Your Questions

Q: Dr. Eppley, How much does rhinoplasty cost in your practice?

A: This simple question unfortunately defies a single answer. There are many variables that affect the cost of rhinoplasty related to how much work is needed and how much time it takes to do it. These variables include whether it is a tip or full rhinoplasty, does it require any grafting (cartilage or synthetic implants) and is there any septal or turbinate work needed. Without knowing the specific needs of your nose, the best cost estimate I could give you is a range from $4500 to $8500, all costs included.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The Lifestyle Lift (lower 2/3 of face only) left me with bunching/folding of skin at the sides of my face next to my eyes when I smile, which looks very unnatural. They are now recommending a forehead or temporal lift to try to correct this problem at my expense. Do you think this would be effective? I am looking for other opinions as I don’t want to waste my money. Thanks!

A: There are no other options for this problem. Although I would not make this effort until you are at least six months after the lift procedure to give it plenty of time to settle and relax if possible. This can occur as a direct result of this ‘cookie cutter’ type of facelift where all of the pull is vertical in front of the ear, creating bunching or ‘excess skin to the side of the eye and in the temple region. This is avoided by having the anterior vertical scar go well into the temporal hairline or out along the temporal hairline The excess skin created by the facelifting pull has to go somewhere and be redistributed. But if the incisional pattern is too limited, all it can do is bunch up at the point of the end of the skin excision. Not everyone’s facial aging problem benefits by a  direct vertical lift, many need a more superolateral directional lift with a resultant longer scar on the back of the ear.

Your best treatment would be some form of a temporal lift. But that must be carefully designed to get an effective result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Is there any upper lip lift procedure that you perform that successfully shortens the upper lip but does not increase the red lip (vermilion) (i.e. no roll out, no extra visible red upper lip)? I’m a male and the last thing I want is a fuller, more feminine red upper lip, although I could greatly benefit from the upper lip shortening procedure. Maybe upper lip lift at the same time with upper lip reduction? Is that possible?

A: All of the lip lifting procedures do create that exact effect, more exposed vermilion although it is not a one:one ratio in a subnasal lip lift.  The amount of skin removed under the nose does not create an equal amount of vermilion exposure below, usually less than half. But the effect is there nonetheless. In theory doing an internal lip reduction at the same time would negate the increased vermilion ecposure. But it may do at the price of increased incisor tooth show which may not be a good trade-off. The other option to consider is a staged approach to the subnasal lip lift only removing about 4mm in two stages. This would give the upper lip time settle (vermilion relapse) while not causing too great of an immediate increased vermilion effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in  getting Brow Bone Augmentation surgery done.I am a 21 year old girl with big eyes. But my problem is that my eyeballs stick out from my upper eyelids making me look really ugly and scary to people. Now I want to get this surgery done but I have very important questions that I would like you to answer for me. Will brow bone augmentation surgery help hide my eyeballs that stick out? I have a perfect nose and i like my nose just the way it is, but i’ve been told that having my full brow bone  augmented could lead to changing the shape of the nose. Is this true? I would like to know the price range for a full Brow Bone Augmentation (BBA) surgery. I know this answer has to do with the type of material used, but out of an estimation I would like to know a range of price for both HA and PMMA. Lastly are the results of the BBA surgery permanent,meaning my eyeballs will be hidden for the rest of my life without worrying about any bad affect on my eyes in the long run. THANK YOU.

A: What you asking about brow bone augmentation is true. It can help deepen the look of the eyeball. It is just a question of how much. It has no effect on the appearance of the nose or the function of the eyes. The results would be permanent since the materials used are non-resorbable. The total cost of the procedure is in the range of $ 9500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking revisional rhinoplasty. I have had two prior procedures in 2001 and 2007. I am seeking to make the following changes to my nose. First I want to eliminate the ethnicity of my Middle Eastern nose. I am seeking a more European looking nasal appearance with significant improvement in the nasal tip and narrowing of the nostrils with less nostril show. Second, my septum as a result of my last rhinoplasty is slightly off midline with a deviation to the left. This will need correction. Cartilage from the right ear was used to support my tip in the past. My left ear is intact and can be uaed for further reconstruction. Lastly, my columella requires shortening without flattening my nose. Thank you for your kind assistance.

