Your Questions

Q: Dr. Eppley, I had a jaw/chin implant 14 weeks ago, it was two separate pieces that were screwed in. I would assume most of my swelling is gone but I have asymmetry as one side is lower….my Dr. is a reputable surgeon and is working with me, we meet approx every 5 weeks or so….he said if necessary he can go in to the one side, make a small incision and file it down some (not remove it)…he also put some filler in the area right where the implant starts at the jaw so you can see it….said there is permanent filler we can use down the road….I guess my question is how does this sound to you…..is filing down of an implant an option when there is tweeking to do?? I greatly appreciate your help….also is filler routinely used to help “fill in” near and around an implant for a more natural appearance and do you advise that. Thank you for your time!

A: Let me make sure I understand exactly what implant you have. Using the term jaw/chin implant could be either an isolated chin implant or a combination chin and jaw angle implants. I suspect you mean a chin implant because it is two-pieces which would also make it a Medpor two-piece chin implant. If there is asymmetry between the two positions of the two pieces  and you are certain that it is not just swelling (more than 3 months after surgery), the best approach is to go in, unscrew the implant, reposition it higher and screw it back into place. There is nothing wrong with cutting down the lower side but that can be harder than it seems to do smoothly and evenly with the implant in place. As a general rule it is always better to fix the primary problem (implant) rather than investing in camouflaging the problem by injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My goals are increased horizontal projection of my chin( no vertical lengthening)and a more square chin. Jaw angles flared out with augmentation of the angle itself and of the ramus but not the body? ( not necessarily a drop down of the angle itself as I think the angle is low enough currently). Rhinoplasty to decrease the hump in the nose possibly decreasing the width of the bony part of the nose when viewed from the front and the tip refined somewhat( picture with red hat)( My morph( lateral view of my nose in the blue shirt) I admittedly got a bit crazy/unrealistic with the tip of the nose. Finally, liposuction below the lower jaw/chin area to get rid of the adipose tissue that has always been there no matter my weight( a good 10-15 mm in various spots under the jaw/chin when I do a pinch test.) Also, wondering if the chin implant can be placed through an existing scar on my chin from my childhood.( picture added of scar 20 mm long and 10 mm long in the 2nd aspect and around 3 mm of width to the actual scar line( the scar is basically a T shape) Attached are some before and after pictures that I’ve done in photoshop as what I’m kind of looking for in general terms. I don’t know if this is even possible / what would be proportional for my face, but thought I would include them as a rough reference since I’m not there in person currently. My overall goals are increased balance in my face as I think the upper 1/3 of my face/ head is much larger then the lower 1/3. Also, I’m looking to do this with IV/ twilight sedation and not general. I’ve had septoplasty (2004) and a hernia operation in the past with just iv sedation(+ spinal for the hernia sx) and prefer this option. Thanks a lot.

A: Thank you for sending your pictures and doing the array of imaging. My review of the imaging matches fairly well with your goal descriptions and I would agree with much of it with the exception of a few minor variations.

For your chin you seek more horizontal projection, a more square shape in the frontal view and no change in its vertical length That would be possible using a square silicone chin implant, probably of at least 7mm to 9mms in thickness placed through a submental incision. It would not be wise to use your existing scar as it is too small, would become more prominent as the chin is pushed forward and would dive through the mentalis muscle in the process. A scar revision can be done on it but it would not be used to place the implant.

Your jaw angles show width expansion, a sharpening of the angles and no vertical lengthening. That could be accomplised by a 9mms silicone lateral augmentation implant placed directly over the existing angles.

The only comments about potential results with these implants is that the angularity of them (point of the angles and sharpness of the chin corner) may or may not be as sharp/pronounced as you have shown. The other issue is the continuity or smoothness of the jawline from the chin back to the angle. While the ends of a square chin and jaw angle implants will overlap, these overlapping areas are not as thick as the other parts of the implants. This it is not clear that the jawline will be as perfectly smooth from front to back as you have imaged.

The nose can be changed through an open rhinoplasty with a hump reduction and tip narrowing and some mild lift. I think those results are very achieveable.

