Your Questions

Q: Dr. Eppley, I am interested in a browlift after having a browlift. I had some injectable filler placed into my forehead and, because I did not like the result, I have it reversed by hyaluronidase injections. NowI think the skin has probably been stretched a bit by the product, making my brows lower. 

In light of this, I’ve started considering a browlift. I’d actually considered a subtle one before all of this anyway, but didn’t think I’d need it so soon. My question is, how would the skull implant affect the browlift? Would it make it hard to do? I am quite serious about this, so if you could share your thoughts I would really appreciate it!

A; When it comes to a browift, it depends on what technique you are contemplating as to how your current skull implant would effect the result or whether such a browlift can even be done. The one type of browlift that can not be done is an endoscopic technique. The endoscopic method depends on an epicranial shift which would now be impossible given that there is a skull implant in place. An excisional technique s possible using either your existing scalp incision or a hairline or pretrichial technique.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in reversal jaw reduction surgery. I used to have a very strong square jaw, and last year I went and had a sliding genoplasty to add some shape to my face. The surgeon suggested that I should shave down my jaw angles a little to elongate my chin without increasing the vertical projection too much as it would make my face look too long for my body. However, they went completely overboard and shaved down so much of my jaw that I now have an oval face, which I am not happy with. I am looking to put in a jaw angle implant to bring back some definition.

A: I would need to see some pictures of your face for my assessment and recommendations. If you have any before pictures prior to your last surgery that would be very helpful as well. The typical treatment for overzealous jaw angle reduction would be vertical lengthening jaw angle implants to create a reversal jaw angle surgery effect. Because very few jaw angle reductions are symmetric, there are can be a role for custom jaw angle implants as opposed to standard shapes depending upon that degree of jaw asymmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a recent recipient of a skin only lip lift, from another doctor. Unfortunately the top lip I was left with a triangular in shape and overly close to my nose (about 7-8mm). I was told that the doctor removed about 8-9mm of skin. I’m mortified. It looks very unnatural and I am so unhappy now. I’m only 27 and terrified to think that I might have to live the rest of my life looking like this! I saw a post on real self from a girl in a similar situation, to which you commented that it would be possible to reverse the lip lift by performing a Y-V? Would this be something that can potentially help me?  I’m assuming this could lower the Cupid’s bow 4-5mm so that it looks more natural? No other surgeons that I’ve reached out to are willing to help. Please let me know if you can help me.

A: A subnasal lip lift that removes over 50% of the vertical distance between the lip and nose will likely end up with an overdone result…which appears as a triangular shape to the upper lip with an inverted smile line. You did not say how long along this lip procedure was done but I assume it was fairly recent. It is important to know that all subnasal lip lifts do relax in the first three to six months after the procedure. That relapse (due to lip stretching) can be as much as 25%, so some improvement will naturally occur.

A V-Y lip advancement is an internal mucosal procedure designed to lengthen the upper lip smile line (drop down the vermilion) That can be effective is some overdone lip lift cases. The outward vertical sin distance can only be increased by skin grafting which would create an unnatural patch of skin so this is not advised.

I would need to see a picture of your upper lip yo provide a more qualified answer as to what and is not possible your current situation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a revision rhinoplasty. I did my first rhinoplasty surgery because I didn’t like my nose tip it was a little bit to large for my nose, but that was the only aspect of my nose that I disliked and wanted changed. The doctor said that he could make the tip a little bit less large but he also said that he would need to take 1 mm of my nose bridge to take the hump out (that I didn’t have too much) and with that my tip would be raised 1 mm too because he would change my hump I asked him to just do the tip but he said that it would be better. So I agreed, but after my surgery I noticed that he took way more then 1mm of my bridge and raised way too much my tip. Now my nose has a C shape and my tip is too high. I want my bridge raised again to the previous shape and to add more length to my nose as it was before the surgery. Would that be possible? I don’t think that my tip needs anymore change I was want it to look less upturned.Thank you so much in advance. Please see the pictures attached.

