Will A Caudal Septoplasty Change The Shape Of The Nasal Tip?

Q: Dr. Eppley, I have some questions about caudal sep[toplasty> Is this basically a deviated septum repair?  While I didnt originally intetend to ask about repairing a deviated septum, I think Dr. Eppley identified an issue I’ve long had.  We discussed that it should bring symmetry to my nostrils, but will this procedure also help breathing?  He said he couldnt diagnosis accurately until I was there, but what are the risks?  I’ve read some realself reviews septoplasty can have negative effects on the appearance of the nose tip, but others say it improved that.

A: In answer to your caudal septoplasty questions:

1) A caudal septoplasty is a limited form of septoplasty that only address the end of the septal deviation behind the columella of the nasal tip.

2) Generally a caudal septoplasty is more about removing the obstruction in the visible nostril area and improving nostril asymmetry than about improving breathing.

3) It usually does not have any effect, positive or negative, on the shape of the nasal tip…unless the caudal septal deflection is very large.

4) You are correct in that only dissolvable sutures are used.

Dr. Barry Eppley

Indianapolis, Indiana

How Type Of Forehead Reshaping Do I Need To Get Rid Of These Forehead Bumps And Have More Feminine Curve to My Forehead Shape?

Q: Dr. Eppley, I am interested in forehead reshaping? I’m very unhappy with the ridges & bumps on my forehead. On a side profile view, it looks very straight and doesn’t have a pretty feminine curve. What are your recommendations for improvement?

A:Thank you for your inquiry and sending your forehead pictures. You have four prominent forehead bumps, the paired medial brow bones and the upper paired forehead horns. Normally those would be reduced to eliminate them but that is counterproductive in them presence of a non-curved forehead profile. Thus the forehead reshaping concept of covering over these bumps to create a more feminine curves to the forehead would achieve both forehead reshaping aims. The only debate is whether this should be done using a custom forehead implant with a more limited scalp incisional approach or to use bone cement with a more open scalp incisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Are My Skull Augmentation Goals Achievable?

Q: Dr. Eppley, my head is narrow at the sides, it lacks height and the shape of the skull is smaller. The back is flat with no volume. No overall roundness or volume. I would like my narrow volumeless and small forehead to be more masculine, what’s your outlook on it? What procedure is the best in my case? 

Goals: Skull 💀 Taller head, wide at side, Round back of the head sticking out, overall round with volume. 

A: The key questions in any skull augmentation patient are; 1) What are the zones of the skull that need to be covered (there are 5 – forehead, top, back and sides(2)) and 2) with how much volume for each area? (the maximum immediate volume that can be placed is 150ccs) While on the computer any extent and size of custom skull implant can be designed, that does not mean it can be successfully placed given the constraints of the tightness of the overlying scalp. The basic principle is the more skull areas that are covered the less each area can be in thickness due to the flexibility of the scalp. This is why in larger surface area skull implant coverages or in subtotal  skull implants that are fairly thick, a first stage scalp expansion must be done.

Given some of the examples of skull implant designs you have shown and in your side view drawing these suggest that you would require a first stage scalp expansion to come close to your aesthetic goals. 

To help you think about this clearly you need to answer and prioritize these questions:

1) What are the skull zones that need to be covered and what is their order of priority? You have really described a total overage skull implant of all zones.

2) Can you sacrifice implant volumes to avoid a first stage scalp expansion.

Dr. Barry Eppley

Indianapolis, Indian

Will Chin Augmentation Fix My Tight Smile?

Q: Dr. Eppley, I want to know if a chin surgery is the solution for my case. I have a kind of small chin but is really protruding specially when I smile, I actually feel difficult to smile like I have to make a big effort with my chin muscles. Also I dislike the dimple on it, i would like you to help me.