Lastly, this collection of combined facial structura procedures can be done very well under just IV sedation. These are operations that are best performed under general anesthetic to get the best result.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had an operation on my forehead almost 16 years ago that changed my life. My frontal sinus was backed up causing me to have had my forehead bone removed and replaced with my hip bone in fear that it was infected. I have a cut along my hair line but my forehead does not look the way I wish. How much does a reconstruction cost to have some material to over lay the bone for a more normal look? Thanks!

A: I am assuming based on your description that you originally had a frontal sinus obliteration procedure in which the sinus lining was removed and filled in with an iliac marrow graft. This undoubtably healed in a very irregular fashion, leaving the brow bone area with an uneven contour that may even be a bit sunken in. The brow bone/forehead contour can be significantly improved by an onlay frontal cranioplasty using hydroxyapatite cement. That can be done using your existing hairline scar. In order to properly estimate costs, please send me a picture of your forehead for my assessment so I can see how much cement may be needed which can highly influence costs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have had surgery for migranes the first one was 2012 all four trigger points and deviated septum. about 4 months later I developed a very suttle yet painfull pressure pain in my right temple. It was relentless. feb 2013 the surgeon went back in and removed an artery. for a week I was sure it was better then it came back again. since then I have had steroid injection and anestetic injected in the temple.. no help then botox injected.for two days after I felt great accually thought I might have a life. then the pain came back and remains and it sometimes triggers a full blown migrane, yesterday I got a shot for a migrane I was given demerol toradol and benadryl and phenigan. It helped in all areas but not in the area in the temple I still had the pain.. I cant live like this. the surgeron removed a portion of the zygomatic nerve.

A: Based on your description it sounds like you have had every migraine surgery approach for your right temporal migraines. The zygomaticotemporal nerve has been avulsed and the anterior branch of the temporal artery has been ligated/removed. Short of a temporalis fasciectomy, there are not other surgical options that I know. The fact that Botox had little to no sustained effect does not bode well that any further surgical manipulation would have a high chance of being effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to get the upside frown surgery.  Can you please tell me how much this would cost?  How long would recovery take?  Is the surgery painful?  How long does it take to get an appointment?

A: Thank you for your inquiry. It appears that you have an ‘upside down froen’ issue. In looking at your pictures what i see in a level smile line but an overhang of the mouth corners turning into deep marionette lines. This is not a problem that will respond well to a more simple corner of mouth lift alone. While that will get rid of the overhang at the corners of the mouth it will not improve the deep marionette lines. That problem can be simultaneously treated with either fat injections or (ideally) a jowl line lift to pull back the tissues that are falling forward.

For the sake of providing some sort of a cost quote, let me for now assume it would be a combined corner of mouth lift with marionette line fat injections. I will have my assistant pass along the cost of that procedure to you later today. This is not a painful procedure with minimal recovery. (just some mild swelling) Surgery can be scheduled as soon as your schedule permits.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I can not seem to find any surgeon who performs shaving or burring of the jaw angles! They all do osteotomies of the angles and the results look awful and unnatural. Would you know why most facial feminization surgeons do not shave the jawline? They cut off the bone (angle resection) instead. I am wondering if it is a typical technique used by FFS surgeons? Because they operate men to become women so they go extreme. I am already a woman and just want a softer jaw. Would you know how many mm can be shaved off the angles? and how many mm off the jaw close to the chin? maybe it is so limited that they rather cut so they can remove 1 to 2 cms, which to me, seems a lot on a face. I wonder if I should go to a maxillofacial surgeon instead?

A: My best answer is that is just a lack of experience and knowing the different options that can be done. Also total jaw angle removal is easier to technically perform than outer cortical reduction with jaw angle preservation. It is important to apply the right operation to the patient rather than just the one operation you know to every patient. Most likely you can get about 5mms reduced from each jaw angle reduction, tapering to about 3mms behind the mental nerve.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had a open rhinoplasty during June of 2012. My nose in the beginning looked great, but gradually it got a bit more but it went down gradually in time, though it is still swollen on the tip. But approximately two months ago I was washing my face and pressed on my nose and I heard a “click” and some blood came out. Since then I always get a bit of blood from my nose in my snot. I put vaseline inside my nose, which made the blood to stop coming, I guess it was dry on the inside. A month after the “click” in my nose, it became really swollen. Even though people don’t see a swollen nose, I know that my nose don’t look like this. Ive cleansed my nose with salt and water on the inside, I’ve used cortisone nasal spray, I’ve got antibiotics and cortisone tablets. The cortisone tablets really helped but only for a day or so, after that my nose went back being swollen. I do not know what to do, and would really appreciate your help.