A: Thank you for sending your pictures and providing your rhinoplasty history. If I understand your goals now, you would like some bridge augmentation and the nasal tip brought back down. (derotated) Both of these can be achieved by onlay cartilage grafting of the bridge and the infralobular tip area. Assuming your septum was not harvested during your initial rhinoplasty you have adequate graft material to accomplish both nose reshaping goals.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Six weeks ago I had my right (undescended) testicle removed due to a mass detected by ultrasound and replaced with a Mentor Coloplast prosthetic testicle implant. This implant is very ill-fitting, riding high and fixed in position by a permanent suture. Two weeks ago I asked the urologist to remove the permanent suture because it was painful and did not permit any movement of the implant. Unfortunately, he accidentally punctured the implant which caused it to leak and deflate. He then stitched up the incision he had made trying to cut the permanent suture (which is still there causing pain/irritation) and said that another surgery would have to be scheduled. He is willing to replace the Coloplast prosthesis with a soft/solid version like you use, but the surgery center here will not permit the surgery because this type of prosthesis is not FDA approved. Can you help me?

A: Your experience with a saline-filled testicle implant has exhibited all of its downsides. A saline implant usually feels very hard (water under pressure), has a lifelong risk of eventual rupture and deflation and the frequent use of a fixation suture can prohibit natural mobility. A silicone testicle implant that is to sutured in has none of these liabilities. They always feel much more natural. Getting a good size match is always important and a silicone prosthesis has much bigger size options than those that exist in saline-filled implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a reduction genioplasty (chin reduction) six days ago and there is some significant swelling. The doctor who performed the procedure said that I have to wear a compression garment around the chin to help the tissues to mold around the new chin. Whenever I remove it I find that the tissue has taken the shape of the garment. Will this be the long term result once the swelling goes down? Does the garment play any role in the shape?

A: It is important to realize that the result from any bony genioplasty procedure, including a chin reduction, takes a full six to eight weeks to be fully seen. At just one week from surgery there is tremendous swelling, most of which has not yet resolved yet and causes a lot of chin distortion. Thus your chin will appear mishapen and far from the final result regardless of whether you wear a compressive garment or not. The chin strap will help some of the swelling to go down quicker and get a normal chin shape sooner than if it was never worn at all. But I would certainly not worry about the shape the chin is caused by the garment with the early swelling present.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin implant removal. I had a large chin implant put in about four years ago. I have finally become convinced that it is too big and I want it removed.

A: When it comes to chin implant removal, I have some pertinent questions about your existing chin implant:

1) What incisional approach was used for placement? (intraoral vs submental)

2) What type of chin implant is it? (Medpor vs silicone)

3) What size is the chin implant (amount of horizontal projection)

4) In managing the chin ptosis that will likely occur with chin impant removal alone, what management strategies were you thinking? (intraoral resuspension, submental tuck up, replacement with sliding genioplasty)

Removal of small chin implants, or those more recently placed, is as simple as just removing the implant. But with larger chin implants, particularly those that have been in for some period of time, it is not so simple. While removal of the implant is simple, what happens to the overlying chin pad must be considered. It has been stretched out and will slide off the chin bone once the support has been removes creating a chin ptosis condition. How this should be managed must be consider as part of the chin implant removal surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking jawline enhancement. What really bothers me is the lack of definition in my jawline and the bulge under my chin. I feel like everything just blends together, I also have no cheek contour.  

I had liposuction done twice in the under chin area (never along the jawline though).  I had a chin implant and then another chin implant stacked on top of the first one by a different doctor two years later. (so I have 2 chin implants on top each other)That same doctor also did buccal fat removal in the same year.

As you can see from the pics there hasn’t been much progress, I would love to have a stronger/sharper more defined jawline.  What do you recommend? I am 30, 5’3 and normal weight range for my height 125 pounds.

A: Thank you for sending your pictures. I can clearly see all of your stated facial concerns. Given that you have a double stacked chin implant and a persistent submental bulge, you need to remove your chin implants and have a replacement sliding genioplasty. Pulling the chin bone forward will stretch out the neck muscles which is clearly the source of the bulge. It will also create a greater horizontal chin projection and will make the chin look more defined and less round. With the sliding genioplasty vertical lengthening jaw angle implants can be done at the back of the jaw to give it more shape and angularity.(total jawline enhancement) For the cheeks you need a small malar shell implants to give them more projection. The triangulation effect of chin, cheek and jaw angle augmentation will have the biggest effect on changing the shape of your face to make it more defined.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting buttock implants. I am small but want a nice round buttock size result. I have attached what my buttocks looks like now and the kind of result I want. I think I need 550cc buttock implants. What is your recommendation on implant size?