A: Thank you for sending your pictures. Based on your two prior surgeries (which appear to have been done via closed rhinoplasty ??) and the thickness of your nasal skin, any tertiary rhinoplasty is challenging in terms of achieving your goals. Your skin thickness makes it impossible to truly have a classic European nose which is more thin-skinned. As you experienced, removing cartilaginous structure underneath is not a guarantee that it will be well reflected on the outside. While you have room for some improvement, I am not optimistic that it can ever achieve the degree of tip narrowing and refinement that you desire. The purpose of your ear cartilage graft used in the past is mysterious to me as such tip grafting will only cause it to become thicker not thinner. Columellar shortening is not possible without causing a downward tip pull and is almost never done anyway except in cases of large projecting nose reductions.

While I think certain features of your nose can be improved (septal straightening, some limited tip narrowing) I have concerns about achieving your goals in a nose that is already scarred and grafted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in laser resurfacing to help reduce the growing number of wrinkles on my face. I don’t know much about laser surgery and how it works. I have seen some very good results and then read some bad stories about it. I know to get a really good result it is not s one day recovery. Do you think the results will be noticeable or rather worth the ordeal?

A: In laser resurfacing the historic rule is…the deeper you go, the better the results. Simplistically, the more bad skin you remove the new skin that heals over it will look better. But laser skin resurfacing is not all one tool and there are different ways to do it. By far today’s use of fractional laser resurfacing is superior to what has been done in the past. What makes fractional laser different is that it only treats a fraction of the skin’s surface. (as the name implies) But each penetration of the beam goes deeper, creating a better effect but with less recovery. These laser treatments can be done at all levels from light to deep and is based on the severity of the problem and how much time one has fofr recovery. Even a lighter fractional laser resurfacing treatment does really produce a noticeable result with very tolerable recovery. It can look pretty bad the first day or two (by your standards) but by five to seven days be completely healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a gummy smile that I don’t like. I would like to achieve four things: 1) straighten gum line 2) reduce amount of gums shown when smiling 3) improve lip seal at rest and 4) reduce horizontal protrusion of upper lip area in profile. (least important) I have attached some pictures. Do you think my gummy smile is caused by vertical maxillary excess, or short upper lip, or hyperactive upper lip muscle or some combination? Will jaw surgery for vertical maxillary excess reduce my face length too much?

A: In looking at your pictures, I do think your gummy smile is a result of a combination of a short upper lip and some degree of vertical maxillary excess. The short upper lip is the bigger component of the problem however. The first step you need to do is consult with an orthodontist to find out if you are even a candidate for a maxillary shortening. This is going to require a model and x-ray analysis. It is impossible to anyone to say, based on these pictures alone, that you have a significant VME and whether it merits surgical shortening.  If it is determined that a maxillary osteotomy is not an option, then you may consider soft tissue management of the gummy smile through various upper lip techniques such as levator muscle release and mucosal V-Y lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a chin implant inserted 8 months ago, which turned out to be too big. I was very unsatisfied with the result and it was removed 2 months after the initial surgery, which is 6 months ago from now. The problem is that chin ptosis has developed. I am suspecting that adequate mentalis reattachment was not performed after the implant removal. Moreover, the central part of my lower lip would not move downwards, even when I smile widely, always covering my lower incisors totally. This seems different from typical lower lip incompetence caused by mentalis muscle ptosis, since I believe that ptosis of mentalis muscle causes lower lip to drop downward with inability to close mouth properly. This lower lip issue is not a newly developed problem, since it was present immediately after the initial implant insertion surgery and never went back to normal. Also, my lower lip seems to have become shorter in vertical length. My labiomental sulcus area looks like the soft tissue is fixed to the bone making it look unnatural when i speak or smile. I am thinking a mentalis resuspension would help my problems but my question is why would my lower lip not move downwards? This sometimes interfere with my pronunciation when I speak which bothers me a lot. One more question is would sliding genioplasty combined with mentalis resuspension give a better result than mentalis resuspension alone? I want to know the best solution to correct my problems. I am looking forward to your answer. Thank you.

A: You are correct in that the lower lip may sag with chin ptosis in some cases, but not always. Many chin ptosis patients have a normal lower lip position and function. Rarely you will have a patient like you who has the opposite lower lip problem in which the lip will not evert. This can occur if the implant was inserted from below (submental incision) and the implant pocket was made up close to the mandibular vestibule. This disrupts the attachments of the labiomental sulcus and blocks lower lip eversion. Even when the implant is subsequently removed, the muscle fibers remain disrupted.