A: I am going to assume that your open rhinoplasty was done using your own cartilage and no synthetic implants. In an open rhinoplasty a columellar strut graft is often used and this is really the only thing that can cause any clicking after a rhinoplasty if you move the nasal tip. But this is a natural material and not a source of infection or would cause an open areas inside the nose where the incisions where.  At 10 months after surgery you are rapidly approaching the time when you are reaching the final result although I would not pass final judgment until a year from surgery. You may consider doing some low dose kenalog injections in the nose to get some further nasal tip refinement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr Eppley,I was interested in getting a chemical peel or something for my skin type to help reduce/get rid of acne scars, melasma, freckles on my face.  I am half asian/white and I am concerned about scarring and hyperpigmentation from doing such a procedure.  I wanted to know your experience has been with asian patients and the success you have had with them.

A: I am not very enthusiastic about treating patients with intermediate skin pigments for discoloration issues because, as you know, those skin types are very problematic and often as many problems are created as are solved. Acne scars are problematic in any skin type in terms of the degree of improvement and the concept of completely getting rid of them is not usually possible. The fractional laser can help but, again, in intermediate skin types one has to balance the depth of treatment with the risks of hyperpigmentation. Scarring is not a concern in my experience.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having the following procedures done:

* Ear surgery – ear pinning + fix right ear that sits lower than left ear or fix left ear that sits higher than right ear + improve general appearance of ear cartilage
* Blepharoplasty – lower eyelid of my left eye (when I smile, it creates a prominent bag under the eye – not the case with my right eye though)
* Septoplasty – nose veers a little bit to right (possibly due to deviated septum)
* Rhinoplasty – remove slight bump & also looking to have a thinner nose
* Lip augmentation – improve general appearance
* Liposuction under chin – just to get rid of dreaded dubble chin
* Other possible procedures (if doctor recommend them): cheek implants, jaw implants and chin implant – I would like to have more masculine facial structure
Other possible procedures, if you offer them: tear trough implants, cheek lift
PICTURES:
First pic: how I actually look
Second pic: alterations I made to my face on your website (not perfect, just played around).

A: In answer to the facial procedures:

1)      It is possible to raise an ear .5 to .75 cms but it is not possible to lower an ear. Ear pinning or antihelical fold setback can effectively reshape the outer ear cartilage.

2)      The ‘bag’ of the left lower eyelid is hard to appreciate in your non-smiling views so I am not sure if it is a skin issue or a fat issue.

3 and 4) A septorhinoplasty is needed to straighten the nose, reduce the bump and have a thinner tip.

5) To make that amount of lip augmentation change, you would have to think about fat injections even though their survival in the lips is anything but assured.

6) Submental liposuction can be done but, more importantly, significant chin augmentation will eliminate that concern on its own. Cheek and jaw angle implants would be complementary to the chin and, in your thin face, would make it very sculpted and angular.

7) Cheek implants will obviate the need for a cheek lift. Tear trough implants can be done to fill out the under eye hollows.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I want to put something inside my upper lip,  a piece of jewelry I have. I also have big lips so this should work. What I’m using is a tiny Christian cross. I want to litterally implant it into my lip through the pink part of the lip, meaning you would not see it at all as it would be inside my upper lip. Could you do that or would having a piece of metal jewelry inside my lip cause an infection like tetanus?

A: A small metal implant can be implanted inside the lip as long as it is not too big and is placed in a sterile fashion. This also means that the implant must be sterilized before its surgical implantation as well. There is always the lifelong risk of infection or extrusion as long as the lip implant is in place although it is impossible to predict exactly how significant that risk is. That would be based on how deep or superficial it is placed and what the metal composition of the implant is.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, two weeks ago I got silicone malar cheek implants done. At first the healing process seemed to be going fine but then I started to feel pain and discomfort in the area where my implant was at on the left side. My dissolvable stitches also broke so I was bleeding a lot and went back to the Dr. .He said the cut was half healed half open and from what he could see it looked raw and red looking, I was also having some fluid coming out. Obviously he said it was infected but said it wasn’t enough to concern him and put me on Amox/K Clav 875 for 2 weeks. It’s been 4 days & it doesn’t seem like it’s getting worse or better what do you recommend is the next step. It still hurts when I smile or chew and is more swollen then the other side. Could there be a pus pocket like an abscess in the location of the implant? How can I find out? I’m thinking maybe an x-ray or MRI can show if there is something forming around the implant causing the discomfort? If so can it be drained? I just don’t want to have my implant taken out if there is some other way to go. Thanks in advance.