A:Thank you for your inquiry and sending your pictures. While you have a smaller chin you also have a deeper labiomental fold and a central chin dimple. This suggests tight musculature which is why it feels difficult to smile. While your smaller chin can be slightly augmented my concern would be whether that would make your smiling issue even more difficult. Thus I am uncertain whether chin augmentation for you is worth that risk. You could, of course, treat the chin dimple by fat injections.

Dr. Barry Eppley

Indianapolis, Indiana

Would Tissue Expansion Be Needed To Lower The Eyebrows Before Placement Of A Custom Brow Bone Implant?

Q: Dr. Eppley, In references to the challenges of lowering the male brow ridge to create an ultra low brow common among male models, you stated “the soft tissues of the eyebrows is very tight and can not be driven down below the existing brow bones unless these tissues have been first expanded before a brow bone implant is placed.” 

Is undergoing tissue expansion before any implants are added likely to make that sort of look a reasonable possibility, or would it still be impossible in most cases? 

What I’m trying to determine is if achieving the combination of a low bony ridge brow ridge/low eyebrows—the “angry” look, so to speak—is simply a matter of expanding tissues before the implant is placed, or if tissue expansion preceding brow bone lowering is something of a “pie in the sky” procedure that may work in some cases, but on the whole has a highly uncertain outcome.

A: As I have previously written the eyebrows can only be significantly lowered if ‘excess’ soft tissue is first created. (soft tissue expansion) A brow bone implant will not usually do not alone. The concept of soft tissue expansion is not a theory, its use has a long history in plastic surgery of which eyebrow expansion/lowering would just be another example.

Dr. Barry Eppley

Indianapolis, Indiana

Can A Custom Brow Bone Implant Lower The Eyebrows?

Q: Dr. Eppley, In one of your blog posts you state: “many models display a very strong or exaggerated brow bone appearance. It borders on being an almost angry appearance but is better anatomically described as an ultra low brow bone projection with near complete coverage of the upper eyelids. While I frequently get requests for such a brow bone augmentative change, I have to advise such requests that is almost always not possible. This is due to the fact the soft tissues of the eyebrows is very tight and can not be driven down below the existing brow bones unless these tissues have been first expanded before a brow bone implant is placed” 

I assume what is meant by this is that lowering the solid prominence brow ridge is possible, but it will not move the eyebrows into a lower position, creating the angry looking appearance many patients desire. 

Are you saying that it is rarely possible to create a lower set, bony prominence, or are you saying that it is rarely possible to get the eyebrows to move along with the prominence when creating a lower set brow ridge. 

It seems like if a patient wanted to pursue a lower set brow ridge, without significantly moving the eyebrows, then the soft tissues of the brows would not be a limiting factor in that sort of augmentation.

A: Your understanding of the brow bone and eyebrow movement issues is correct. While brow bones can be augmented such that the inferior level of the supraorbital rim is lowered, and this is regularly done, there is no guarantee that the overlying eyebrows will follow down with it. At least not to the extent that some patients desire it to do so. But for the patient where downward movement of the eyebrows is not important, lowering the horizontal projecting level of the brow bones can be done.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Son’s Flat Back Of The Head Be Fixed With A Custom Skull Implant?

Q: Dr. Eppley, I am writing to you seeking some advice about my 17 year old son. When he was a baby (approximately 6 months) we noticed the back of his head was flat. We took him to our family Dr and he said make sure you get him to sleep on his side and rotate him regularly. He also gave us a wedge to try to enforce the side sleeping. To make a very long story short, the little refused to sleep on anything but his back and nothing we did, helped.

Now as a teenager his head shape bitters him a great deal. He does lack some confidence and is continually commenting on his head shape and how much he hates it. He refuses to cut his hair short because it shows his head shape. I would greatly appreciate some information on this procedure (prep, duration of surgery, recovery time, potential impact on his cycling and costs)

Thank you for your time and consideration. 

