Your Questions

Q: Dr. Eppley, First I must say I’m very impressed with your forehead contouring method and I think I come to the right place for my procedure. I am an Asian male who had goretex custom implants placed for brow bone augmentation via a bicoronal incision and fixed with screws. From beginning I was unsatisfied with the result. It gave me extreme brow ptosis with a paralyzed left eyebrow that interferes with my vision. I can not raise my left eyebrow at all. The paralyzed left eyebrow seems like it is caused by implant placement which is placed slightly higher than the right eyebrow. I know because I can feel it. The brow ptosis dramatically changed my youthful eyes shape and made me like an old tired man. I have to keep raising my eyebrow muscles constantly everytime I meet people to make my face look ‘normal’. It has been three years since this surgery and I don’t want to look this way anymore. Now I’m considering brow lift to help my issue. Am I good candidate? What is the best brow lift method to address my complex issue? I tried to avoid bicoronal incision again because it left me with 1 cm width scar ear to ear with no hair growth at all in that area. I even want this ‘bald’ scar removed if possible. Can this brow lift method change my youthful eyes shape back like before?

A:  To lift your brows now, the only option would be to re-use your bicoronal incision. The good news is that the scar needs to be excised anyway to obtain a substantial narrowing of it.  That scar is unacceptable. That would work in helping with the browlift since the amount of brow movement upward should be roughly the same amount as the width of the scar that needs to be removed. I believe this will be successful. Whether it will get the brows elevated as much as you demonstrate with your hands may be overly optimistic but much improvement should be obtained.

As an aside, I suspect your left eyebrow paralysis is the result of an injury to the frontal nerve branch of the facial nerve on that side from the raising of the bicoronal forehead flap. It would be unlikely that the eyebrow doesn’t elevate because it is ‘stuck’ on the brow bone implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 26 years old and have a very flat midface. I would like to do something that will give my midface more projection but I don’t know what is the best thing to do. I read that some doctors use implants while other recommend injectable fillers. I have been through orthodontics to correct my crossbite and it is now perfect. But my face is still pushed in and unattractive with deep nasolabial folds. What do you recommend?

A: By description and as evidenced by your orthodontic treatment, you likely have some amount of natural midface retrusion with a corrected Class III malocclusion. This would indicate a more panfacial or significant midface deficiency of which injectable fillers would be a poor treatment choice. It would take a fair amount of filler volume to achieve a visible improvement not to mention the need for repeated treatments, provided a good aesthetic change could be achieved. There are a variety of facial implant options which can provide both improved midface projection and a permanent result. Malar, submalar, paranasal, premaxillary and infraorbital rim implants are all potential options for augmentation depending upon the amount and location of the midface retrusion. Most patients do well with combined malar and paranasal implants. However the malar deficicency usually has an infraorbital component as well. Similarly, the nasal base deficiency may include a more extensive premaxillary retrusion and not just the lateral pyriform aperture areas. A good eye is needed to determine the type of implant styles that would best treat any patient’s specific concave facial shape.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a condition known as facial lipoatrophy. From what I have read it is type III or IV based on how my face looks. I am 24  years old and have had this look since I was a teenager. It makes me look older than I really am and I am concerned if I look this way now what I will look like in 10 or 20 years. I have high cheekbones but they are very skeletal-looking with indentations beneath them with loose skin sitting atop them. What type of surgery will make my face look more normal?

A:  The look of facial lipoatrophy is easily identifiable with loss of some or nearly all subcutaneous and buccal fat over the central portion of the face. Surgery must incorporate both hard and soft tissue augmentation since the problem extends over both bone-supported and non-bone supported facial areas. One successful treatment strategy is a combination of submalar implants to fill out the upper submalar triangle and fat injections for the lower submalar triangle and the sides of the face. Temporal implants can also be used for the always present temporal hollowing which is often overlooked in the treatment of facial lipoatrophy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Could my prominent, asymmetrical eyes be corrected with fillers? A nurse told me that the bones in one eye socket are further apart causing that eye to be able to stick out further. Could they be made even and the bulging eliminated? They are quite “bug eyed” to me which is just genetic. All the women in my family have these eyes. Also, the wrinkles beneath my lower lid when I smile– will the increased volume in that area from the filler eliminate them? Will it also correct the dark skin/shadow under my eye?  I think they really age my face. But I think it’s lack of volume that causes it.  How much would something like this cost in total? Do u use Restylane for this? I really appreciate your time.

