic surgeon who is experienced with rhinoplasty in clefts and just want her to be comfortable with her appearance.

A: All orofacial clefts (with the exception of isolated cleft palate) has some detrimental effects on the development and appearance of the nose. While the entire nose is almost always affected, the greatest deviations from normal occur in the nasal tip. Because the tip shape is controlled by the underlying septal end and the paired lower alar cartilages, it is particularly susceptible to very noticeable and classic tip shape deformities. Most commonly the lower alar cartilage on the cleft side is weak and misshapen, resulting in it being positioned lower (slumping) and having a widened and oblong nostril. This is exaggerated as the end of the septum is deviated away from the cleft side into the opposite nasal airway. This causes the entire nasal tip to be asymmetric and have the classic slumped appearance. For reasons unknown, the vast majority of cleft noses have a thicker skin cover, an issue that has great relevance in the outcome of rhinoplasty correction efforts.

Most cleft noses need a full septorhinoplasty approach to both optimize correction of the bony cartilaginous framework but also to correct any internal airway obstructions (septum and turbinates) which are almost always present. The relevant question is always the timing of the rhinoplasty surgery given the congenital nature of the nasal problem and the sensitive psychosocial development of children and teenagers. The traditional thinking of doing any rhinoplasty is when facial development is near complete, age 16 or older. However, I have always taken an earlier approach to some rhinoplasty patients particularly the cleft patient and I don’t think age thirteen or fourteen is too young.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wanting to get saline breast implants. I am probably considered and A cup and would like to be around a full C cup. One of my biggest concerns is cost. How much would it cost from start to finish to have breast implants done by you? (Including any pre and post-op appointments). I am hoping I can find a good surgeon that is able to do the procedure in my price range because my husband would be the one paying for it and he takes a lot of convincing 🙂 Thank you!

A: As a good working number for saline breast implants, the cost of $4700 can be used. This includes the before surgery consultation, all surgery costs (implants, anesthesia, operating rom fees, surgeon’s fee) and any after surgery visit up to six months after the procedure. You may use this number in your ‘negotiations’ with your husband. May it work favorably for you in these discussions.

The advantages of saline breast implants are their lower cost, the ability to place them through hidden armpits incisions and the capability to adjust the volume of the implant during surgery for any differences seen in the two breasts as they are enlarged.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have breast implants but I want to be bigger. I think I may have maybe 300ccs ?? But I want to go bigger like 500 cc’s. My only concern is that I am really thin and weight about 110lbs. However, I think they should go that big . I have had 3 kids nursed and had weighed more. I have a really small frame I don’t want them too big but I want a DD . Right now they don’t look big at all. I think it’s because of weight loss and having children.

A: One of the advantages of having existing breast implants is that you have a reference about size. (volume) As a general rule in breast implant exchange for larger breasts you should always go at least 100 to 125cc bigger to see a cup size difference in most patients. Obviously that number changes based on the body frame of the woman. (smaller frames may be 100ccs, larger frames may be 150 to 200ccs) Based on your description, the size change of 200ccs sounds about right in your case. If 300ccs is not big at all and a DD cup is your goal, then at least 200ccs would be appropriate in my experience for your breast implant exchange.

Dr. Barry Eppley

Indianapolis, Indiana