A: In looking at your pictures, you have very small buttocks and a petite body frame. You are simply too small to have such large buttock implants, at least in an intramuscular location. You are either going to have to accept a much smaller buttock augmentation result than you desire (with lower risks) or have larger implant sizes that carry much higher short and long-term risks. It is important to have realistic expectations based on what your tissues can tolerate. This does involve the placement of implants whose initial acceptance and long-term success are based on a delicate balance between tissue stress and the volume of the implanted material.

There are my three buttock implant size recommendations based on how much risk you want to take:

Safest           270cc intramuscular         350-375cc subfascial

Aggressive   330cc intramuscular          425cc subfascial

Riskiest       not possible intramuscular  500cc subfascial

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin reduction surgery. My chin sticks way out and doesn’t fit the rest of my face. How would I go about fixing this? I have attached pictures for your review.

A: Thank you for sending your pictures as they clearly show your lower facial concerns. Pure horizontal chin excess is one of the most challenging of all chin reshaping surgeries in terms of deciding the approach. A submental skin incision approach allows for the most effective technique as both the excess bone and soft tissue can be removed….albeit at the aesthetic ‘price’ of a submental scar.The intraoral wedge reduction and reverse sliding genioplasty method is scarless but has the potential to create some submental fullness as the chin is moved back. (as it does not address the soft tissue excess) The bone is cut and then slide backwards. (hence the term reverse sliding genioplasty) Because the chin bone is moved backwards it pushes the attached soft tissue with it, creating a potential submental bulge.

The choice between a submental or intraoral approach to chin reduction surgery depends on which of their tradeoffs you can best accept. (submental scar vs submental fullness) Most men would choose the submental scar.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in chin augmentation. I’ve gotten other reviews for doctors and most of them said for me to try chin fillers or a sliding genioplasty.

A: There are three chin augmentation methods which have their own unique advantages and disadvantages. It is not a question of whether one method is better than the other, it is as question of which one is most appealing to your aesthetic needs. An injectable chin augmentation method uses synthetic fillers which has the advantage of being non-surgical but the disadvantage that it is temporary as the filler will dissipate over time. This method only makes sense if one is uncertain as to whether chin augmentation would be beneficial so it is a good trial method. A chin implant offers a permanent augmentation method though a fairly straightforward operation whose result depends on the implant style and size chosen. Its disadvantage is that it is an implant that creates the effect and, like all implants, has some surgical risks. (infection, asymmetry, under/over correction). A siding genioplasty moves the actual chin bone and is the most ‘natural’ chin augmentation method. It is the most invasive surgery and requires the longest recovery from a swelling standpoint but it has the advantages of being a natural method that will not cause any long-term potential issues once the bone has healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had orbital tear trough implants, Alloderm to eyelids, canthoplasty, and a mid face lift performed on me almost three weeks ago and I am not happy with the results. I wonder if I should have the implants removed and Alloderm removed (or possibly injected with steroid if possible)

My cheekbones seem to high and a little fake. I previously had 1ml of JuvadermVoluma in them prior to surgery. Is there any chance to dissolve them? Would it make a difference? I look forward to hearing back!

My plastic surgeon suggested two options:

1. I either have the tear trough implants removed as soon as possible, or

2. Wait 3 months to re-evaluate

Thank you so much.

A: You are going through what many young men experience after this type of facial surgery….impatience and jumping to premature conclusions. You are just three weeks from surgery and it is important to understand that the true final result takes a full three months to see when all the swelling has subsided, the tissue have shrunken around the implants and you have become accommodated to your new look. You are making a change to your face that you have seen your whole life. There is going to be a transitional phase where it will be uncomfortable…all change involves this process.

Your options are to either wait out the three months and be certain of the result or prematurely reverse some of the surgical changes. It is important to realize that you had this surgery for a reason and you probably put a lot of thought into it. It would be a shame to just throw some or all of the surgical efforts away before you even saw what the final results were.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to improve my face and have attached pictures which show my concerns. For some reason, the selfies make my face look longer than it really is. I have a very square face. I would like very much to have more of a heart shaped face… and to address the skin laxity that is showing my age.  These pics are without makeup and do show a little of the perioral mound that keeps a heart shape away. I am wondering if that needs to be removed or if I would do better with a form of facelift to lift some of the fullness/wrinkles from my mouth area. By the way… I have had an upper bleph (love it!), but do wonder about a little brow lift as well. I have a very short forehead and low brows. It looks quite wrinkly when I try to keep them raised. Thank you.

