Your Questions

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

Dr. Eppley

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

Thank you again for your explanations and patience!

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Sorry for such a long message. Thank you!

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

I look forward to hearing from you soon.

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

Dr. Barry Eppley
Indianapolis, Indiana

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

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

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

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

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

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

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

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

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower buttock lifts. mI have been trying to correct my saggy buttocks for over a year now. I have been very athleltic all my life and no matter how toned the rest of my body is there is always a saggy pouch below my buttocks. I had fat injections which didn’t take then I asked my surgeon to excise the sagging skin and fat. But he didn’t emove much at all and it’s basically still the same. I have found your website and it appears you know what you are doing with this. So I am wondering if you can correct this (no implants or anything required, simply removal of that pouch) and what sort of recovery I will be facing?

A: Lower buttock lifts are really the only technique that can improve redundant tissue that hangs over the infragluteal fold or loose tissue just under the fold. Please send me some pictures of the your lower buttocks so I appreciate the issue that you have and where your current lower buttock scar is. Most likely your last surgery simply did not remove enough tissue to see much change. The recovery from lower buttock lifts is really only limited by how much you can bend over after the surgery to avoid excessive pulling on the suture line. One should avoid returning to most forms of strenuous exercise for four to six weeks after surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Can you please tell me whether a custom high cheek implants for males can also be adapted to provide augmentation to the under eye area? And also can custom cheek implants be designed to give more volume than other implants as I desire noticeably higher cheekbones whilst still looking natural.

A: It is actually very common to have an infraorbital extension under the eye as part of many custom cheek implants as part of their design. (compared to a standard cheek implant which is the darker blue one) This can be seen in the attached custom cheek implant image example. Not only can there be an anterior infraorbital extension but often there is a posterior infraorbital extension back along the zygomatic arch as well. By definition custom cheek implants are usually bigger and thus have greater volumes than standard sized cheek implants. It is important to know that the design of the implant and the bone that to covers is more important than thickness or size. It doesn’t matter how big the cheek implant is of it is not the right implant style and design. This is why i do so much custom cheek implants as many patients don’t get the right design of the implant for the look they are trying to achieve.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I asked for your consult about getting a more chiseled and angular face with much more symmetrical proportions through facial reshaping surgery. I had a surgery three month ago including putting in a chin implant, buccal fat removal and very small cheek implants. Unfortunately I didn’t get the desired results with those procedures. In the coming week I’ll go to visit my Doctor again. But it seems that I have to find out my problem and reforming options by consulting with you and then asking my own doctor to do that. Maybe you have gotten my before operation photo so I will send you my present look photos. In my opinion and after watching your videos on Youtube, my chin implant shall be removed and I should get a vertically shortening and horizontally augmenting sliding genioplasty plus jaw angle implants and submalar big cheek implants. Please let me know what do you recommend, even if its possible in details, such as size and shape of implants.

A: The creation of a more defined and angular face is not going to come just from chin and cheek implants and a buccal lipectomy in most patients. These procedures may be part of the solution but they alone are usually going to be inadequate. This could have been predicted before your prior surgery. The creation of a more defined jawline is a big part of creating an overall more shapely face through facial reshaping surgery. What jawline procedures, or other procedures, would be best in that regard must be determined by the doctor who is going to do the surgery. It is not medically appropriate that I provide a list of procedures and specific implants so you can pass that information along to another surgeon. That decision must be made between you and the treating surgeon.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have purchased a book in which you were a co-author of called “Aesthetic Surgery of the Craniofacial Skeleton”. I have an inquiry on a certain procedure that is in it. I am looking to increase the width of my actual eyes (horizontally). (Lateral Orbital Rim Osteotomies) The book entry says you can reduce the width of the eyes by cutting the outer orbit bone and putting it closer in. But is is possible to do the reverse and position it further outward and this would lengthen the eyes?

Do you perform this procedure or have a college that performs is? I really want to make my eyes longer.

A: While Lateral Orbital Rim Osteotomies can be done to narrow eye width, it does not work in reverse to make the eyes horizontally longer. This is because of the lateral canthal attachments and the position of the lower eyelids. By moving the bone or corner of the eye outward, you end up pulling the lid margin away from the eyeball. That will cause multiple eye symptoms of irritation, dryness and even excessive tearing. The eye requires that it maintains good apposition of the lid margin right up against the eyeball.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’m a 48 year old HIV positive male who is healthy, have undetectable viral loads, and have been on Atripla for many years. I have always had a full round face and cheeks and was thinking of getting buccal fat pad removal.  (buccal lipectomies) I workout with weights and cardio. I will be getting cheek implants. Do all people on HIV meds get facial waiting? Is buccal fat pad removal totally contraindicated for me?