Since there was a reason you had the chin implant in the first place, it would make the most sense to consider a sliding genioplasty. In that way all three problems can be simultaneously treated. (chin deficiency, chin ptosis, labiomental sulcus muscle repair)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 5’6” and weigh 125lbs. I am fairly thin for my height but my thighs are just to big for my body. My lower half doesn’t fit my upper half and no amount of exercise or weight will change that. I now know that fir sure as I have tried for years. I am a size 6/8 in jeans and that just drives me crazy . I know that liposuction removes fat and helps contour areas of the body. But does that mean it can give the appearance of thinner legs and make me able to fit into smaller jeans?

A:  Your question  is both a good and a common one. I  have seen many people who are disproportionate in various body areas. They are not overweight but one area of their body doesn’t fit the rest. This is very common in the thighs or saddlebag areas. Liposuction can effectively reduce prominent saddle bags and, when combined with inner thigh and knee liposuction, can give the leg a much improved silhouette. For some patients this will make their leg thinner and they may be able to fit into smaller jeans. For other patients, despite the improved look, they make not end up with truly thinner legs and may only feel more loose in their current jean size. I think it is always best to think of liposuction as contouring or spot reduction. Making any body area truly thinner may be expecting more than the procedure can do in many cases.  

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi I am 18 yrs old and I have been insecure about my body for quite some time now. At the time I was born to the present I have been very depressed because I have a huge navel. (outie). I really find it hard to wear clothes without thinking about my navel. For example, If they are going to  see it, what will their reaction be, etc. I am tired of being unable to wear bathing suites and clothes and I need a solution. Today was the first time i heard that there was a surgery called Umbilicoplasty that can change an outie into an inne. I need help. I am wanting to know what  can be done.

A: The belly button or umbilicus is really nothing but a scar that extends from the skin down to the abdominal wall. Originally it was where the umbilical cord extended through the abdominal wall. Thus it really represents a small hole or defect in the abdominal wall. In most people, that scar is inverted or v-shaped and is an inne. In the minority of people it can be an outie because a small amount of peritoneal fat protrudes through the abdominal wall pushing the scar outward making an outie. In essence being a small abdominal wall hernia. Some outies are just everted scar but bigger ones are actual small hernias. Either way, an outie can be fixed by changing the scar to attach directly down to the abdominal wall or fixing the hernia. This is known as an umbilicoplasty and changing an outie to an innie is the most common non-tummy tuck form of it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severe breast asymmetry. Left is a D cup and right is an A cup. I also have very large areolas and my breasts are pendulous. Because they are so uneven I have had upper back soreness and other aches and pains. Would insurance cover me at all? It is just as disfiguring as other birth defects and even cancer. I am not at all exaggerating.

A: Whether your medical insurance would cover the reduction of your larger D cup breast is a determination of the insurance company. No physician can say with any certainty whether they will or won’t. This requires a written letter with photographs by a plastic surgeon to your insurance company. This is known as a pre-determination process. Once they have this information, they will then make either an approval or denial in a written response. They will definitely not cover any form of a breast lift such as may be needed on the smaller right breast and this would not even be submitted, lest it jeopardize any potential approval of the left breast reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, because of an accident at an early age I had some weak chin and facial asymmetry on the right side. Four years ago I had a chin implant whichi resulted in horrible deep hollows on the side of the chin. My chin implant was a button type. So I’ve had three fat grafting surgeries to correc the hollows and also using fat to lessen the asymmetry. (underdeveloped right side of my face) The results are not bad but still lots ofasymmetry and the fat is starting to melt unevenly so I am looking for a more radical solution. I want to remove the button type implant and replace with an extended anatomical chin implant as well as jaw angle implants to look more solid. What is yourt suggestion about this? Thanks a lot.