A: Thank you for sending all of your pictures. Selfies do create facial distortions as your face is certainly not long but vertically short with its more square shape. Your pseudo perioral mounds are really caused by the skin laxity along the jawline. As the skin falls forward it ‘piles up’ against the corner of the mouth creating these tissue mounds. Ideally what you need is a small ‘tuck up’ lower facelift also known as a jowl lift. That will resolve the jowls and eliminate the buildup of tissue in the perioral mound area. To help make you face less square and more heart-shaped some vertical chin lengthening would go a long way in that regard. This can be most simply done by a small vertical lengthening chin implant but also by am opening bony genioplasty as well.

For the brows an endoscopic browlift would be beneficial as it would not only lift the eyebrows but would vertically lengthen the forehead as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if it’s possible to get a cheek augmentation at the same time as a rhinoplasty or would swelling from either interfere with the other. I also have a deviated septum. Do/can you fix that as part of a more general cosmetic rhinoplasty? Thanks.

A: Having a rhinoplasty and cheek augmentation at the same time is both common and not problematic. Even though they are anatomically close the tissue disruption of one does not affect the other. The swelling from these procedures does not start until after surgery so one procedure does affect obscure the visualization of the other.

In a rhinoplasty it it very common to perform and achieve dual benefits, changing the shape of the nose as well as improving one’s breathing. Known as a septorhinoplasty, it is both an internal and external nasal procedure. Besides being able to straighten a deviated septum, the cartilage from the septum can also serve as a support material for the cosmetic nose reshaping part of the operation. A septorhinoplasty is truly a synergistic procedure that for some patients absolutely has to be done together. In some cases the functional airway part of the operation may be covered by one’s health insurance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to enquire about lower blepharoplasty. I am a 45 year old male and have been suffering from eye bags getting worse over the last five years or so. (particularly the last year) I have been to see three plastic surgeons about this, but am confused as to the approach to take. All three plastic surgeons have confirmed it is herniating fat and not a tear trough or other problem that is causing the bags. 

The first surgeon preferred a transcutaneous approach, though said I may benefit from a tiny skin excision, it may not be needed. The other two both said skin removal was not needed and both recommended the transconjunctival approach with no fat transfer or redraping. Now, since I have done quite a bit of research on this I realize that a transconjunctival approach is regarded to be less risky, due to not cutting through the lower eyelid muscle, especially since a skin excision is not required it seems a needless risk.

However, where the last two surgeons differ is that one said they rather be repairing the lower orbital septum, (he called it Transconjunctival Septal Suture Repair for Lower Lid Blepharoplasty) and that this would involve a miniscule fat removal as the septum would hold the fat pads in a more natural position. He said this would not only give better long term results in terms of preserving eye shape and lid level, but also prevent a common problem of a skeletal look that can arise from a basic transconjunctival approach, he even claimed that this marginally would improve the upper eye skin look, as the eye would be sitting more naturally in its socket – looking at before and after pictures I can see this is indeed a happy side effect.

What I would like to ask is:

1) Which approach would you take (I am happy to send in more photos)

2) Is it common with a basic transconjunctival approach to have a skeletal look long term or is this always simply caused by excess fat removal?

3) Would a transconjunctival approach, with septal suture repair produce more inherent risks or recovery time, and if so would the results be that much better that (2) such that the risk is worth it?

A: In looking at your pictures and your age, it is clear that you don’t need skin removal. Thus a transconjuncival approach to your lower blepharoplasty should be done rather than a transcutaneous one. Your debate is in how to handle the herniated fat pads…either subtotal removal or retrograde repositioning. (septal reset) The simple answer to this debate is if you can keep your fat and it can be brought back in (like a hernia repair) this is always better long term. However it is much more technically challenging than fat removal through the transconjunctival approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get augmentation of the brow ridge/supraorbital rim. I also have a backward sloped forehead which I was hoping to make more vertical at the same time. I have consulted with another surgeon who told me that my lack of supraorbital rim projection extends to the lateral orbital rim too. So I was wondering whether it would be possible to design a custom implant to cover all three of those areas at once? A couple of other issues are these;

– It appears as if my supraorbital rim is not only under projected but also that it sits at an upward angle ‘away’ from my eyeball itself. Is it possible to fashion an implant that both angles downwards and sits lower down on the supraorbital rim to ‘surround’ the eye?