A: In looking at your pictures, injectable fillers under the eyes is NOT going to correct you eye concerns. What you have is what is known as pseudoptosis. The eyes bulge out, not because they are too far forward, but because the bone around them (orbital rims) is recessive or deficient. You are not going to lift up the lower eyelid by placing injectable fillers underneath it, that simply will not work. What you need is to have the orbital rims built up with an implant material. For the lower eyelids this would be infraorbital rim implants. For the upper eye area, this would be brow bone augmentation. Understand that the problem is a bone deficiency of which it requires surgical augmentation not injectable fillers.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost weight and have an apron of loose skin that hangs over, plus some fat at my waist that I would love to not have to look at anymore. I have looked at your gallery and have seen a couple of pictures that are very close to my condition, and like the after photos. I would be very happy to look like that. I am 60 years young and still have a lot of living to do. I am very healthy with only a thyroid condition that I take a small dosage of synthroid to correct.

A: Your age of 60 is certainly not a limiting factor in having tummy tuck surgery. As long as you are healthy and have no restrictive medical conditions, which it appears you are, there is no reason not to enjoy the outcome of removal of an overhanging abdominal pannus. Such a removal can be very liberating and improves not only your clothing options and hygiene but your self-image as well. Tummy tuck surgery is performed as an outpatient surgery under general anesthesia. The biggest issue in after surgery recovery is that you will have a drain for 7 to 10 days afterwards. This is more of a nuisance than anything else as you can move about and shower normally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have some questions concerning adding implants to the top of the head. How thick can the implant be at most in your opinion? How is PMMA implants fixed to the top of the skull? Is there any risk of getting loose later and cause infection? Will it thin the skin?Thanks in advance.

A: The thickness of any skull augmentation that can be achieved is directly related to how much the scalp can expand over it. Short of a first-stage tissue expansion procedure, most scalps can stretch 5 to 7mms and have a tension free skin closure. Once you get anything over 10mm, a tension-free scalp closure may become more difficult. Anything cranial implant is secured by small titanium screws through a ‘rebar method’ when it comes to cranioplasty materials that are applied initially as liquid-powder or putty mixtures that then set up. Looseness or infection are two potential complications that I have not seen. There is always some slight tissue thinning around any body implant that expands the overlying tissue. But the scalp is very thick and any tissue thinning over a long time does not affect the skin or the hair follicles.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a little nervous about a cranial reshaping/augmentation procedure so if you don’t mind I have some questions regarding it. Does this type of surgery come with a high risk of complications/ what are the complications? From the location of my indentation can you give me a general idea of how big and where the location of the scar would be? How long would an open approach surgery take to correct my indentation/ how long would recover time take? How much would this surgery cost roughly? If my research is correct I understand their are different methods/ materials that can be used with an open approach can you explain them? and the pros/cons of them? What method would you recommend?

A: In answer to your questions. This is not a high-risk procedure. There are no major complications that I have ever seen. The complications are of the aesthetic nature, meaning how does it look, is it smooth, etc. You need access to both sides of the skull. There fore the incision would be bicoronal, meaning it would go across the top of the head just about from one ear to the other. Surgical time for this procedure is 2 hours. Your recovery would be very quick, so swelling but no significant pain and no real restrictions after surgery other than strenuous physical contact. That information will be passed along by my assistant. The other decisions/options about an open approach is the choice of cranioplasty material. With large surface area to be covered like your cranial indentations, the PMMA (acrylic) is the most affordable. I am not sure what you mean by method. This would be an open cranioplasty with midline bone reduction and build up of the deficient sides.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can a direct vertical incision be used for women with vertical bands of turkey wattle?  I had a facelift 20 years ago when the platysma was tightened and there is no flesh left behind my ears (very bony and thin).  If it were performed as an “H” on its side, then it may be confined to under the chin and not be so visible on the actual neck?