A: I would agree that changing the chin implant to an extended style is much better for a male than a central button style. The jaw angle area could be permanently enhanced by lateral extension jaw angle implants. The only area that will not be filled in as well is the area between the two. But I don’t think in your case that would justify custom implants to be made. Fat has been a good intermediary step to see if the changes are favorable but it is definitely not a permanent solution. The combination of chin and jaw angle implants provides a permanent volume solution to jawline enhancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I planned for long time to get calf augmentation and feel that now is the time. I am 170 cm tall and weigh about 72 kg and am very athletic. But I have skinny calves and they haven’t grown like the rest of me. My calves are 34 cm around.  I am ready for this mentally and financially. I want to know which type of method  is best for me and about the price and how much bigger will they be?

A: The most reliable method for calf augmentation is using soft very flexible solid silicone implants placed through a popliteal incision. The amount of calf size increase that can be obtained is based upon whether one (medial) or two (medial and lateral) calf implants are used and how tight or soft the calf skin is. Calf augmentation can also be done by fat injections but that method is limited by how much of the fat will survive and whether one has enough fat to harvest for the procedure. At your height and weight, I do not envision that you have any significant fat to use.I will need to see some pictures of your lower legs to see what may best for you. The price of surgery is based on how many implants are used so seeing the pictures first is important.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 33 year old male who has a very prominent brow which over hangs my eyes by at least a cm especially from the bridge of the nose to brow. This severely affects my looks. I have already had surgery where the surgeon shaved the area down after peeling the skin over my face which did slightly improve my appearance but nowhere near enough. The only answer I can see as someone obviously without any knowledge of a medical procedure to facilitate this is that if the brow bone was trimmed from the sides and the brow and presumably nose ‘pulled back’ and recessed. After googling cosmetic surgeons you appear to be one of the few doctors that may be able to help me with this. I don’t consider myself a vain person but just wish to have a relatively normal life. Do you think my brow bones can be further reduced? If so what potential risks are involved. As a cosmetic surgeon I am sure you are more than aware of the psychological damage that looking unusual can be and I am placing hope that maybe this can be changed. Thank you in advance.

A: Brow bone reduction by shaving rarely produces a satisfactory result. It may be a simpler procedure but it can only reduce the brow prominence by a few millimeters. Any further reduction will enter the frontal sinus cavity. Men in particular require an osteotomy technique for brow bone reduction as the amount of reduction can easily be 5mm to 7mms, if not more.

Please send me a few pictures of your forehead for my assessment. You have already been exposed to the greatest risk of the procedure, that of a scalp scar

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a man who is 37 years old. I am bothered by nipples which stick out too far. It is not just that they stick out too far when I am cold but they protrude all the time. It is embarrassing and has been so for years. I wear shirts to try and hide it but it is difficult particularly in the summer. They are often sore and raw from being rubbed on by clothes because they stick out. I just have to do something about it. How is nipple reduction surgery done in men?

A: Management of the excessively protruding nipple is usually done the same whether it is a man or a woman. The outer aspect of the nipple is reduced by a wedge excision, How much is removed depends on the patient’s preference. Most men want the nipples to be coimpletely flat while women prefer a small raised nipple that stands out above the surrounding areola. When done alone, this is an office procedure done under local anesthesia. Small dissolveable sutures are used and only bandaids are used as a dressing. One can shower the very next day and there are no activity or work retrictions. The scars on the nipples heal so well that they can not be found later in most cases.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have large earlobes and I want to get them reduced. I have always had them since I was child. I was constantly teased about them even by my parents and it has bothered me deeply ever since. They simply don’t fit with the rest of my ear. They are big, floppy and hang down. I am now 45 years old and have decided it is time to finally do something about it. How is earlobe reduction surgery done? What is the recovery and is the scarring bad?

A: The earlobe is uniquely different than the rest of the ear since it does not contain any cartilage. It can become big either by genetics (as in your case) or from becoming stretched over time by ear ring wear and gravity. Either way, earlobe reduction is a fairly simple surgery that canbe done under local anesthesia in the office. The earlobe is cut down in size by removing a central wedge of tissue, reducing both its height and width. Usual reduction is around 50%. There are no dressings used and the tiny sutures on the outside of the earlobe are removed one week later. You can shower and wash your hair the very next day. Scars on the earlobes heal so well that three months after surgery that are undetectable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can excess skin be removed and remaining skin lifted up and under the eye? Can the outer corners of the eyes be lifted for “sad eyes” at this same time? How is this done? I have tired and sad looking eyes that need some help as they make me look so bad. The outer part of my eyes has always been turned down since I was young and I have never liked it.