– The same issue seems to be apparent with the lateral orbital rim in that it sits too far away from the eyeball. Can the same be done here as with my question above?

– Not only is my forehead backward sloping and sagitally underprojected, but it is also horizontally convex. The sides of my forehead sit too far back relative to the centre of the forehead. Is this a fixable issue?

A: Using a custom forehead and brow bone implant concept, it can be designed to any desired shape and dimensions. The key issue is not whether an implant can be designed to accommodate your aesthetic desires, but whether your tissues can adequately stretch to accomodate the desired augmentation. This is of a particular issue as one tries to create augmentation on the lower aspect of the brow bone. Besides there being the supraorbital nerves (responsible for feeling sensation of the forehead) which exits through the brow bone and can become injured when an augmentation drops below the brow bone, this is also a brow bone area that is hard to expand as the tissues are very tight.

The other aesthetic issue is that it is potentially problematic when the forehead augmentation crosses the temporal lines at the side of the forehead. Unlike the bony forehead, the sides of the forehead (or the upper temporal region) is muscular and not bone. Any augmentation that crosses into this area can create an unnatural line of demarcation. (the temporal line is a natural line of demarcation)

In short, a custom forehead and brow bone implant can be designed to meet most of your aesthetic augmentations. But there are some aesthetic considerations that may not allow every aesthetic/forehead desire to be met.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about three years ago I had a Mentor Coloplast prosthetic testicular implant put in. It is sooo hard and unnatural feeling. The good news is It isn’t sutured in and I do like having the mobility. I really want to know if they make a softer squisher testicle. I know a prosthetic testicle will never be 100% like the real thing, but this is sometimes causing me pain because it is so rock hard.

A: Saline-filled testicle implants (Mentor Coloplast) are by their very composition hard and quite unlike what a natural testicle feels like. Saline placed inside a silastic silicone shell creates a very firm prosthesis. It is fundamentally a flawed concept for a testicle implant not to mention the risk of deflation and need for eventual replacement. Very soft low durometer silicone testicle implants exist that feel very similar to a natural testicle. They are extremely soft and squishy and have no risk of eventual failure or need for replacement. This is because it is a solid implant material and not a fluid-filled bag.

With an existing testicle implant in place, it would be a straightforward surgery to remove the hard saline implant and replace it with a very soft silicone testicle implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m inquiring about a cheekbone augmentation and possibly a bossing reduction. I’ve always been bothered by my side profile. To me, it looks more flat (or even mildly concave) than convex. I was seen by a craniofacial specialist about this concern, and he stated that my forehead shape and slope were fine, but I had very flat cheekbones and that it could be fixed. I’m not certain why I didn’t speak about a cheek augmentation procedure at the time.

I was wondering if a cheek augmentation, possibly a frontal bossing reduction, would help give the impression or a more convex profile. I’ve attached images. It may be hard to see in the images, but the areas under my eyes are completely flat, and vertical.

A: Thank you for your inquiry and sending your pictures. I would say that you are correct about your facial profile in regard to the lack of midface (cheek) projection and some frontal bossing protrusion. On a practical basis for a man, it is easier to undergo cheek augmentation than upper forehead reduction because of the incisional access and the resultant scar line.

Your cheek deficiency is really a more infraorbital-malar deficiency that encompasses from under the eye out to the sides of the cheeks. This is why you have a negative vector. (the cornea of the eye sticks out further horizontally than the projection of the cheeks.

This is not ideally treated by a standard cheek implant as this will provide no improvement to the under the eye area. This is best treated by a custom infraorbital-malar implant style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I just want to receive more information on forehead reshaping procedure. I have always been very unhappy with my masculine looking forehead and although I am a male I have always wanted to obtain a more feminine looking forhead and eliminate my heavy brow ridge. I did have a procedure done abroad about 7 months ago and had my brow bone shaved off but to say the least the surgeon that did my surgery did not remove enough bone to make my forehead straighter and less slopped. Ideally I would like my forhead to be rounder but at the very least eliminate the bump on my eyebrows and make my forhead smoother. I would like to consult on forehad reshaping with possible upper forhead implant.