A: The most typical postoperative time period for an infection to occur from facial implants is 10 to 21 days after surgery…so you are right in that time period. But whether you have an actual infection or not is not clear. It is either an infection or a wound dehiscence (incision separation), both of which can give you pain on mouth movement. There is no value in getting an x-ray or other radiographic assessment as that is not going to change the clinical management of your cheek implant problem. You have two approaches to do. One is to stay on the antibiotics, see how the intraoral wound heals, and let time dictate what will happen. If improvement is going to occur it will be slow and will not occur in just 4 days. If it is an infection, it will eventually get worse and be obvious. (antibiotics alone will rarely cure an implant infection) This is the most convenient approach (not surgery)O even though it is not the most efficient. The other approach is to go back to surgery, wash out the implant site and thoroughly clean the implant, re-insert it and get a good wound closure. This is not convenient (as it is surgery) but it is the most efficient approach and the most assured one to retain the cheek implant long-term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions about the fat grafting procedure to correct the tear trough. I’m 20 years old and have had hollowness under my eyes causing dark circles for my whole life. The skin under my eyes is pretty thin, so all around my eyes looks purple, and there is a depression under my eyes causing shadow. This is exaggerated by my pale skin. I’m strongly considering fat injection for a more long term solution. I’m wondering how much of a risk I would have of developing lumps or cysts or scarring if I get this procedure. Are you very skilled at this procedure? How many of your  patients return with complaints about lumps, cysts, etc after getting the surgery? Are most of the side effects I’ve read about on the internet the result of less advanced techniques that are used?

A: Fat injection grafting in into the tear trough and lower eyelids is a common facial augmentation procedure. No matter what technique that is used for fat injections, there is always the risk of developing some unevenness or small lumps. Usually these are relatively minor and not a long-term problem. The key is to placed the fat deep along the infraorbital bony rim and not superficial under thin eyelid skin. The formation of cysts or scarring are not complications that I have ever seen with fat injection anywhere on the face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Where do you do surgery? What are the facility fees? What would the price be to narrow or burr the chin just at the bottom edges to make it look less square? Also, I have a flat forehead in the center with prominent eyebrow muscle, which makes the flat forehead area look flatter. How wold you fill in the flat forehead or the center of the forehead in a female? Fat injections? What would the price be?
And can you shorten the forehead skull if the hairline is a little high?

A: In answer to your questions:

1) My cosmetic surgeries are done in a private outpatient cosmetic surgery center. The operating room and anesthesia fees are based on the time that it takes to perform the procedure(s). That must be determined on an individual patient and the specific procedures they are having.

2) Narrowing the chin is done by intraoral ostectomies or removing the sides of the chin through a reciprocating saw technique.

3) A flat glabellar area can be built up by a variety of techniques with fat injections being the simplest to perform.

4) If one’s frontal hairline is too high, its length is not going to be lowered by reducing the height of the skull as that amount of skull height reduction can not be done. Shortening the long forehead is done by a procedure known as scalp or frontal hairline advancement.

I will need to first review some pictures of your face to see exactly what needs to be done before the costs of the procedures can be provided.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am considering liposuction again after having it 15 years ago on my abdomen. I am now 61 years old, 5’5″, 138 pounds and in good health. I’ve developed a spare tire around my middle since menopause. Do women my age have a good outcome with liposuction? I had some dimpling with my prior experience although I was delighted with the results. Also, should my doctor use a particular size cannula? I have also considered a tummy tuck but don’t want that much down time.