A: The answer is that direct necklifts can be done just as  easily in women as in men. However the design to which you refer to is known as a submentoplasty where the scar is completely under the chin and not onto the neck. Direct necklifts, by definition, involve a vertical cutout of skin and fat down the center of the neck. But the cutout pattern always is like an H its side with the final incision closure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 42 years old and i have just one concern about my eyes showing a bit too much sclera and lack of support of lower eye lids…i had fillers injected but I must say that the improvemnet was mild to non existant and did little for the scleral show even if the lateral volume was improved. Also fillers tend to be pulled by gravity and the infraorbital fillers the shifts and becomes more of a feminized cheek implant. I was imagining that infraorbital rims will be more precise and long lasting. Also I was wondering if the rim itself will push the lower eyelid enough to show les sclera or if it would be better to tighten up the sides as well. I always found that I look much better when I squint slightly which makes me believe this is what i need…how natural doesthis procedure look? is it a spectacular change? Do rim implants shift as easily as jaw angles? Thank you

A: The position of the lower eyelid is affected by many factors but one of the most significant is the amount of bony support from the lower orbital rim. Adding permanent volume through an implant is a logical choice. The amount of volume added is dependent on the style and size of the infraorbital rim implant. Regardless of the implant, tightening the lower lid through a lateral canthoplasty is always advised/done. Moving the level of the lower eyelid up is never an easy task but the combination of infraorbital rim implants and canthoplasties gives the best chance for that to occur. Since I always screw the orbital rim implants in, like all facial implants, I have never seen implant shifting.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a midface deficiency which is causing the skin of my midface to sag alot causing it to look pigmented, I have been told I am more suitable for orbital rim implants (after many consultations for standard cheekbone implants) but it seem a subtle implant is all that can be used due to my skin not being very hefty. What I want to know is how far around from the nasion area around to the malar lateral area does the implant reach? Will it fill out the area on outer corner of eyes where a normal persons cheekbones would normally be located? I generally have good projection on the sides of my head, but I have developed a fat face appearance and I’m only 24, this is giving a pigmented look to the unsupported skin. It’s like I’ve lost a lot of weight which I haven’t as I’m only 150lbs.I have been told I could go with fat transfer after implants if I wanted a more drastic change later on down the road. Will subtle rim implants be enough to lift the sagging skin as it feels like there is a lot? My face has no angles like it used to and has become very doughy. I’m depressed over this as I simply don’t know what to do.

A: While I will have to see pictures of you, I can make some general comments in regards to infraorbital-malar implants. There are numerous styles and designs of orbital rim, malar and combined infraorbital-malar implants. Some do reach the whole way from the medial orbital rim around and onto the malar region and up on the lateral orbital rim. How much midfacial tissue lifting these implant styles do is limited. Some malar tissue elevation is obtained but more significant amounts will likely need some form of a midface lift done concurrently with implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a chin implant that was placed 35 yrs ago when I was 18.  My dentist tells me that the bone has eroded behind the implant and that some teeth that are now moving in that area.  It is a silicone implant. I know I have to get it removed but can I have a new chin implant or is that that? My surgeon said to take it out and consider a new implant when it is healed but I do not want another silicone implant and there’s a lot of info on the internet stating they too have had serious bone problems with silicone chin implants. Is this common? Thank you.

A: Never confuse passive implant settling with active erosion. Chin implants do not actively erode bone, they merely respond over time to the pressure of the overlying soft tissue and something has to give. This phenomenon can particularly be seen when the implant sits too high over the softer and thinner bone cortices in front of the roots of the mandibular incisor teeth. Obviously you have an old implant that is positioned too high, which is why it is closer to the tooth roots. A properly positioned chin implant sits down on the basal bone, some distance away from the level of the tooth roots. You simply could have the implant removed, an allogeneic bone graft placed into the cortical defect and a new chin implant placed in a lower proper position if desired. Whether that should be a silicone or Medpor implant is a matter of debate. I suspect the implant is small and, because it is positioned too high, probably has little actual influence on the horizontal projection of the chin.
>
> What has happened is a natural long-term process that is not reflective of pathology or some mysterious substance leeching from the implant causing this bone/radiographic reaction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, thank you for doing the imaging. Regarding my chin and jaw I had something different in mind, I wanted something more defined and v- shaped for my jawline. Some implant that would probably wrap around my whole jaw and give me a more defined look. I’ve attached a picture of Matt Bomer to illustrate what I exactly have in mind and please tell me if I’m being realistic or not. If getting such a structure is a bigger job and you feel that a custom implant is more suitable, I’m more than fine with that. Too be honest doctor, I want to have everything perfect even its going to cost me more. Regarding the cheek bones? Do think augmentation is suitable for me or not?

A: The purpose of computer imaging is to transition the talking to a visual interpretation. It is a starting point for refining goals. What you have seen and do not like is what off-the-shelf chin and jaw angle implants do. They are fine for many patients but will not give a smooth jawline connection between the two. Only a custom wrap-around jawline design can do that.