A: I am not surprised that just shaving the brow bone in a male did not give adequate forehead reshaping and reduction. Almost all males with really prominent brow bones need an osteoplastic setback procedure rather than simple shaving. A few millimeters of reduction in a male is just going to be inadequate. In addition some males with prominent brow bones have a significant backward slope to their forehead which often needs to be augmented at the same time as the brow bone reduction to get a much improved forehead shape.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a 28 yr old who was born with a unilateral cleft lip and palate and have undergone a diced rib cartilage rhinoplasty within the past 6 months. Although I am very happy with the rhinoplasty, I feel a midface augmentation would very much improve any midface deficiency caused by the cleft. I am also interested in a potential forehead augmentation as my forehead slopes back quite a bit with a prominent browbone. Can this all potentially be done in one visit,? I am looking to have this done within the next couple of years. I would like to schedule a Skype consultation to get a better idea of what can/cannot be done in my case. My main concern lies with potential extrusion of any silicone implants in the midface. I have heard some horror stories of infection and extrusion of non-autologous/man-made material implanted into the face, especially into an area with a lot of muscle movement. I look forward to your response.

A: All facial clefts cause some degree of midface deficiency on the clefted side which may become more apparent with an augmentative rhinoplasty. Building up the deficient paranasal/midface area can be very beneficial in the cleft patient and there are lots of ways to do it using various autologous and alloplastic materials. It is a shame this was not done during your rhinoplasty since you had access to one of the best long-term materials to do such midface augmentation…rib cartilage. Since you still have the chest wall scar from the harvest this probably remains a possibility. But considering other options, a wide variety of implant materials exist to do the job. While synthetic implants have a risk of infection, particularly when placed through the mouth, it is fortunately very low. I have put in thousands of facial implants over the past 30 years and these risks are incredibly low in my experience. However it is important to acknowledge that they are not zero. Only the use of your own tissues poses the lowest risk exposure to infection. (and even that is not zero)

I would need to see some pictures of your face for a more detailed assessment of your midface and forehead for further recommendations.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib shave surgery. I think what I have what is called costal cartilage protrusion on my left ribcage. My right ribcage is normal. I have done some research and some say it can be shaved down. If possible, I  would like to have my rib shaved down so it looks normal like my right side. I would also like to know the downtime for such a procedure. Attached are some pictures. Thank you for your time.

A: Thank you for sending your excellent pictures. You are correct as that is protrusion of the lateral cartilaginous portions of ribs # 8,9 and maybe a bit of #7. A cartilage shave procedure of this protrusion would be the appropriate procedure through a 3.5 cm long skin incision right underneath it. Because the dissection passes through the rectus muscle (split vertically) there will be some soreness for awhile. This is ameliorated for the first few days through the use of Exparel injections placed at the time of surgery into the muscle as well as intercostal nerve blocks. This is a local anesthetic that will last for up to three days after surgery. Some soreness will persist for about a month after surgery as one would expect. When you could return to work depends on what type of work you would be doing and when you feel comfortable doing it.

Dr. Barry Eppley
Indianapolis, In

Q: Dr. Eppley, I am interested in occipital augmentation. The back of my head looks exactly like the picture that I have attached and the issue is the protruding occipital bun at the back of the head of which I am concerned. However my skull is quite small or a man (22.5 inches circumference) and I do not want to reduce it anymore than it already is. I was doing some computer morphing and I found that the result that I want can be obtained (on the morph) by augmenting the area at the bottom of the back of the head (the concave curvature underneath the occipital bone to the neck). I understand that the area is complex and that it is partly muscular. Is there any way to augment this area either by custom implants, custom soft tissue implants (similar to those used for temporal augmentation), fat transfer, fillers etc.?