A: Traditional lower blepharoplasty or eyelid tuck techniques can remove fat that causes bags and to tighten loose skin under the eyes. At the same time, the outer corner of the eye can be changed. The position of the corner of the eye is controlled by a tendon that attaches it to the inside of the bony socket of the eye. This tendinous position can be changed to raise the corner of the eye, known as a cantopexy procedure, making it either level to the inside of the eye or higher if one desires more of an upward tilt to the eye. This can be done at the same time as a lower blepharoplasty (or an upper blepharoplasty) through the same incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to do something with my tummy area but am confused as to what to do. I have had several consultations and have been repeatedly told that I need a tummy tuck. However I don’t want to have a tummy tuck as I am scared of being cut like that and also fear the recovery. I lost 50lbs over the past two years and now weigh 140lbs and am 5’ 2” tall. If I just have liposuction will I be left with hanging skin and look worse?

A: It is clear based on your description of your body from weight loss and the recommendations of several plastic surgeons that a tummy tuck will produce a better result. But if you can not accept the excisional nature of the procedure and the resultant scar, then it is not a good operation for you. This is a common dilemma for many patients. Better result aside, liposuction is a more acceptable procedure for you and appears what you can accept at this time. The key to undergoing just liposuction is your acceptance that the result will not be as good as a tummy tuck. That is the price you pay for a procedure that does not ideally match the problem that you have. Always remember that you can always have a tummy tuck later if you find the deflated abdominal skin unacceptable. Based on your result from liposuction, you will either be glad that you choose just liposuction or will become convinced that a tummy tuck really is a good operation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have three areas of concern physically. I have a buffalo hump frm HIV meds, relatively severe gynecomastia and belly fat also mostly from HIV meds. Those are in order of priority for me. Any experience with any or all of those? Is it possible to address all three? Is there chance of re-occurrence?

A: All three areas to which you are concerned are common sequelae from HIV medications, of which I have seen before. The neck and chest concerns can be surgically treated but the abdominal fat usually can not. Almost all of the belly fat that you see is located behind the abdominal muscles and around the organs. (intraperitoneal fat) That is why your belly most likely feels hard like a watermelon. This is surgically inaccessible fat. Only fat that is outside of the abdominal muscles (subcutaneous fat) can be treated by liposuction. Such fat location would make your belly feel much softer.

The buffalo hump deformity is commonly treated by either liposuction or direct excision. There are advantages and disadvantages to either approach. The simpler approach is liposuction although the fat in the buffalo hump tends to be more fibrofatty tissue than pure soft fat alone. This is why direct excision would produce a better result but creates a permanent scar down the middle of the hump afterwards. The gynecomastia is treated like any gynecomastia surgery using either liposuction with or without open excision.

I could provide more definitive answers if I saw pictures of the buffalo hump and your chest.

Recurrence of neck and chest fat can occur since the use of the medications (cause) is ongoing. But in most cases I have seen the results are fairly sustained.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, in your blogs about temporal augmentation have you ever come across a patient whose hollowing us deepest 6 mm to 7mms above the zygomatic arch? I ask because that is my situation. Can temporal implants correct this area adequately. Do they go down to the zygomatic arch under the fascia that far?

A: Most temporal hollowings are deepest 5 to 10mms above the zygomatic arch. They are not commonly deepest at the zygomatic arch since that is a supportive bone. Like a trampoline, the temporal hollowing is most deep away from the surrounding edges. Therefore, subfascial temporal implants will bring up these areas quite well. The implant in a subfascial location will push up the fascia right up to the upper edge of the zygomatic arch in most cases. But I have seen a few patients where the deepest indentation is right at the upper edge of the zygomatic arch. To make for a smooth transition between the arch and the temples, the implants in these cases must be placed on top of the fascia as subfascial implants can not create enough push on the strong bone fascial attachments.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a short midface and we had previously discussed using cheek, paranasal and premaxillary implants to give me more midface projection for an improved facial look.  At your suggestion, I also visited an orthodontist who advised me to have a Lefort 1 procedure because there is an issue with my tongue not having enough room in my mouth and is constantly sore from rubbing on my teeth at the right side. He says implants would not help this but a LeFort advancement would. What are your views?