I think using the picture of Matt Bomer is helping to define your objectives but you can never have his exact jawline because his facial tissues are thinner (less fat). Therefore, his jawbone anatomy is very well revealed including the angular flare. Your facial tissues are a bit thicker so you can end up somewhere between where you are now and his look.

In regards to the cheeks, I think they would also be helpful in achieving your desired facial look. I have done additional imaging based on these concepts.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering a jaw and/or chin augmentation procedure. I believe my chin would look better if increased length-wise, but I am unsure if a chin implant is able to achieve this (as opposed to the bone shift procedure). I am attaching some pictures so you can see my face from the front and side. I apologize about the poor lighting–I spent several months cultivating a beard, and these are the only pictures I have without the facial hair.

A:I have taken a look at your photos and feel that you are correct…your chin is deficient both horizontally and vertically. Your facial hair shows the vertical increase already and perhaps, consciously or subconsciously, this is why you grown it.  Either a chin implant or a chin osteotomy can create vertical chin lengthening but it depends on what you want the overall dimensions of the chin to be. A chin osteotomy will lengthen the chin but will also narrow it in width by doing so. (unless a simultaneously placed thin extended implant is placed along the bony margin at the same time) A chin implant can make the chin longer and wider (more square) but it would have to be a custom implant. There are no off-the-shelf chin implants that create that effect.

Q: Dr. Eppley,  I an a 45 year old female with a total avulsion of my left ear with skin graphing to cover the skin loss.  My car accident was twenty years ago and the ear was found at the accident, however it was macerated and nonusable, as well as the tissue behind the ear.  As I am getting older I am having numerous eye issues with severe dry eye syndrome and having to wear glasses and this is quite difficult with missing an ear.  Unlike the lady in this segment, I do not have an ear lobe and no extra skin.  I would even be happy with some sort of way to hold up my glasses.  I wanted to know if there was anything that could be done to help me function normally to wear my glasses.  Look forward to your response.  Thank You.

A: I think there are two approaches to your ear reconstruction depending upon exactly what you want the final outcome to be. The skin graft in place precludes any attempt at making and inserting a cartilage framework through a traditional microtia reconstruction approach. This requires supple skin that can either be elevated or tissue expanded. The standard approach would be the insertion of endosseous implants followed by the attachment of a prosthetic ear. This provides good prosthetic retention and should easily hold up a pair of glasses. A secondary approach would be to create a shelf of cartilage above the skin graft or at its edge onto which glasses could rest. This will not create an ear but more like just the upper ¼ or 1/3 of it. Whether this is possible will require reviewing a picture of what the ear site looks like and the exact location of the skin graft.
Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  I had a terrible broken nose when I was 10. The resulting deviated septum (and septal perforation) caused terrible nosebleeds throughout adulthood, but the structure of my nose looked good visibly. I had a septoplasty to correct the deviation in 2005 and hopefully stop the horrific nosebleeds. The results were terrible. My septum (which I was told before surgery had a pinhole in it) collapsed and I now have a saddle deformity and the tip is much wider and bulbous. I am told the hole in the septum is about the size of a pinky fingernail. Functionally, it is average. The septum is straight but crust builds up in the perforation and usually blocks one side of my breathing. Aesthetically, I am very disappointed. I still have very bad nosebleeds, but not quite as severe. How experienced are you with this procedure? About how many have you done? Successful results? If you think you may be able to help correct this, I would like to set up a consult. Thanks!

A: You appear to have two separate but challenging nasal issues, that of a septal perforation and a saddle nose deformity from collapse. This combination nasal problem is not rare and loss of septal support is the main reason for a saddle nose problem. The saddle nose deformity is best corrected through an open rhinoplasty approach using a rib cartilage graft to build back up the dorsal line and provide some tip projection and support. That is a very effective and successful procedure. Septal perforation repair, particularly if it is large, is a very difficult problem and has a high rate of failure. This is due to the lack of good mucosal tissue to move and provide a vascularized lining coverage on both sides of the nose. If it is a perforation bigger than 10mm in diameter, it may prove to be quite difficult to try and fix and you may be better served to leave that part of your nasal problem alone.

Q: Dr. Eppley, can breast implants be injured during sex? While having sex with my husband he leaned on my breast and it caused some immediate pain. For the past few days now, I have had lingering pain although it has gotten better. That breast also feels a little harder now. Could I have a breast implant rupture? I had silicone implants placed three years ago.