A: As you have correctly perceived, the area on the back of the head that you are interested in augmenting is not a bony structure. Unknown to most people is that the bottom edge of the occipital bone sits at above the level of a horizontal line drawn across the top of the ears. There is no effective way to do occipital augmentation in what is essentially the top part of the back of the neck. This is tight skin over muscle with little fat in the subcutaneous plane. Neither an implant, fat transfer or any synthetic filler can provide any significant augmentation in this non-skull area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had small cheek implants placed last year, but they are definitely too small. I’m looking to get some fillers for further augmentation. I just have a couple of questions:

1) Can a filler like Radiesse be placed over the implant safely?

2) My malar deficiency seems to be causing some mid-face sag and folds. Would adding fillers to the cheeks help address these concerns?

Thank you!

A: Any form of synthetic injectable fillers or injected fat can be placed over cheek implants. No complications will occur unless the injectate ends up violating the cheek implant capsule. This is where the role of using blunt-tipped cannulas for fillers are better than injecting using a needle.

I doubt that injectable cheek augmentation will do much for soft tissue elimination of your midface sagging. Larger cheek implants would be more effective in that regard but even they will not significantly improve your nasolabial folds. But an injectable approach to the cheeks and nasolabial folds would be a good initial approach to see how much improvement may be possible. I would not be optimistic about this approach but at least it is reversible if ineffective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very large and disproportionate face. My brows are hugely overgrown and my jawline is equally as big. I look like a Neanderthal! What type of facial reshaping or facial reduction surgery would be beneficial for me?

A: Thank you for sending your pictures and I can clearly see your brow and jawline overgrowth concerns. While reduction of these facial bones is certainly one part of the solution, it is not the complete or most effective approach for either area. For your brow bones, their prominence is partly contributed to by the recessed or backward sloping of your forehead. That would be become very apparent if the brow bones were reduced alone. The best result comes from a combination of an oteoplastic brow bone setback (not just shaving) and forehead augmentation above it. I have shown this type of result in the imaging attached. From the jawline standpoint, bone needs to be removed along the inferior border of the jawline from the angles to the chin. But the chin bone needs to be vertically lengthened and setback a bit to make the jawline more harmonious and smooth. I have attached imaging of this type of combined chin and jawline change. For all facial areas it is also important to not overdo them as your entire face is skeletally strong and any drastic change to one area would look out of proportion or even feminizing to your face.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of cheek augmentation. I have a concave portion of my face that I would like augmented. From the semi profile view, I find the circled area below may have missing volume. I found someone that had a similar shape in this area and had it fixed with fillers (photo under mine). I assume the jaw implant would have no impact on this area? Assuming not, do you think putting fillers there would be appropriate to get a similar outcome as in the photo under mine in this area?

A: The volume deficient cheek area to which you refer is in what I call the ‘trampoline area of the face’ which is a non-bony supported area between the cheeks and the jawline. No form of an implant will improve that area so an injectable approach needs to be done for that lower type of midface or cheek augmentation procedure.. If one wasn’t having surgery then a synthetic injectable filler would be used. But since you would be having surgery then fat injections should be done. While fat injections are unpredictable in terms of retention they are a ‘surgical’ choice and are better than having a known temporary synthetic filler placed. Fat may or may not survive. But at least it has a chance unlike any synthetic filler.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have chin asymmetry and am looking to get it corrected.  I am a 31 year old trans woman who has been on hormone therapy for about a year. The hormones have significantly feminized my face, however one thing that has been “revealed” in the softening and rounding of the jaw/chin is that one edge of the chin appears to come down a bit more than the other. The jaw is even And the chin “point” is even, it just seems like theres a bit of excess bone on one side. It’s very subtle and the goal would be for no one to notice i had surgery. Please let me know what options you might recommend for going about this in a way thats conservative, and would not affect overall facial proportions (I don’t want a shorter or more rounded chin!, and also i have a somewhat larger nose and wouldn’t want to have a surgery that then required an additional rhinoplasty) Here I have attached some photos to help you get a better idea. All I want fixed is the larger corner of my chin so that it be brought into balance with the other side. I don’t want a chin thats any more “round” OR “square” than what I already have, if that makes sense? In other words, I don’t want anything done to the smaller corner/mid point of the chin. Let me know what you think. Thank you so much!

