Your Questions

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

A: In answer to the facial procedures:

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

A: In answer to your questions:

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

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

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

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

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

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

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

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

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The rib graft in premaxillary augmentation can change the smile or make the lip longer? Also would the implant be placed on the bone or in the soft tissues at base of nose? I read on one of your replies that it can be placed either way. Where would it be better in my case? I have heard that a lot of people get the premax or paranasal implants removed because they are too bulky and change the smile. Do you have a way of avoiding these problems. It seems like a rib graft would be big and then it might not be subtle.

A: A solid carved rib graft for paranasal or premaxillary augmentation is placed in a subperiosteal position on the bone. It needs to be skillfully carved to shape and not be too big. I have never seen it change the smile. It may have a slight chance of making the lip a little longer depending on its size. Diced or injected cartilage is placed under the skin and well above the bone, it is a subcutaneous implant material for premaxillary or paranasal augmentation.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, My face is slightly asymmetrical; the right side of my face is less wide than the left side. Consequently, my jaw line is more square and substantial on the left, and less so (its a little more rounded) on the right. There is also a greater fat buildup in my right cheek, since it has less area to distribute itself over than the left. Finally, my nose has a fatty round tip (I am not sure of the proper medical term for it, but I can feel that the problem isn’t the cartilage, so it must be a fat buildup), and it obscures the definition of my nostrils.

So, the surgeries I would like to have done are 1) rhinoplasty (reducing and defining the tip of my nose; the cartilage and bone are fine), 2) buccal fat removal from my right cheek, and 3) a jaw implant on my right jaw to balance with the left side. Each of these features affects the others, so I assume that it is best done by the same doctor, and at the same time under general anesthesia. The reason I am writing to you about this is because of all the plastic surgeons I have researched, you are one of the only ones who explicitly does jaw implants, not just chin implants or facial injections. I understand my face will not be totally symmetrical after this procedure (my whole left skeleton is slightly wider than the right side), but I do want to balance out the corner of my jaw, the fat in my cheek, and the nose with the rest of the face.

I have attached an informal frontal shot of my face, so you have some sort of visual to accompany my description.

A: Thank you for your inquiry. I believe your description of your facial asymmetry and your approach to improve it is spot on. I would just make a few modifications/clarifications on your proposed procedures. First, the round tip of the nose is not primarily caused by the subcutaneous fat under the skin. It is a component to it and minimally modifiable due the risk of skin necrosis of the overlying skin. The major component to making one’s nasal  tip less ‘fat’ is to modify the underlying lower alar cartilages, particularly that of the dome area. Thus a tip rhinoplasty changes the size and width of these cartilages to make the tip more refined. Second, a buccal lipectomy affects the fullness right under the cheekbone and not further out on the face. Lastly, the type of jaw angle implanted needed would be a lateral augmentation style that only adds width and not length to the jaw angle area.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I do like the rhinoplasty images that you have shown. However, I’ve given it some more thought and was wondering if you thought I could have a more sculpted tip?

A:  What I was showing on the frontal images is the amount of refinement or sculpting of your tip that can be achieved. There are limits as to much tip refinement can be obtained in any patient and that is based on the thickness of their nasal skin. Thicker skin, like yours, will only shrink down so much no matter how much the underlying nasal cartilages are modified and narrowed. I try to show predicted results that are realistic so patient expectations are in line with what may actually happen… that is the best way to have a happy patient should they ever have the actual imaged rhinoplasty surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, during my maxillary jaw surgery my upper jaw was advanced too much by 3mm and impacted by 2 to 3mms. As a result, it makes my nose look wider…is there anyway to make the nostrils look slightly narrower?

A: The nostril flaring to which you refer is very typical for a maxillary osteotomy and has nothing to do with that the fact that the maxilla was impacted or  vertically shortened. Every maxillary osteotomy detaches the facial musculature, and unless that is put back at the end of the operation by a V-Y mucosal closure and alar cinch sutures, nostril flaring (increased bi-alar width) is going to result. That can be narrowed by a very simple alar narrowing procedure through a sill excision technique.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a bimaxillary osteotomy in August 2002 although was not at all happy with the results due to a advanced upper jaw and the genioplasty height was too long. I had corrective surgery in February 2003 to correct the upper jaw and genioplasty as well. I have read that this forms scar tissue and if I underwent a third genioplasty to shorten the chin slightly and to advance the chin forward and then have the chin muscle reattached or stitched in a more favorable position to reduce the lip incompetence and improve lower lip symmetry is this likely to be risky due to two previous surgeries done 10 years ago? From this information can you tell me if I’d be a suitable candidate or not and explain possible risks?

A: Thank you for sending your pictures. My perception is that your chin is too vertically long which is very evident on your x-ray. (although it looks longer on the x-ray than it does in your pictures) This would also account for for lip incompetence/sag. In theory, a bony genioplasty that brings the chin forward and shortens it slightly should be beneficial for both aesthetic and functional issues. My only reservation is that you have had two prior genioplasties and at least the second one should have addressed both of these chin issues. I am curious as to why you think this second or revisional genioplasty was ‘unsuccessful’.

In regards to your jaw angles, your x-ray show a high jaw angle and a shape that often occurs after a sagittal split mandibular ramus osteotomy in which there can be some reshaping of the angle with accentuation of the antigonial notch. While on the x-ray jaw angle implants look like they would be helpful, I am a little concerned about that when doing the computer imaging of you. Your jaw angles are a little wide naturally and even just vertically dropping them down may make your face look too full or ‘bottom heavy’. That may be particularly so when bringing the chin forward and vertically shortening it.

I have done some computer imaging from three angles and on your x-ray to get your thoughts on these potential changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, do all full face lifts require sutures? The reason I ask is because I am not scared of having a facelift done, and I certainly need it, but I don’t like the idea of having to have sutures taken out later.

A: Any type of facelift will need sutures to close the incisions. There is virtually now way to get around that issue and end up with good looking and discrete scars around the ears. But the skin sutures may be dissolveable so they do not need to removed after surgery. I have used a 5-) plain suture for skin closure on all of my facelifts over the past ten years and have never seen a single problem…and the patient did not have to endure suture removal!

Dr. Barry Eppley

Indianapolis, Indiana