A: Your question is actually a common one and let me provide an overall explanation. The shell or bag of a breast implant is made of a very flexible but strong silicone elastomer material. It is designed knowing full well that it will regularly be exposed to a compressive crushing force…known as mammograms. Any woman that has ever had a mammogram can testify to the fact that their breast is really squashed between two paddles to do a mammogram. Millions of breast implants are exposed to lots of mammograms every year in the U.S. and around the world and there is no evidence that they induce rupture unless the implant shell has already been weakened. So it is highly unlikely that rupture of breast implants can occur as a result of sexual activity. It takes a high energy force to rupture a breast implant such as might occur from an automobile accident or other traumatic injury. What you are likely feeling is a mild bruise around the implant capsule which should go away in a few weeks. If in doubt, an MRI or a high definition ultrasound will be needed to answer the breast implant rupture question conclusively.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can you tell me if placing a temporal implant about 9mm thick under the temporal fascia, does this cause the eyes to appear smaller? Like does it pull the skin more to the temporal area and away from the eyes? It would be helpful for me to know, thanks.

A: That is an interesting question and one that I have never heard before. Temporal implants may push the skin in the temporal fossa outward but they do not cause any pull on the eyelid skin or the corner of the eye. Thus, temporal augmentation would not have any direct effect on the appearance of the eye. Whether it may secondarily cause the eye to appear smaller because of a more flat or convex temporal region is possible but not a complaint that has ever been voiced to me nor one that I have seen.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting paranasal/premaxillary implant to build out my nose area. I have a few questions/concerns with these implants.

1.  Will the implants cause my nostrils to show more, less or the same from front and side views? I don’t want a pig snout.  I think my nostrils show too much already since my rhinoplasty so I don’t want it to get worse. 

2.  Will the implants cause my upper teeth to show less?

3.  Approximately how long will my face be swollen and bruised?

4.  Will the implant show bulky or any bulges under my skin?

5.  Can you fix the area under my lower lip between the chin and lower lip to not look like it is pushed in?  It’s hard to tell on the pictures, but having some teeth removed prior to orthodontics has made my lower lip look pushed in and my chin come down with smiling which you said you could fix.  Is there a filler or implant I can use to get that projection instead of the dent/depression I have under my lower lip? 

A: In answer to your questions about parasnasal or premaxillary implants,

1) I don’t believe it will change your nostrils to any significant degree. I am assuming when you mean nostril show that you mean the tip of the nose would move upward thus exposing more nostril show. This will not happen.

2) There should be no impact on your upper tooth show. In other words, it doesn’t lift or shorten the upper lip.

3) There will be some swelling that show largely be gone by three weeks after surgery. I have never seen any bruising with paranasal or premaxillary implants.

4) The implant will not have any visible edges. The nasal base/midfacial tissues are too think to ever show an implant edge. 

5) I believe you are referring to the depth of what is known as the labiomental sulcus or crease, which is the groove between the lower lip and chin. This is best softened in depth by the placement of a subcutaneous implant (Permalip) made just for that type of augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been doing a lot of research to find out ways to fix an indentation I have on the left side of my skull and I read on your website about a procedure that you do using kryptonite bone cement to reshape irregularities in the skull. These irregularities were caused from birth. I would like to send you some pictures to see if my problem can be corrected using this method. Also other then overcorrection are their any other risks with this type of surgery? Another question I have is does insurance cover it, or is it considered purely cosmetic.

A: Of the available cranioplasty materials, Kryptonite is no longer available for use. The company that produced it has withdrawn it for any further sale currently. Therefore, there is no longer any injectable approach to skull augmentation or indentation correction. An open cranioplasty incision would be needed to place any of the other cranioplasty materials. Other than the scar, minor contour issues remain as the only risk. Skull reshaping or indentation correction is not a procedure that would be covered by insurance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I just want to have a strong chin and don’t want to narrow it, I think from side view my chin is receding and weak. Please take a look at my photos and give me some advices, what should I do with my chin , I want to bring it forward as much as possible and in your website I see amazing before and after photos, your work is very artistic. If I were in the US I would have flown to your clinic today but unfortunately I am far away and I can’t afford to come for a surgery. If you know someone in overseas who you think his work is excellent please recommend me so that I perform my chin surgery some months later. I may refer to any doctor based on your recommendation because I have trust and confidence in you. You know finding a good doctor is very important.

A: Based on your photos, your chin deficiency is very mild and you already have good chin width in the frontal view. I would recommend an implant as opposed to an osteotomy. This is the most assured way of getting better horizontal as well as transverse width increase. An osteotomy will bring your chin forward but will also make it more narrow as well. Otherwise, I have no surgeon recommendations for you in your part of the world as I simply do not know any surgeons either professionally or personally.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my son who is in college has been very sensitive since he was in junior high to take his shirt off. Whether it is by the pool or playing sports, he has never wanted to take his shirt off. I actually have never seen his chest since he was a little boy but I think he is embarrassed by his man boobs. He is not really overweight but for some reason he has had some small breasts develop. I really want to help him and I know it involves surgery but I don’t know how big of a deal it would be for him to go through.  

A: Gynecomastia is a common problem in both young and older men alike. A surprising number of young men have it and I suspect it parallels the increase in obesity in society although it occurs in many lean men as well. It can be caused by a variety of factors although in most young men the cause is never known.

Male breast reduction is fairly simple and does not require much downtime. How it is treated depends on how much and what type of breast tissue that exists. When the breast tissue is soft and is mainly fat, liposuction may be all that is needed. When there is a firm lump or glandular tissue under the nipple and around it, then an open excision is needed through an incision on the underside of the nipple. It is an outpatient procedure that only has a few weeks of recovery until one can return to full activities.

Of equal interest is that it can produce a thrilling result particularly in younger men and teenagers. The sign of success is when they confidently wear fitted shorts and are no longer embarrassed to go shirtless.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year-old African-American male  and I don’t like one particular part of my nose. It is the area at the upper nose that is between my eyes. I have read that it goes by different names including the radix, nasion or glabella..No matter what it is called, it is very deep and I don’t like it. It is unattractive and even makes me look angry. I want it fixed. Is there a specific procedure for just correcting this nose problem? I don’t need a complete rhinoplasty, just this one part of my nose improved.

A: What you are referring to is the height of your dorsal profile in the upper half of the nose. You could call this area the nasal root or bridge as it is appears the way it does due to the low level of the underlying nasal bones. A low bridge is very common in many African-American noses.  There are numerous options to build up the bridge of the nose from injectable fillers to synthetic implants and cartilage grafts. Each has these options has their own advantages and disadvantages. Injectable fillers, often called the injectable rhinoplasty, are best used if you simply want to make a temporary change to determine if you like the way it looks. If not, injectable fillers are reversible as they will be absorbed. A permanent result can be obtained from either a synthetic dorsal implant or a cartilage graft. (septum, ear or rib donor depending upon how much is needed) Most patients opt for a synthetic implant rhinoplasty because it is simpler and does not require a donor harvest site. In an area where the nasal skin is thick, synthetic implants have far fewer potential risks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a minor rhinoplasty (for instance family and friends did not notice) three years ago.  I am happy with the result, but I cannot breathe at all out of the left nostril.  I believe it is nasal alar valve collapse.  I have to wear breathe right strips at night, and I have a product called Breathe With Eez – a small nasal expander that is a tiny stainless steel thing that I insert.  I have to use this constantly – needless to say, this is uncomfortable and inconvenient.  I cannot breathe well out of the right side either, but the left is much worse.  I do not want to alter the shape of my nose at all because I am very happy with the outcome aesthetically, but I need to be able to breathe.  When I told my surgeon, he told me that he could not believe I would complain because most people would just be happy to have such a nice looking result.  When I complained that he is an ENT and I can no longer breathe out of my nose correctly, he told me he could try and fix it but it would leave scars on my face (he would go through the undereye area)…he treated me like I was crazy to expect to be able to breathe right again, and I did not trust him, so I did not go back for this operation – he explained it in a manner that made it sound terrifying. I would like to discuss possibilities on how to remedy my poor breathing problem.