A: Thank you for sending your pictures. I can clearly see that the one side of the chin is vertically lower than the other side. Your chin asymmetry could be reduced without touching the midline or good side of the chin through an intraoral approach. In doing this from an intraoral approach it would be important to resuspend the mentalis muscle back into place since to get to the very bottom edge of the bone requires some soft tissue elevation. Coming from below through a submental incision makes the surgery easier from a technical and recovery standpoint but there is always the issue of the fine line scar under the chin to do so.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, For the past year, I have been having frequent sometimes heavy nose bleeds three to five times a week. I wanted to mention this to you. Is this a cause for concern going into rhinoplasty surgery? It usually stops easily if I pinch the bridge of my nose. I’ve noticed it is somewhat related to stress in my life.

A: Having a history of nosebleeds before undergoing a rhinoplasty does not preclude you from having one. Having them at the frequency of three to five times a week and being heavy in nature is a cause for some concern about what would happen after a rhinoplasty and having to manipulate your nose to stop the bleeding. This may have adverse consequences on the ultimate aesthetic outcome of the rhinoplasty.

Stress is not really a reason or cause of nosebleeds, there would have to be a more anatomic explanation. I would recommend that you have an evaluation by an ENT specialist to try and determine their source. You may or may not be able to do find a cause but it would be prudent to have that evaluation before undergoing any form of nasal surgery.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’ve gotten a skull reconstruction cranioplasty done while on active duty following a stroke/craniectomy and I have 1) a concave dent on my left temple, 2) a bulging muscle underneath the dent (surgeon said the muscle couldn’t be reattached to the titanium plate, and 3) have an irregular protruding spot where the plate ends in my forehead, almost like it’s not fully connected to the bone, or the plate itself isn’t the right fit. Can plastic surgery fix this? Will it be a major operation, or dangerous? If so, do you think the benefits of the status quo outweigh the risks? Thanks

A: I would need to know two important pieces of information about your prior skull reconstruction surgery, 1) what type of cranioplasty was done and 2) a current 3D CT scan of your skull to fully know the anatomy of your skull and what the cranioplasty looks like and the area that it covers. That being said, most likely the corrective approach is going to be a bone cement only cranioplasty to recontour the area. I would not view this as a risky or dangerous procedure. Since you undoubtably already have a scalp scar the biggest aesthetic risk of such surgery is irrelevant.

Dr. Barry Eppley
Indianapolis, Indiana

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 Dr. Eppley’s 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 still want a masculine forehead.  I do think (based on editing the photos a little myself haha) that reducing the brow bone, and following the natural slope of my forehead, will still allow a little bossing in the brow region where it meets the bridge of my nose.  Although not noticeable in the photos, my brow did not boss in the center between my eyebrows (though it may appear as such in attached photos) creating a hard “valley” between my eyebrows as if the frontal sinus did not fuse together properly during puberty (if that is even possible).  Therefore, I am hoping the results of this procedure will (1) reduce the horizontal protrusion and in effect (2) eliminate the crevice in the center between my eyebrows.

A: Thank you for sending your pictures. I have done imaging to show what type of potential result is possible with a brow bone reduction procedure for you. It is very common to have the brow bone protrusion to be more evident on the sides as the air space of the frontal sinus is often not connected across the midline so the bone protrusion from enlarged sinus spaces is often less evident in the middle or globular region of the brow bones. Both of your brow bone reshaping goals are achievable.

The recovery from brow bone reduction is largely that of appearance. It probably takes about 10 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 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 issue.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in scalp scar revision. This is a 37 cm by 2 mm scar by a hair transplant that was done 15 year ago. My main goal is to be able to cut my hair short so I can wear it like in the pictures without being noticed. It is slightly hypertrophic but more problematic is that it is white and that it is linearly straight. I have tried tattoos – it was not successful and injections didn’t help either. I would to see if we can revise this. How will you be able to handle the hairs that in and around it ?Would you be able to save the hairs? Thanks.

A:The only method that could offer any improvement is that of surgical scalp scar revision. The scar needs to be cut out in its entirety and then reclosed using either a straight line as it is or with a running w-plasty closure line. (preferred) Any hairs that are in the scar would be removed. Hairs that are around the scar would be preserved. I don;t know if it is every realistic that you can have the scar improved to the point where it would never be somewhat noticeable. Like all scar revisions, reduction in its appearance may be possible but complete invisibility is not a realistic goal.

Dr. Barry Eppley
Indianapolis, Indiana