A: Thank you for your detailed inquiry and detailing your son’s head shape concerns. By your description it appears he has a form of brachycephaly or a flat back of the head. The question is not whether the back of his head can be build out with the placement of a custom skull implant but how much augmentation does he needs to get him to a more self-confident state. I would need to see a side view picture of his head with the recognition that hair is a good camouflage of the extent of the problem. With hair the best way to get a good view of the extent of the flatness is to take a side view picture with his hair wet and combed down.

Once I see a picture of head profile I will do some imaging to convey what I think the placement of a custom skull implant can do. (without tissue expansion first) While a first stage scalp expansion always permits the greatest amount of augmentation there are obvious practical travel considerations that we need to consider.

The custom skull implant is made from a 3D CT scan of his skull. The surgery to place it is a 90 minute procedure under general anesthesia. Given his young age such patients usually stay overnite int the facility in most cases Recovery is mainly about swelling which may or may not make its ways into his face. Such swelling is usually resolved by about 10 days after surgery. Once recovered there are no physical restrictions as such a casual implant is really an inadvertent form of skull protection which can make it much harder to fracture (if not impossible) over the area that it covers.

Dr. Barry Eppley

Indianapols, Indiana 

Would I Benefit From A Forehead Reduction?

Q: Dr. Eppley, I’ve just come across your Instagram and I’m interested in getting my forehead reduced. It has troubled me all my life, it’s very protruding and I would love to get it reduced so it doesn’t stick out as much. Do you think it is possible for my forehead to look “normal”?

A:Thank you for your inquiry. The ability to reduce a forehead protrusion (forehead bossing) is based on the thickness of the frontal bone that makes up the forehead. Based on my extensive experience with forehead surgery I would predict that you could achieve the result illustrated in the attachment with forehead reduction reshaping. A preoperative x-ray would be needed to assess the thickness of your frontal bone and whether such result as illustrated is possible.

Dr. Barry Eppley

Indianapolis, Indiana 

I Am Wider After A Tummy Tuck That Before – Can That Be Improved With A Tummy Tuck Revision?

Q: Dr. Eppley, I have small breasts and herniated nipples as well. I’ve been told implants alone would work but I’m thinking not. I had a tummy tuck a year ago and looking for a revision as well. I am small in size at 5’ 2” 105 pounds and I am wider in waist after the ummy tuck.

A: Thank you for your inquiry and sending your pictures from which I can make the following comments:

1) Your tummy tuck has some scar irregularities and dog ears at the ends as well as some residual thickness between the umbilicis and the scar line. I would recommend a tummy tuck revision with  total scar revision with a little more skin removal as well as liposuction to thin out the residual fullness in the lower abdominal area and flank/waistline areas. I suspect that you did not have the waistline treated by liposuction, hence it now appears wider.

2) Your breasts are small tuberous breasts that have some sag. Implants alone would help considerablly and would be the foundation of their ‘reconstruction’ with periareolar reduction/release for the nipples. I would probably consider transaxillary implant placement and not use the periareolar areas as the pathway to place the implants.

Dr. Barry Eppley

Indianapolis, Indiana

Can My Short Chin Be Vertically Lengthened with A Sliding Genioplasty?

Q: Dr. Eppley, I feel like a have short chin that lacks height. When I push my lower jaw forward and down it creates the chin augmentation effect that I am seeking. What are your recommendations?

A: I have reviewed your pictures and did some imaging to which I can make the following comments:

1) Your chin dimensional needs is largely vertical with slight horizontal, thus they sliding genioplasty (technically open wedge bony genioplasty) would be the preferred procedure. 

2) During the bony genioplasty the vertical and horizontal bony gaps would be filled with allogeneic corticocancellous chip grafts (tissue bank bone), not only to fill the expectant bone gaps but also to help soften the labiomentao fold.

3) Submental/neck liposuction contouring would work well with the vertical chin lengthening for the best cervicomenta angle appearance but also would be a convenient fat source for concurrent fat injection grafting into the left chin soft tissue contour deformity from the prior vascular occlusion event.

Dr. Barry Eppley

Indianapolis, Indiana