A: Nasal breathing difficulties after rhinoplasty are not historically rare, particularly when significant tip narrowing modifications are done. If not enough support is left to the lower alar cartilages, they can become weak and bow inward causing internal nasal valve collapse. This problem can be modified if there is also middle vault collapse from a profile reduction as well. While an examination would have to be done to be certain as to the exact reason for your breathing difficulty, there are some standard manuevers for secondary rhinoplasty improvement. These include alar batten grafts to stiffen up the bowed lower alar cartilage on the affected side as well as spreader grafts to the middle vault. These cartilage grafts may have some slight effect on your current aesthetic result but should be relatively minor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am writing about my chin implant that I had placed three years ago at the time of my facelift.  I did not even want a chin implant in the first place but my surgeon talked me into a small one.  After this, there was a huge downward bulge on the right side (wing area).  It was a flowers small implant inserted through the chin.  When I went back to complained, he told me I was imagining it.  I was so intimidated, I left  it in even though it was impossible to miss it and I could not believe he denied it.  Shortly thereafter, I got the courage to re-approach him.  He conceded that maybe he could fix it a little this time and it was an incredibly painful experience, the numbing injections were horrible.  He told me he was repositioning it but there was risk of nerve damage and that if I removed it completely (my first request) there was even more risk of nerve damage, so I was too scared to take it out completely.  Well, he fixed it…but it is still bothering me – it hurts on that side – aches, pains and also I can easily still feel the bulge of the uneven placement even after that “fix”.  I cannot lie down with that side of my face or it hurts quite a lot after a while.  I am afraid it is an infection that flares up from time to time.  Also, many of my teeth are showing cavities or rotting and I am wondering could this be bone erosion of some sort? I would like the chin implant removed, if possible – I am concerned about skin sagging, so I guess I would like the sub-mental tuck done too if you recommend that.  Do you think I have a high risk of skin sagging?

A: The simple solution is to just have the chin implant removed. This is an easy procedure since it is  a smooth silicone implant and has no risk of nerve damage or exacerbating one even if it already exists. Given that this is a small implant I doubt that there will be any risk of significant soft tissue chin ptosis. I would remove it through the original submental incision and do a slight tuckup of the chin soft tissues at the same time. Your chin implant is not the source of your teeth condition and there is no correlation whatsoever between it and your dental or medical health.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to have a rhinoplasty to change the shape of my nose. I am Hispanic and I don’t like my thick wide nose. I will try to the best of my ability to describe what my goals are. I would like my nose to be more narrower from the top to the bottom. I would also like the side of my nose to be smaller and also a smaller yet defined tip. Its hard for me to explain but in person I can explain better but over all this is the work I would like done on my nose. I have attached pictures from the front and side for you to see what my nose looks like.

A: Thank you for sending your pictures. In looking at your nose and your reshaping goals, I think much of that is achieveable. To achieve an overall nose thinning, I would use an open approach with the following steps; radix cartilage augmentation (build up the nasal root), low lateral osteotomies (upper nasal bone narrowing), tip refining through lower lateral cartilage trimming, suture plication and a columellar strut graft, and alar wedge reduction. (nostril narrowing. It is important to realize that the amount of overall nasal slimming that can be achieved is controlled by the thickness of one’s nasal skin and how much it will contract. Given your ethnicity and thicker nasal skin, there are limits as to how much thinning can occur. I have attached some computer imaging to show what I think is a realistic outcome. Most of the benefits of this proposed rhinoplasty procedure will be seen in the front view and not so much in the side view since no dorsal profile change is being done (with the exception of radix augmentation and the tip is not undergoing any projection changes.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a particular head which is pointed at the top and flattened behind. I have already had several consultations of which opinions are different. Thus I am confused. One opinion was to fill the flat areas by a material without touching the  pointed top. Others proposed a craniotomy to cut the bone and reposition it so that the lump is found in the back and the flattening will be  up at the top. Since I know you have great experience in craniofacial surgery and am familiar with many ways to change the shape of the skull, what are your thoughts between these two skull reshaping options?

A: While I have not seen a picture of you, I can only make some general comments. The preferred and more practical treatment to your skull concerns would be to do an external  skull reshaping technique. This would be to burr down the ridge/high spots as much as possible and build up the flat areas with a cranioplasty material. The converse approach would be a craniotomy in which the bone is completely removed and reshaped. This would be a very aggressive approach to a cosmetic problem which is fraught with potential problems when attempted to be done in the very thick and vascular bone of  an adult.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how many injections and where do you give it and what dose of Botox in treating muscle hypertrophy of the jaw? How many visits and what is the cost?