A: There is no question that the best functional treatment for maxillary retrusion is a LeFort (maxillary) advancement. This is the complete opposite of a cosmetic camouflage approach using multiple facial implants. These two approaches are diametric methods for treating midfacial retrusion. The key decision about a maxillary osteotomy approach at your age is whether you are committed for the necessary presurgical and postsurgical orthodontics required and that the amount of maxillary advancement that would be obtained is a minimum of 5mms, preferably 7mms. Any amount of maxillary forward movement less than 5mms would not be worth that amount of effort. It may also be possible that you would need a mandibular osteotomy setback as well to get the necessary forward movement of the maxilla. These are issues that would be known in advance through comprehensive orthognathic surgical treatment planning. Even with maxillary advancement you will still benefit by simultaneously performed cheek implants as the maxillary osteotomy moves the dental and nasal base bone but not the cheek bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had a chin advancement done several months ago due to my severe lower jaw deficiency.  I just want to ask a question. I definitely feel there has been an improvement since having the chin moved, but I was wondering what your opinion is on whether moving my jaw itself would ever be possible in my case because I still feel that my lower jaw deficiency is problematic.   I would assume as an oral surgeon it is a procedure you are familiar with.   I have had a lot of dental work done which definitely complicates things unfortunately, but the appearance of my lower jaw is still something that bothers me.   I am currently 24 years old and have been bothered by it tremendously for years now.  I do realize that jaw surgery is very costly unfortunately, but the financial realities aside, I just wanted to hear your opinion about whether it even is a possibility given the dental work I have had done in your opinion.  I definitely regret not taking better care of my teeth and would do it all over again if I could because of how much of a toll this problem has taken on me.

A: In looking at your x-rays, you do have an overall lower jaw deficiency with a Class II malocclusion. Your indwelling dental work aside, the question of whether you could ultimately have a sagittal split mandibular advancement first requires an orthodontic opinion. Such orthognathic surgery requires a period of orthodontic preparation and after surgery orthodontic fine tuning. While I suspect you are an orthodontic candidate, how much time that would require and the associated costs would have to be answered by an orthodontic evaluation. This orthodontic process is the rate-limiting step for any patient considering orthognathic surgery as the jaw(s) can not be moved without it in place and having the teeth realigned for such surgery. As an cosmetic camouflage alternative, that is why you have a chin osteotomy initially.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have big eyes and it looks like my eyeballs stick out from my upper eyelids and it makes me appear very scary to people. I even sometimes get mistaken for being an Egyptian even though I’m not. I searched over the net and found out that by having brow bone augmentation my eyes will look deeper . That could be the solution to my problem since I want to hide my eyeballs that stick out of my upper eyelids. Do you think brow bone augmentation surgery would help. The thing is that I’m in desperate need of this surgery but at the same time I’m really scared when it comes to surgeries around my eye area. So my question is how safe is brow bone augmentation  surgery and what are the risks and the worst case scenario in terms of the surgery and could it ever effect my eyes negatively in any way in the long run? Thanks alot

A: When it comes to eyes that are too prominent, you want to first be sure that the cause is not some form of exorbitism due to intraorbital tumor or medical condition such as hyperthyroidism. But for the sake of answering your questions, I will assume that yours is natural condition of your anatomy. Therefore, brow bone auugmentation could help as it builds out the upper out eye socket rim, thus making the eye look more recessed. This is a perfectly safe surgery from an eye safety standpoint since it is done from above and does not involve entering the intraorbital space. The potential complications with it are mainly aesthetic, the scar from the coronal scalp incision to do it and whether the brow bone is built up too much or too little.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I had a tummy tuck six months. Although there is much improvement in the lower half of my stomach, the area above my belly button up to my ribs still seems too thick. I was wondering why liposuction wasn’t done to thin that area out at the same time as my tummy tuck. It was the perfect time to do it. Did my doctor overlook it or just forget to do it?