A: The contour results of liposuction at any age are based on a variety of factors including the quality (elasticity) of the skin and how the fat is removed which definitely includes cannula size and type. In today’s numerous liposuction methods, however, there is so much more involved than just cannula size that determines the amount of fat removed and the resultant smoothness of the overlying skin. A variety of liposuction technologies now exist based on different energies (ultrasonic, laser, high pressure water, power-assisted etc) as well as techniques to use them. How your liposuction is going to be performed and why should be discussed with your plastic surgeon. All of this aside, the risks of skin irregularities always exists with any liposuction method and given your prior liposuction experience it is always important to remember….past history predicts future behavior. If you have had skin dimpling before you will likely end up with it again.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Are malar cheek implants considered soft tissue augmentation? Are porous implants mainly used for submalar or malar cheek implants? Do malar cheek implants sag with time if not screwed in? Sorry if I am asking so many questions! Thanks!

A: Malar or cheek implants are onlay bone implants that create overlying soft tissue augmentation by pushing from beneath it. Porous or Medpor implants are one type of facial implant (silicone being the other) that can be used for facial augmentation. The material has certain advantages and disadvantage compared to silicone, which neither makes it better or worse than silicone in overall implant characteristics. Malar implants may shift or move from their original implanted position over time if not secured into position by screw fixation. (I would not call that sag but implant displacement)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have visited your website and am aware you do skull reshaping surgery. I was wondering if you could review the attached picture and can you notify me on what could be done for a skull bulge on one side that is just above my right ear.

A: The bulge to which you have shown is the temporal area which is composed of more muscle than bone. That can be very effectively reduced through a small vertical temporal incision, shortening the thickness of the muscle and reducing the bone a bit. I have done that type of skull reduction successfully numerous times. It is a short one hour procedure done under anesthesia. There is very minimal pain afterwards, no real recovery other than a little bit of swelling after surgery, and no physical restrictions afterward. It does result in a very fine vertical scalp scar measuring about 3.5 cms in the hairline.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, do you perform rib removal/resection surgery? Perhaps shaving down of ribs? I have one side of my lower chest that juts out too far and it is definitely from the ribs. I have attached some pictures so you can see what I mean. I hope to hear from you soon.

A: Thank you for your inquiry. Yes I routinuely perform rib grafting harvesting for rhinoplasty as well as occasionally done rib resection/shaving for chest contouring. It appears from the pictures is that your left subcostal area( ribs 6 through 9) protrude compared to the more normally-shaped right side. For left subcostal chest contouring, you need the cartilaginous portions of ribs 8 and 9 removed and ribs 6 and 7 shaved (beveled down) to get rid of the portion that sticks outs. This is done through a low subcostal incision of about 4 cms.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Specifically I have had a problem with “marionette lines” since my early thirties, I am now 41. I had Juvaderm twice about five years ago and I had Restylane this past October. I definitely prefer the Juvaderm and I was going to do that again. Maybe with some Botox as well because I also have smokers lines around my lips. I am not a smoker but I have a habit of constantly chewing on the sides of my mouth and that, along with genetics, appears to be a big contributor. I have not actually tried any Botox yet but research indicates the two treatments together could get me a nice result.

The reason I am inquiring about the Thermage is because my face is aging just like my mother’s, she had Thermage done in 2009 and had a great result. She has not had any follow up treatments and her face is looking very saggy again but I do think if she had kept up treatments she would be looking pretty good right now.

I am wanting to know which treatments would give the best long term results. The Thermage appeals to me more than injecting things into my face and it appears that it is something I could maybe do around once a year, where as the injections would need to be done more often. I am not opposed to injections and pain is not a factor. It is more about what is being injected into my face.

I currently get microdermabrasion every two weeks and I use vitamin C and lots of sunscreen because I am very pale.

I have been doing research on line for years about procedures. Now that I have some background information on what seems like a million options, I need to know what would work best for me and still be in my comfort zone. I have a big fear of looking plastic and unnatural, but now my fear of looking older than I really am is becoming bigger.

A: Thank for clarifying your problems. While the options for your concerns may seem endless, they really are not. The reason it seems there are so many is that none of the non-surgical approaches have any lasting effect and the differences in the results many of them produce are negligible. Hence, many things exists when none of them really work that well…at least compared to surgery.

For marionette lines, injectable fillers are the only real effective non-surgical option as you already know. Botox is not going to help the marionette lines because that it is not a muscular/animation problem. Botox can be effective for helping reduce some vertical lines in the lips and may help turn up the corners of the mouth a bit but it is a deanimator not a filler.

The use of Thermage is for the treatment of jowls and for some mild facial skin tightening. While once state-of-the-art in its day, it has largely been surpassed by many other ‘tissue heating’ technologies such as Ulthera or Exilis. They all work the same even though the energies that cause their effects are different. (ultrasound vs radiofrequency) While they do some good facial effects for some patients, they don’t really make new collagen that is sustainable and thus their effects are short-term. It takes a lot of maintenance treatments to keep their effects and that can quickly surpass the effects of surgery which is much longer-lasting. Face and neck treatments like Exilis when combined with overlay treatments of light fractional laser  resurfacing skin treatments is a very fine combination that for the right patient can produce some really good effects.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to have my jaw angles lengthened but don’t want to use the Medpor material due to infection concerns and being hard to get out. I can’t find a silicone jaw angle implant that does anything more than wide one’s existing jaw angles. What should I do?

A: New silicone jaw angle implant designs are currently under design and manufacture with the Implantech company. I am very familiar with that development as I am the plastic surgeon behind their design.  These silicone jaw angle implants will provide vertical lengthening that most jaw angle implant patients need. I believe they will be available through the company as part of their catalog of offerings by the summer and certainly no later than the fall. They are available for my use now since I have access to these newer jaw angle implant styles through the development process.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 38 years old and in good general health. However, I was born with very small testes. They seem to be normally functional. I had two children before my vasectomy. I have always been self-conscious about this and wanted to explore the possibility of silicone implants. Is that a procedure you would perform? Or is that something normally performed by a urologist?

A: Thank you for your inquiry. Testicular absence or small testicles can be cosmetically enhanced through the placement of testicular implants. This is done though a small incision on each side of the scrotum in a short 60 minute procedure for both sides. The only FDA-approved testicle implant in the U.S. is a saline-filled silicone elastomer shell implant available through the Coloplast company. (formerly Mentor) Other than the oval shape change, it is very much like a miniature breast implant. It comes in 5 different sizes based on dimensions and the volume of saline fill. It is a procedure that can be done by a plastic surgeon like myself or a urologist based on their experience with implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, this is a question regarding the lip line, particularly the tubercle area. I have an uneven “dip”; the left side has almost a cusp while the right side is much smoother. Other then that, I have full, almost Taylor Swift Lips (except for the left side unevenness), lips. Is there any particular recommendations to make both sides ~symmetrical, particularly the left which the problematic (visual) area? Thank you.

A: What you are referring to is a higher/sharper cupid’s bow on the left side. The goal then would be to lower the higher side to make it match the smoother and lower right side. That can be done through a small excision of the arc of the cupid’s bow done under local anesthesia, just like a miniature reverse lip lift.  That would be very effective at lower and ‘desharpening’ the higher cupid’s bow but at the price of a small price of a small scar along the vermilion-cutaneous  junction. Whether that would be a good trade-off would depend on the degree of upper lip asymmetry that you have.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m actually planning to have a revision rhinoplasty done at the end of the year to remove the L-shaped silicone implant that was initially placed. But I am just curious as to what my options are. If I would like to get a sharper and lowered nose tip, together with a higher nose bridge and some glabella augmentation, do you think a silicone implant for the bridge and ear cartilage for the nose tip and glabella would be preferable to rib grafts?

A:By definition, to replace the existing L-strut  silicone implant in your nose you would need the same dimensions and that would mean a rib graft. Even with lowering the tip I think there is the need for just too much cartilage to rely on an ear conchal graft alone. This would be particularly true when trying to make the nose tip more defined (pointy) as it would be much safer and and more effective to have a strut graft ‘doing the pushing’ so to speak. Such a graft harvest would then allow a more complete rhinoplasty to be done with the dorsal bridge and glabellar area to be cartilage grafted as well

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had Medpor midface rim implants placed a year ago and have had no issues so far. However, I have been considering getting a malar shell or combination submalar implant to add more contour and definition to my cheeks and midface. My only concern is that having the medpor implant would preclude this procedure. Would the cheek implants overlap the existing Medpor implant and can they be secured and screwed in over the Medpor implant? Also, would the surgery be much more difficult as I hear that Medpor implants are hard to remove, and I assume that this difficulty in removal might make it harder to create a pocket. Thank you for taking the time to read this!

A:  The simple answer to your question is that is no problem on any of those issues. The silicone malar implants can be placed and overlap the Medpor material and then secured by screw fixation into place. The pocket dissection over the top of the Medpor implants is minimally more difficult and that also is not a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got the scar 10 years ago from a car accident my air bag deployed and broke my radius and ulnar. I had staples in place the first time and during the revision done in August of 2012 the doctor sutured it from the inside and glue it but it still widened. I’m not sure what to do next or if i should or could do anything else. Currently I get acupuncture and massage on it every week and I am using essential oils. I don’t really understand what re-excision means so could you please explain. Does it mean you have to go in it again with surgery? I really appreciate and thank you for getting back to me. I’m going to see the doctor who performed the surgery on Friday for a check up and I want to tell him I’m unhappy with the results but I don’t really think that will change anything. I feel hopeless, disappointed and embarrassed. If there really isn’t anything I can do then I won’t and live with the scar. I just want an honest opinion.

A: Given your recurrent hypertrophic scar, the only way to have any chance of improvement is to recuit out the scar and reclose it. (re-excision) I was interested in knowing how it was closed to try and figure out why you developed this scar widening. Sometimes the scar revision technique can influence the result. If a repeat scar revision is considered youw ant to make sure that the exact prior technique is not repeated. For these type of scar revisions, I use a subcuticular skin closure using barbed sutures to try and prevent scar hypertrophy and widening which you are prone to develop given your skin type, ethnicity and the location of the scar. While it remains to be proven if re-excision would offer great improvement, it is hard to believe that what you have now is the best scar revision result that is possible.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had submitted this question via the website, but never received a response so not sure you received it. I had a sliding genioplasty with you probably close to 2 years ago now. I am interested in further enhancing my jaw and chin. I know the sliding genioplasty was brought forward as much as possible, but I am looking at the possibility of a custom jaw/chin wraparound implant as I a.) want to move it even more forward and b.) want it to appear that the entire jaw has been augmented rather than just the chin. I also want to widen things as I think the sliding genioplasty makes me lower face appear much narrower. I wanted to find out how closely this could resemble my having jaw surgery (I do have a class II malocclusion, but jaw surgery would be more complicated in my case). By this approach, how much further forward could the chin/jaw be brought by an implant? I know it is a much more expensive approach than off the shelf implants, but they are not going to help me I don’t think due to my unique problems. If I sent you a current picture, could you demonstrate to me what this would look like from the front and side?

A: This is the first I have seen your question. To create a wider and more prominent entire jawline, you are correct in that some type of wrap around implant approach is needed. The question then becomes whether it is done best by off-the shelf-implants (square chin and lateral augmentation style jaw angle implants) would suffice or whether a custom chin and jaw angle implant approach is needed. I would need to see some pictures of you currently, do some imaging, and see exactly what type of changes would be satisfactory. Please send me a few pictures at your convenience.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my face is vertically long and very narrow which gives my face a dog snout appearance would you recommend a sliding genio or vertical chin reduction? Suppose I vertically shorten it will it still give off the forward look? I would like to align my facial profile minus the implants, is there any way I can build it up from my own bone anatomy? I’m African American and I’ve seen Caucasian people whose faces are both vertically and horizontally more proportionate and that’s the look I want to get. What are your recommendations? I would have split jaw surgery to widen my face instead of implants as well. 

A:  Without seeing your facial pictures I can not give you an accurate answer. But I can make some  general comments. If you want to use your own bone to shorten and widen your face, the only two aesthetic procedures to consider in doing that are a vertical chin reduction and widening cheek osteotomies. Neither of these will make the back of the jawline wider and there is no natural bony way to do that. That always requires jaw angle implants to widen the mandibular ramus.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have developed an osteoma directly over the inside of my right brow bone. The osteoma developed approximately 15 years ago, and has steadily grown over time.  Currently, it measures  0.9 cm x 2.5 cm transverse  x 1.8 cm and extends into my right superior orbital rim. This is a benign osteoma. I was interested in Endoscoptic Osteoma removal.  I was wondering if you thought it would be an option given the size and location of the Osteoma?  If not what other procedure do you suggest. I hope you can help me. I truly appreciate your taking the time to look at the pictures.  Thank you so much.

A: Thank you for your inquiry and sending your pictures. The first important question about your osteoma is its potential involvement with frontal sinus. Is it just located on the outer table of the frontal sinus or does it extend into and involve the frontal sinus air cavity?Since you provided such specific measurements you must have had a CT scan in which it was so measured. What does the CT scan show in this regard? Secondly, almost irregardless of whether it extends into the frontal sinus cavity or not, it removal will necessitate the anterior table of the frontal sinus to be removed and replaced (reconstructed) with normal bone. Simple burring it down will result in opening up the frontal sinus cavity, which would be impossible to fix through an endoscopic approach. If your osteoma was just about anywhere else it could be treated by a limited or endoscopic approach through burring or an osteotome…but not over the frontal sinus. This is going to necessitate an open scalp approach so it is removed under direct vision and the frontal sinus managed properly and a smooth brow bone contour is obtained. An open scalp approach means either a traditional scalp incision way behind the hairline or a pretrichial incision which is an irregular incision placed right at the frontal hairline. There are advantages and disadvantages to either incisional approach. I have done frontal sinus osteomas exactly identical to yours and they always involve the entire anterior table of the frontal sinus cavity wall and require some form of brow bone reconstruction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hello..I was looking into getting butt injections prefer the hydrogel. I was seeing if you do this…thank you.

A: Any type of synthetic filler injections into the buttocks I do not do. None of these injectable buttock augmentation materials are FDA-approved nor, quite frankly, should they be done. There are neither safe or indicated for this type of cosmetic procedure and they have never been formally evaluated by an FDA regulatory process. Thus these are ‘black market’ treatment procedures and are what we as plastic surgeons consider to be both illegal and unethical to be done. The only safe and approved injectable buttock procedure is fat injections. This is done by using your own fat acquired by liposuction, concentrated and then immediately re-injected into the buttocks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 21 year old male and I have a protruding nipple problem. My nipples have been pointy for about 2 years now and I get made fun of every day for it. I saw some pictures of your surgeries, and I was wondering I you could help me out by giving me some more information about how to help this embarrassing problem?

A:  The ‘protruding nipple’ in a male could be one of two problems. One type of male nipple problem is due to the development of breast tissue that lies right underneath them. This is the smallest gynecomastia (male breast enlargement) problem which I call areolar gynecomastia as the excessive breast tissue does not extend much beyond the areolar margin.  This can be treated by a direct excision of the areolar gynecomastia through a lower areolar incision to flatten the areolar mound from sticking out. This is a simple outpatient surgery done under anesthesia

The other male nipple problem is that the nipple itself sticks out but the surrounding areola is flat. This usually produces the ‘point’ that is seen sticking through a man’s shirt. This is not a true gynecomastic problem since the undelying breast tissue is nor overgrown. Excessive nipple projection can be reduced through a simple wedge excision and closure done in the office under local anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve attached a photo of my side profiles and front. The main issue I have is with my eyes, which effects my self esteem the most. They also protrude quite a bit and I was hoping orbital decompression could be done whilst aligning them? I know it’s a very complicated invasive procedure.

The others issues are my jaw, hairline and eyebrows. I clench my jaw (whilst sleeping) predominantly on the left side resulting in having to get a root canals to subside pain in those teeth. So it’s more function than anything.

If it’s possible to get the alignment sorted out, I would possibly at a later stage want augmentation done on my jaw and cheekbones to balance my face out. What would your opinion be on that? Thanks again, your time is very much appreciated.

A: Thank you for your inquiry. You are making an incorrect eye diagnosis. You do not have true orbital proptosis or bulging eyes. You have pseudoproptosis…meaning the eyes appear bulging because the orbital bones around them (infraorbital rim and cheek bones) are deficient. Thus the eyes appear bulging when in fact the eyeball has a normal position. Thus orbital decompression surgery is an incorrect and inappropriate treatment for you. The correct treatment is to build up the underlyling bones which are deficient through onlay facial implant augmentation.

In regards to other issues, Botox injections are the ideal treatment for painful masseteric muscle clenching, which can work spectacularly well.

Dr. Barry Eppley

Indianapolis, Indiana