A: Botox injections can be very beneficial in the treatment of bruxism, masseteric muscle pain and large masseter muscle size. The injections take but a few minutes and are done in the office. A good starting dose is 25 to 35 units per side or each masseter muscle. The injections are placed in the bulk of the muscle near the jaw angle. It is not a good idea to place the injections above a line drawn from the corner of the mouth to the top of the earlobe. Injecting above this line runs the risk of paralyzing one or more of the buccal branches of the facial nerve, resulting in upper lip paralysis for the duration of the Botox effect. Masseter muscle size starts to shrink down even after the first injection session. How many injection sessions it takes to cause a permanent reduction in muscle size, if that can really be achieved, is controversial. Some report three Botox injection sessions spaced four to six months apart as the protocol. Dramatic reduction in masseter muscle size can certainly be achieved with three sessions. Whether that creates a permanent result varies in each patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently got a fat transfer done to give my pecs more definition but I have noticed that as the swelling has gone down, my pecs have gotten smaller. I called the clinic up to ask them why this has happened but they said that this is normal and that the fat is volumizing.

A: Fat grafting for pectoral augmentation is an uncommon procedure but is part of the burgeoning expansion of injectable fat grafting use throughout the body. Unlike pectoral implants which produce an immediate volume that only goes through a swelling resolution phase, fat grafting is a more dynamic process that is associated with a triphasic recovery on the way to the result. There is phase one which is the immediate effect of the fat injections which are associated with the visible change in volume right surgery. As the fluid and some of the fat cells die and are resorbed in the first few weeks after surgery, the volume then goes down. (phase 2) If the fat cells take and multiple through preadipocyte conversion (stem cells) then the result will expand again in volume. (phase 3) This is what has been referred to as ‘volumizing’.  This is the unpredictable phase of fat grafting and how effectively that occurs will not be known for months. Usually the result will be evident by three months after surgery but may take as long as six months. Certainly what you see by six months after surgery is the final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking into a chin reduction for quite a few years now, but I have never gone through with it because I’ve always been afraid that the results would be terrifying. I read through your case studies on chin surgeries, and I must say it’s a relief to see someone with as much experience on the subject of chin surgery. Perhaps other doctors have just as much experience or more, but it’s relieving to be able to read about it instead of them briefly talking about it. I’m a man who has a larger than average chin (or at least I think so). My main reason for wanting a chin reduction is because I feel that I look weird when I smile, and it was not always that way. When I was a child I thought I had a great smile, nowadays I’m sad to say that I smile much less simply because I feel self-conscious. The other goal is to ensure that the chin surgery doesn’t make me LOOK like I’ve had surgery (this may be an obvious goal, but this is the one reason why I’ve been so reluctant on getting surgery in the first place). If a random stranger would introduce themselves to me, I don’t want there first thought to be “that man’s had work done’.

A: Unlike chin augmentation, chin reduction surgery is much more difficult and technically precarious. In plastic surgery, it is usually much easier to make something bigger than it is too make it smaller. Chin reductions are done either removing bone by an osteotomy or burring or reducing the soft tissue envelope. In many cases, both bone and soft tissue need to be reduced to get a good result. Most male chin reductions are a function of too much bone and leaving them with a smaller but still strong chin is acceptable. As you have stated, some improvement is better than too much change that would look unnatural. That is a good approach for any type of male facial plastic surgery in general. In looking at your pictures, I can see that a vertical chin reduction by wedge osteotomy would be a good approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severely chapped lips. I have tried everything for years, been to over ten doctors, and tried every lip balm and salve that exists. It gets so chapped that it is painful and a source of constant embarrassment. I have read that chapped lips can be improved by a procedure known as a vermilionectomy. What does it look like after surgery? Will there be a bruising and will the vermillonectimes heal quickly. I have been researching the internet about the procedure. The closest thing I can find about the lip procedure is for people that  have lip cancer . I don’t have lip cancer but it does give me an idea about the procedure. I have not found articles  for people that  severe chapped lips.

A: A vermillionectomy is used for a variety of lip procedures such as cancer excision as well as cosmetic lip reductions. It is nothing more removing a strip of vermilion with the posterior edge at the wet-dry line and the anterior edge as far forward as needed to removed the desired amount of aberrant vermilion. The excision is widest in the middle and tapers to a feather edge as it comes to the corners of the mouth. It is closed by a combination of the outer lip rolling in (vermilion) and the inner lip (mucosa) rolling out. Dissolveable sutures are used for closure. Any lip surgery does tend to swell considerably but there usually is not much if any bruising. For chapped lips, which occur exclusively on the dry vermilion, the amount of improvement obtained depends on how much of the involved vermilion lies within the excisional area.

Dr. Barry Eppley

Indianapolis, Indiana