A: Liposuction is not done in the central upper abdomen at the time of a tummy tuck by many plastic surgeons in an effort to a avoid wound healing complications. While it may be viewed as an ideal treatment approach that offers more complete abdominal contouring, it does introduce risk of wound healing problems. By traumatizing the blood flow to the upper abdominal skin flap which may be also partially undermined, a partial necrotic skin flap can potentially develop below the belly button. Even it that develops and is small, you will then wish that liposuction component had been omitted from the procedure. It is much better to have a tummy tuck that heals well even if there is some residual fullness in the upper abdominal area. You can always undergo a secondary upper abdominal liposuction procedure later which is a much more tolerable ‘problem’ than to go through the time and tremendous inconvenience of a long healing process of an open wound…not to mention the ugly scar which will result. It was not an overlooked or forgotten procedure but one omitted for your safety.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an interest in a revision rhinoplasty. I had a prior rhinoplasty to try and make my nose thinner and smaller. But unfortunately that has not been how it has worked out.  As you have previously written on your blogs, the more skeletal framework we take away from a thick nose such as mine, the more shapeless it may become. I have finally come to accept that my nose will never be small, but I am hoping that the tip can be a bit more defined. Also, I noticed that my nose exhibits lots of nostril show since the surgery.  Would it be possible to make my nose longer, so that the nostrils will be less noticeable along with further nostril size reduction? Maybe you can see that my nose kind of looks like a pig’s snout similar to the “before” picture of the lady’s picture I have attached. I’ve attached a picture of myself along with a before and after picture I found online.

A: What you are talking about is that you have a bit of an overrotated nasal tip from the prior procedure, resulting in excessive nostril show. This can definitely be improved by a revisional rhinoplasty procedure using a derotation manuever with a tip lengthening graft (to push it down and forward) and nostril rim grafts to lower the outer alar rims. This would require a septal cartilage graft, which although some has been taken from the prior procedure, most likely enough may exist to do these extension tip grafts. This is an unknown variable that can only be determined at the time of surgery. As a secondary option, we would have to be prepared to use ear cartilage if necessary. Septal grafts are preferred because they are straight and more stiff.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have had Restylane and Juvederm injections infrequently over the past 6 years. Two different Dermatologists did them. However even though my results were exceptional at times, the most recent Juvederm treatment seemed lumpy and inappropriately placed. I am hoping a surgeon might have a better result with better knowledge of where the product should be applied. Also, I was wondering about whether very slight eye injections to soften laugh/smile lines would be available? I am 65 years old look 40. I had a mini-facelift 24 years ago and it was the best decision I ever made. Now, however, I would like to also consider a Lifestyle Lift if possible. Less of course is more in the long run, although I am noticing a slight  sag under the chin now. Possibly Juvederm or Restylane can smooth that with out changing my facial features. My hope would be to have this all completed in one or two visits as soon as possible.  I would like to be treated on first visit as I am very busy with work.

A: While injectable fillers can make some wonderful facial changes, they are not useful for every facial aging problem. They are of little value in the crow’s feet or periorbital line areas as these are very superficial wrinkles. Injections of crow’s feet have a high incidence of irregularities and lumpiness. This is usuallya better area for Botox and fractional laser resurfacing. But it would depend also on how deep the smile lines are. Also injectable fillers will not be able to smooth out loose skin under the chin. This would be better treated by some type of a face or necklift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve always been aware that my jaw is asymmetrical.  The right side of my jaw looks fuller and more defined than the left.  It also leaves my face with sort of a twisted look. I did have surgery about ten years ago to remove a tumor in my jaw.  They took bone from my hip and grafted it in to replace what the tumor had  destroyed.  The right side just looks and feels (both externally and internally) too full, while my left jaw doesn’t look full or defined enough.  Furthermore, the right jaw protrudes further out from my neck, while the left side is much closer and less discernable from the neck. I’m just writing to inquire about what options I”d have to correct this issue.  I don’t experience any issues with teeth alignment or any pain, it’s just something that is really bothering me from a purely cosmetic standpoint.  I don’t think I look normal.  Any insight you can offer would be greatly appreciated.

A: What you are describing is asymmetry of the ramus or back portions of the jaws, known as the jaw angles. When evaluating asymmetry, it is important to determine if there is a ‘good’ side or whether both sides are off. That obviously would determine whether you only treat one side (augment the deficient side or reduce the larger side) or whether both sides need to changed. Based on your description, I suspect that it is a combination of both sides for your jaw asymmetry surgery.