A: Historically HIV medications did cause a lipodystrophic spectrum of facial lipoatrophy and body lipohypertrophy. Newer medications, like Atripla, have a much lower incidence of causing these fat altering side effects. If your face is round and always has been then I would say that buccal lipectomies are not contraindicated and can be performed without concerns about adverse aesthetic long-term effects..

The key question now is not whether buccal lipectomies should be sone but whether they would produce a noticeable external facial thinning effect. That would depend on how round your facial shape is and where most of the fullness is. I have performed buccal lipectomies in a select few HIV positive patients whose face merited a facial defatting procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I have had rhinoplasty one year ago. I got the results for what I asked for, my nose was straightened and the hump was reduced. My tip was never corrected as I was told by my doctor there was not need for it. It really seems to bother me and I would like it corrected. Would this be classified as a revision rhinoplasty surgery and would it be more harder to perform then the first surgery?

A: I am going to assume that your original rhinoplasty was done by an open approach. Secondary tip work would be no harder to perform now than during the first surgery. The scar tissue that is present would pose no issues for doing secondary degloving and tip work. Preoperative computer imaging may have been able to show whether tip work as needed.

If your original surgeon performed the tip rhinoplasty it may be considered a revision. But this would certainly not apply to a new surgeon performing the procedure. For the new surgeon this is a new procedure for which he/she has no obligation stemming from the prior rhinoplasty. An isolated tip rhinoplasty is, however, less costly than a full or complete rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had breast reduction surgery on November,2015. I have had no problems and healed nicely. The tissue that was removed came back as clean with no cancer. At this time I have felt a hard small lump under the vertical incision at the left breast. It is hard and round just under the scar line. I am concerned about this. Thank you.

A: It is very common after breast reduction surgery to have firm lumps in the breasts due to scar tissue and fat necrosis. This is particularly evident in the first year after surgery. Many go on to soften over time but some never do and are permanent. That fact that it is situated right under the scar line speaks to how this is probably what you are feeling. But if you have any cancer concerns about this lump, these should be addressed by a breast cancer surgeon or the plastic surgeon who performed your breast reduction surgery..

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in fat injection breast augmentation. I’m 27 years old and have three children. I’m a 34/36 A cup, barely. I have an abdominal ‘pooch’ that I don’t think will ever go away. Breast augmentation is something I’ve been researching for over a year now. It’s something I want to do because it’ll make me feel better about myself and gain my confidence back. I would like more information about the fat injections as I’ve been concerned about implants and can’t decide between silicon or saline and I really don’t want to have to get “redone” years from now. Any information is appreciated.

A: Fat injection breast augmentation is only successful in a very few selective women. First and foremost one has to have an adequate amount of fat to harvest…and it takes a lot more than most women think. Your abdominal ‘pooch’ alone is not going to be remotely enough to do the procedure. With fat graft survival at way less than 50% of whatever is injected, even in women that have better fat harvest volumes, the best breast augmentation result can hope for may be a 1/2 cup size increase.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin advancement surgery for my obstructive sleep apnea. (OSA) Let me explain that I had an extremely underdeveloped chin and I had a chin implant out in over twenty years ago. The OSA has always been present and I snore really loud. I have made a few attempts to have this corrected but I’m a mouth breather. I have a CPAP machine but it really puts a lot of pressure on the chin implant and it hurts me to wear that awful mask. I have had the machine for over five years. I’m ready for a surgical solution. Ive spoken to my sleep doctor but she is not qualified to answer the surgical question.

A: Thank you for your clarification on your OSA history. With an extremely short chin it is very likely that mandibular advancement would be the most beneficial approach or even bimaxillary advancement surgery.. But doing so would require pre surgical orthodontics and that is often not feasible or very desirable when one is older. The other option, albeit less effective, is a sliding genioplasty chin advancement. This can  help to bring the tongue somewhat forward…although not as much as a total lower jaw advancement.

I aska about whom recommended surgery for your OSA because that may have meant that the sleep doctors had exhausted all they could do and detected a jaw bone deficiency in you.

I would need to see pictures of your face and your current bite to see whether these surgical options may be beneficial for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant done by you last week. In looking at my result this week I feel that the chin is too big and the jaw angle look a bit asymmetric. I have talked to several close friends and they are in agreement.  I am thinking that I need a revisional surgery and would like to do that as soon as possible.

A: I am gong to repeat now what I stated from the very beginning…as you are going down exactly the path to which I pointed out to you that many young men take in this type of facial surgery. You are just one week from surgery and have a long way to go before seeing the final results. Much will change in both appearance and your perception of it. You are already prematurely critiquing your results and trying to pass judgment on issues to which you are not yet close to seeing the final results. As we have previously discussed, your premature reactions are not uncommon, but it’s important that you understand they are indeed premature.

The advice that I am going to repeat to you now is that you must allow the healing and adjustment process to complete. I will not discuss any facial situation that is in an evolutionary state, as it is a ‘moving target’ and it is not in your best interest to do so until the final results are clear, in 8 to 12 weeks after surgery.  It’s best not to entertain discussion at this point about pre-surgical implant design decisions and premature outcomes, as that would serve no purpose at this juncture.

This position may seem unduly harsh but it seems to be the only way in some patients to get them to understand the reality of the situation. I make it a priority before surgery to ensure patients understand how the process will unfold in these cases after surgery and, more importantly, how I will handle it after surgery. While your friends may offer their own opinions regarding your procedure and certainly know you on a personal level, it’s important to note that I have a great many years of experience in surgery, and am a specialist in this procedure.  I have spent thousands of hours in surgery and am your best resource regarding the postoperative process, and as such, will offer you expert medical advice as opposed to uneducated opinions.

You came to me for a reason…if you are not willing to accept my advice and recommendations then I can not offer much further help. If the early results are too distressing to tolerate or do not permit one to allow for the allotted recovery time to see the true final outcome, then the only alternative option is removal of the implant.  My advice again, is to allow the body time to heal and the postoperative process to resolve before any further considerations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some deep acne scarring and red pigmentation. I had Matrix laser done with 4 treatments. They promise at least 80% improvement. There was no change. Even they admitted to no improvement. But no offer to help any further. It was a complete waste of time and money. I read your testimonial and hope you can help. As I get older scars getting worse. I have watched about all types of acne scarring procedures on Youtube, excision and then follow up with deep laser seems to be my guess. But I’m not a doctor. I’ll send pictures.

A: Trying to improve acne scarring is a challenge to say the least. There are no magical treatments and modest improvement at best is really what is obtainable. You are correct in that excision without or without fat grafting of the deepest ones is the most effective. Fractional lasers and the newer HALO system offers some improvement of the more shallow ones. Older patients also have another treatment option as their loose facial skin contributes to the worsening acne appearance. Tightening the skin on the side of the face (mini-facelift) can also be effective as the scars get stretched out and more flattened by some doing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Thank you very much for getting back to me. Please see attached, a few pictures. Two show the lower lip at rest. As you can see, there is virtually no display of the upper incisors and significant display of the lower incisors. Also the one showing me smiling shows some drooping of the lower lip on my right hand side (photos taken in selfie mode so it’s flipped). I have had a genioplasty done previously – the drooping may or may not have been related to that. I cannot remember if it was present prior to the genioplasty. 

I don’t know if I am a suitable candidate for a lip lift but I was thinking of getting assessed for an upper and lower lip lift. In terms of a lower lip lift ,I am not sure if you do this particular procedure?

A: Thank you for sending your pictures. As for the upper lip, a subnasal lip lift would help with the show of the central and lateral incisors a bit. The other alternative would be an upper lip horizontal mucosal resection, a more direct approach, if one also thought their vermilion show of the upper lip was excessive. Your central lower lip droop reminds me of what can occur after a genioplasty procedure. Raising up the lower lip is very challenging and often not that successful as there are not anatomic structures to fix it to like that of the upper lip. I have used the V-Y advancement many times on the lower lip for that purpose and have found the improvement obtained is usually moderate and not a complete correction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After having read your in depth knowledge on jaw implants I wanted to get your opinion on what has happened to me. I have recently had jaw implants removed and I feel as though the masseter muscles have not been reattached correctly – they do not wrap around the angle of the mandible, instead they just go straight down. This has led to a strange look when I clench my teeth – a distinct difference of the masseter muscle and and bone angle itself. Can this be remedied? Will it resolve by itself over time? The implants I had were Medpor RZ. Thank you for your time.

A: What you have is disinsertion of the masseter muscle from the jaw angle. This is why when you clench your teeth the muscle bulges above the lower border of the mandible higher up on the ramus. While there is a procedure to try and reattach the muscle back down lower onto the edge of the bone, it has a low rate of success and leaves an external neck scar to do it. It is probably best to accept that this new position of the masseter muscle as permanent.

Dr. Barry Eppley

Indianapolis, Indiana