The first place to start is to make the correct diagnosis. This starts with sending me some pictures of your face. A recent x-ray such as a simple panorex film from a  dentist’s office would also be helpful at some point. In an ideal world, a 3-D CT scan and jaw model is the perfect way to custom design a jaw reshaping procedure. But it is premature at this point to say that such a model is needed.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am a revision rhinoplasty patient.I had a rhinoplasty rib surgery done 4 weeks ago. My bridge is too high. I did not know I would have a graft go up so far between my eyes. My tip is pointy. My nose was botched by the primary surgeon who did not listen to my minor adjustments requests. I had a straight bridge, and a normal round tip. He made my bridge crooked zig zag and my tip turned up and triangle shaped.I went a year looking like that. I do not want to look like this for a year. Is there anything that can be done. I want the tip collumella part just taken out. It is too long and pointed.It is rib cartilage, it will not change with time.The bridge all the way up makes me look terrible, and my eyes look different. I spent so much money on all of this, what is your suggestion?

A: I am sorry to hear of your current concerns. While swelling undoubtably still exists at this early time after your rhinoplasty revision, your concerns about being too high in the radix area of the bridge and too long and pointy in the tip may well not change appreciably given those locations and dimensional concerns. The first step is to revisit your plastic surgeon and get their take on it. Of course, you are going to be told that swelling is still there and to wait. But if you don’t want to then I would express that clearly and see what you can work out. They either will agree to do it or they won’t. If they won’t despite your insistence, I would give it  up to three months after surgery and see if your feelings about it have changed. If not, they revisit the surgeon and if you can’t come to an agreeable plan then it is time to seek out another surgeon. There are some benefits to waiting even when a revision is known to give some swelling and inflammation time to settle down.

While the rib graft may have been perfectly appropriate, like all implants, it is easy to get a result that looks oversized or is ‘too much of a good thing’. There is a fine line in a rhinoplasty sometimes between a good augmented result and one that is too big.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Hi, I’m interested in using filler to augment my low nasal bridge and droopy, bulbous tip, but the problem is I have had 4 unsuccessful nose surgeries, and am not sure if filler can help. My concern is that my nose was built using rib cartliage and I know how the skin tends to exert a lot of force on the cartliage, so I’m not sure if my nose condition is ideal for filler, especially on the nasal tip. How do you go about and evaluate if my nose condition is ideal for using filler? Thanks!

A: With four prior rhinoplasties and a rib graft in place, I would be very concerned about the risk of skin necrosis with any injectable material. Between the scar tissue and the push of the rib graft underneath, you do not have normal flexible and distensible nasal skin. More relevantly the blood supply to the skin, particularly in the tip area, has been affected by all of these surgeries. Any additional pressure exerted by an injectable filler may tip the balance in the nasal tip to one of vascular compromise. You are far safer in the bridge area with injectable fillers where there is a more robust blood supply that is not on an island so to speak. Even putting it there I would be cautious about doing too much filler at one time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, In considering getting temple implants for augmentation, I have read some bad reviews about the use of silicone. I realize that these talk about their use in rhinoplasty. It was stated that silicone had a higher chance to shift and possibly become “rejected” by the body. I had read that Gore-tex enables the tissues to grow “into” it so it was less likely to switch or protrude months or years later. How does this relate to implants in the temple region. Also, I have attached an overview of the temporal augmentation procedure written by a doctor. He talks a lot about risks and complications. He makes it sound like it is a bad procedure. What do you think?

A: What potentially can happen to an implant on the nose has no correlation at all to what occurs in the temples. They are two different anatomic sites. In the nose the implant is only covered by thin skin and has potential to be exposed to the contaminated nasal airway and is, in fact, placed by being directly exposed to nasal air and the nasal linings. In the temples, the skin and fat cover is very thick and the implant is placed deep under the fascia and right up against well vascularized muscle. What can happen to an implant in these two anatomic sites is dramatically different when it comes to risk. They are not remotely comparable.

Neither Silicone nor Gore-Tex material will have tissue ingrowth. They both simply become encapsulated as they are smooth-surfaced materials.

When reading the ‘Risks of Temporal Augmentation’ summary that you sent me that was obviously written from a perspective of having never done a more contemporary method of temporal augmentation and has no craniofacial plastic surgery background/experience. It is written based on an old style way of a big coronal incision and placing some type of material under the temporalis muscle. That might be more relevant to a large temporal defect that occurs from a craniotomy but not a cosmetic temporal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana