Your Questions

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

Injectable fillers have come a long way since the approval of the first non-collagen based product in 2002. While once conceived as only a way to make lips bigger and nasolabial folds less deep, injectable fillers have evolved into a popular aesthetic technology that has a wide number of facial uses.

Injectable fillers are used for two aesthetic facial applications, spot filling and volumetric enhancement. It is the latter that is often coined as ‘non-surgical facial sculpting’. That term is probably more accurate than not as it definitely takes skill and a good eye to get pleasing facial results with fillers. There is more art to it than science.

When it comes to facial volumetric enhancement with fillers, they are often compared to and even viewed as a substitute for surgical solutions to the same problems. Some injectors view synthetic fillers as  a better treatment choice as they are easier to do and have less risk of complications than surgery. While that is partially true,  they rarely  give better results than surgery or offer the best value for the money invested to do them.  Fillers can be a quick non-surgical fix but the benefits will ultimately fade away.

For skeletal augmentation of the three facial highlights, chin, cheek and jaw angles, injectable fillers can be used to create a visible external effect. When placed down at the bone level, I prefer Radiesse. Its calcium hydroxyapatite composition makes it the most viscous filler which provides a better push of the overlying soft tissues per cc of volume.  But when comparing it to synthetic facial implants that have been used for decades, it has several disadvantages. It takes a fair amount of syringe volume to get a visible effect, often at least two or three syringes depending upon the area.  The effect will never be as significant as a surgical implant and the filler material will go away by about one year after injection. This makes using an injectable filler for bony augmentation very patient selective. Filler are best used when one is uncertain about how a surgical implant may look (trial ‘implant’) or if the effect is time dependent based on an upcoming event and one doesn’t have the time to recover from surgery.

The face is also made up areas whose shape is not dependent on the underlying bone. These include two large areas in the lateral face and the temples. In the triangular area between the cheeks, chin and jaw angles, lies the lateral facial region. This area has garnered a lot of attention in facial aging as it becomes more concave in some people as they age due to fat atrophy. Plumping it up with fillers has become popular as a rejuvenative manuever. I prefer Sculptra for the lateral facial triangle because of the volume of material needed. Using an 8cc reconsitution of Sculptra in an almost pure watery form, it is easy to get a good amount of material over this large area. Sculptra does not work immediately and it takes time and three total injection sessions to get a result. But its effect may last for up to two years.

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

The concept of facelifting has evolved considerably in the past fifteen years. Not only has the techniques of facelift surgery changed, but how it has become markerted and advertised has changed as well. When you throw in the media coverage of celebrities and some of their results, understanding facelift surgery becomes even more muddled.

The options in facelift surgery are, however, far simpler than it appears. Facelift surgery traditionally speaks to correction of aging of the lower face only, the neck and jowls. As we age, jowling develops first which then leads to neck sagging and eventually the dreaded neck wattle. At its most simplist form, facelifts can either correct the jowls only, the neck only or both.. Thus facelifts can be done either as a partial (aka mini-facelift) or a full version.

The partial facelift is done when jowling is the main problem and any neck issues are either non-existant or minor. A full facelift is needed when the neck problem is the main issue or just as prominent a concern as that of the jowls. Thus, partial or limited facelifts are usually done on younger patients (less than age 55 or so) who have yet to develop significant neck sagging. The recovery from mini-facelifts is quicker because the operation is shorter and less technical manevers and tissue manipulations are done.. These are also the type of facelifts that have become very popular, largely driven by people in the workface trying to look younger and refreshed to remain competitive. They have been given a lot of different marketing names that imply less surgery and faster surgery and recovery, all of which is true. But don’t let the names fool you, they are all very much the same surgery.

A full facelift is usually needed in patients 55 to 60 years and older when the neck is a noticeable aging feature and either flaps or gets in the way of shirts and neck wear. In these more complete facelift patients, other procedures may be beneficial and are combined with it such as eyelid tucks and browlift surgeries. It is these combination procedures that give the impression that a facelift is a very extensive operation from which it takes a month to recover.

In between the mini- and full facelift patients lies an almost third category. This is where a partial facelift is not enough and a full facelift maybe more than what is needed. This may be perceived as a 3/4 facelift whose level of invasiveness and recovery is somewhere between a partial and full facelift.

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

Q: Dr. Eppley, I have been trying to figure out about the chin surgery. I have asked a couple of plastic surgeons about what is the difference between chin filling and chin implants. Will either one give you the same type results?

A: What you are asking about is the difference between use injectable fullers to augment the chin  as an office procedure with an instantaneous results versus the use of a chin implant which involves surgery and a recovery. The simple answer is no. The effects they will create are radically different. Injectable fillers to the chin are going to create small temporary augmentation changes while an implant is going to create a larger permanent volume change. Each approach has a role to play in the right patient. But injectable fillers to the chin plays a very small role in the overall number of chin augmentation procedures that are done because the changes are both small and temporary. But if one is looking for just a little augmentation, does not want surgery and is willing to accept that the result is not permanent, then this could be a good treatment. In my experience, I find that this is always a female patient who wants just a little central point augmentation to make the chin more feminine. I use Radiesse injectable filler as it lasts fairly long (one year) and its more thick consistency gives a good push to the overlying soft tissues of the chin as it is placed deep down at the bone level.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really like what you have done for my temporal augmentation. But I had read some bad reviews on silicone implants. Would you be able to do Gore-tex implants instead? I am weary of silicone…

A: I have no concerns about silicone facial implants and I don’t know where those ‘bad reviews’ come from. Your body doesn’t care if it is silicone, gore-tex or any other material, it treats them all the same…as a foreign body which is enveloped by a layer of scar tissue. (capsule) Any beliefs that the body treats one synthetic material different than another is not based on any known science of biomaterials.

That being said, it doesn’t make any difference to me what material a patient wants to use as long as it can do the job adequately. I almost always use silicone temporal implants because they are preformed, very soft and flexible and are the most economically efficient for the patient. I can certainly use Gore-tex but it will cost more because you have to buy a block of it and then hard carve out the implants during surgery. It is easy for me to do, it just costs more.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want lip enhancement, exactly like the Robert Pattinson picture which I have sent to you. I have sent three additional pictures also. Is it possible to make my lips look exactly like that?

A: The simple answer is no. It is not possible to make you or anyone else’s facial features look exactly like someone else. This is not a realistic goal in plastic surgery. And undergoing a lip enhancement procedure with the belief that such a result will be the outcome is a setup for disappointment afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be interested in learning more about the jaw augmentation procedure  through the insertion of  mandibular implants (both angle and ramus). I know that it is usually not possible to estimate costs and length of recovery in patients that the surgeon has not had a chance to examine and talk to in person, but still, I was wondering if you could give me a (general) idea of how much the total cost of the surgery would amount to (all inclusive: implants, surgeon, anesthesiologist, facility etc.) as well as how long the downtime would be.

A: In answer to your cost question, part of the cost would relate to what type jaw angle implants are used. (silicone vs Medpor)  There are different styles and shapes based on the jaw angle result desired. But taking that into consideration, the total cost would be in the range of $6500 to $8500.

The concept of recovery after any surgery depends on how one chooses to define recovery. From a significant facial swelling standpoint, think three weeks. From judging the final result, it is a minimum of 6 weeks and ideally 3 months. From a physical recovery standpoint, one can return to work as soon as they feel able., which for most people would be 10 to 14 days.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to get my ears fixed. They stick out and I get ridiculed by how they look. While they don’t stick out as bad as some people I have seen on your plastic surgery website before and afters, they definitely are not normal looking. I want to get them fixed so I can be a whole person and not have to worry about hiding them with my hair. What seems to make them stick out is not so much the outer rim of the ear but the part closer to the hole. It is big and very stiff. What type of otoplasty do I need and how long and painful is the recovery?

A: On the surface, otoplasty surgery can seem all the same being done from an incision on the back of the ear. But how the ear cartilage is reshaped is done differently based on the cartilaginous anatomy of the ear. The two basic cartilage reshaping methods are creating a more prominent antihelical fold by suture placement and conchal size reduction by excision and suturing it to the mastoid fascia. Often a combination of manuevers are done to create the desired effect. Your protruding ears sound like a large and prominent concha is the major issue so conchal reduction and setback is needed.

Otoplasty surgery is not particularly painful but it does make the ears sore for a while. Recovery after otoplasty can be viewed as  matter of days or weeks depending upon how you define recovery. Returning to work and resuming all normal activities will occur in matter of days. To have most of the swelling gone and the ears feel completely normal again, think four to six weeks after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I desire a smoother, lower forehead. Currently I have indentations on each side of my forehead that run all the way down to my cheekbone arches. I would really like to have those indentations filled in using bone cement or some other reliable material. I also have a high forehead and would like to have it lowered. My forehead looks big and masculine right now and does not fit well with the rest of my face. I have attached pictures of me for your review.

A:  The indentations to which you refer are the temporal fossa, which is largely a soft tissue space filled with the temporalis muscle to the side of the forehead. It extends from the anterior temporal line at the edge of the forehead down to the zygomatic arches inferiorly. While these could be filled in with bone cement deep under the muscle, that would not be my approach and could be improved much more simply. Silicone temporal implants can be placed under the deep temporal fascia and on top of the muscle. This is a more effective, reliable and cost effective technique.

When you speak to a large forehead, I am assuming you mean a high one in which the distance is vertically long from the eyebrows to the frontal hairline. That is different that a large forehead in which the frontal bone is bossing or prominent. While the forehead can be vertically shortened by a centimeter or so through a frontal hairline advancement and skin excision, I would be very cautious about performing that procedure in you. A forehead reduction results in a scar along the frontal hairline. In pigmented skin types like yours, I would be concerned about how such a scar may turn out. Hair density and hairstyle is also an important consideration is deciding about the aesthetic merits of a forehead reduction procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have jaw asymmetry as a result of a prior fracture. My idea for the jaw was to break just the mandible in and reposition it as it originally had been before the trauma with a little added refinement. I already had wires/braces and even though it sucked, I don’t mind going through it again for better results. I was also wondering if you could give me a breakdown of the total that a mandibular osteotomy to restore the jaw to its original form would cost with braces, surgeon fee, anesthesia, and facility. Thank you.

A:  When trying to improve jaw asymmetry, the choice of a mandibular osteotomy must be considered very carefully. The reason to go through a mandibular bony repositioning through ramus osteotomies is because of either an existing malocclusion or an occlusal cant with an open bite or a cant with an otherwise good occlusion. The first step is to consider whether a mandibular osteotomy is worth the effort by getting an evaluation by an orthodontist. This is a decision ultimately based on its effect on the occlusion and only secondary on the shape and position of the mandible

But for the sake of discussion, let’s say it is a worthy procedure. This will require 6 to 12 months of orthodontic preparation and 5 months or so of  after surgery orthodontics. A cost estimate would need to come from an orthodontist but we’ll use the general figure of $5,000. The cost of a  mandibular sagittal split osteotomy include surgeon’s fee, operating room and anesthesia with an overnite stay would be in the range of $ 17,000 to $19,000. For an over $20,000 investment, one needs to be absolutely certain that the end result justifies this effort.

If this degree of effort is deemed excessive, then there are other camouflages procedures for jawline enhancement such as implant, bony shaving and reductions and chin osteotomies.   

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 24 years old and 7 years ago had an otoplasty done. The results are very unnatural and unleasing. The antihelix is very large and the ear is similar to “telephone ear deformity”. Is a revision possible to correct these problems?  I would like to know the procedure for them to be fixed and what are the risks?

A: In general, an overcorrected otoplasty creates a prominent antihelix and a retruded helix. This can be caused by either too much postauricular skin excision, antihelical creation sutures that were overtightened or a combination of both. Most commonly the cartilage deformity is the real culprit. This requires it to be released by scoring/releasing the fold and then holding it outward so it heals in this new shape. This is ideally done with cartilage grafts which can be harvested from the concha. The biggest risk of this revisional otoplasty procedure is how well or effective it can be. Improvement is almost always obtained in otoplasty revision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want symmetry in my face after a few events that changed it. I want to breathe better. I want my nose to be as it was before trauma, might need cartilage graft on left side. I want my jaw to be more angular and symmetrical with osteotomy after having broken jaw. I want my left eye to look like my right eye, cause could be previous rhinoplasty or trauma involving prolonged eye poke. Here are some pictures of me.

A: Thank you for your inquiry and sending your pictures. I can clearly see your concerns in all three areas. In looking at your pictures, I can give you the following suggestions for these areas as follows:

1) Nose –  a septorhinoplasty is needed to straighten the septum, harvest a septal cartilage graft, decrease the size of the inferior turbinates, and reconstruct the external nose with a right middle vault spreader graft. Your external nose may benefit by other changes but that is as much as I can say based on these two pictures.

2) Jaw – To correct your asymmetric jaw, I would not do a traditional jaw osteotomy. This requires preparatory orthodontics and a whole change in your bite. The asymmetry could be better camouflaged with a sliding chin osteotomy to correct the midline of the chin and jaw angle implants to create a more angular and defined look. 

3) Eye – Your lower positioned eye needs to have the orbital floor built up with an implant and possibly both the orbital floor and the orbital rim needs to be augmented. This would raise the eye up and help bring it more forward as well.

Your pictures are not really adequate to do good computer imaging but I have attached the best I could do with the one picture.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a chin implant and think I want the Medpor type. I have read about them and what there advantages and disadvantages are.  They say their advantages are that tissue ingrowth decreases movement which prevents erosion of the underlying bone and permits access of the implant to the immune system, reducing the long-term risk of implant infection and rejection. They can also be carved better to solve asymmetries. Their disadvantages are that they are harder to remove, higher risk of infection in the first few weeks and are more difficult to place. Are these accurate?

A:While there are material differences between Medpor and silicone rubber (silastic) for facial implants, choosing an implant based on its material composition is findamentally flawed. What is most important are the following issues in facial implants: 1) What is the correct implant style and size for the facial skeletal problem and 2) How easy is it to place, secure and subsequently remove if need be. If you fail to achieve these first two goals in using facial implants, then it really doesn’t matter what the material composition is.

Neither implant material type and their style and size selections is right for every patient and every facial aesthetic need.  The advantages and disadvantages of each material must be considered on an individual patient basis. Some of your listed advantages and disadvantages of  Medpor facial implants are inaccurate such as being easy to carve and adapt to the bone site, they are actually much harder to shape and place. Medpor has no proven advantage over silicone when it comes to infection/rejection. Medpor also has many less styles and sizes of available facial implants compared to silastic facial implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting implants for my flat cheeks but am not sure what type of implant I really need. I have attached 4 images of three different individuals cheeks I really appreciate and believe to be prominent and masculine. They are Lars Burmeister, Fernando Torres, and Ben Affleck. All seem to have the prominence up on the side of the eyes and they wrap around to the front of the eye a bit. They all look more chiseled, narrow, and angular though, relative to the other examples of cheekbones I have attached. The other examples are of cheekbone structures that I would prefer to avoid. They are Zac Efron, Cilian Murphy, and Peter Facinelli. Their cheeks just cover too much surface area and look like an enlarged cheek mass, rather than finely chiseled cheekbones. They are prominent but look too feminine and bulky. Perhaps you can enlighten me more on what it is I both desire and do not desire in the above referenced cheeks.

Also, will I be getting the inferior orbital rim augmented as well? Reason being that my eye does indeed pass over this bone. Besides creating a better angular appearance to my face, I’m hoping the midface implants rejuvenate my face a bit and help me look less sickly when I get down to 10% body fat percentage or so. Would I need some kind of midface lift along with the implants to give myself this appearance? I am apprehensive to undergo a procedure that is often only discussed with people in their 40s or above.

Lastly I have attached a crude approximation of the area on my cheek I want to be augmented. The black marks denote areas I would prefer to see little to no enhancement on. They include the zygomatic arch, the base of the zygomatic bone, and underneath the front of the zygomatic bone beside my nose. Let me know if this is realistic.

A: Thank you for the detailed information about the desired cheek augmentation result. That is very helpful.

The first comment that I would make is that their is no standard or off-the-shelf ‘cheek’ implant that has exactly those dimensions that you have well outlined in your own photo. I would agree completely that the best aesthetic midface result for you is exactly what you have described, as you have a true combined anterior zygoma-lateral orbital wall-inferior orbital rim deficiency which is a reflection of the overall underdevelopment/flattening of the zygomatico-orbital complexes. Your issue is a bone problem not a soft tissue one so the concept of any form of a midface lift is not a consideration.

So it is not a question as to what you need but how to get there. In an ideal world from a bone standpoint, I would use Kryptionite bone cement/putty to intraoperatively fashion the implant exactly the way I want it and place it from above through a lower eyelid incision. This is most ideal not only because of the ability to create a truly custom implant but the area of augmentation needs to extend across the orbital rim (at least laterally). This infraorbital rim area is the ‘rate-limiting’ step in getting the ideal implant shape as it can not be accessed from below. (inside the mouth…the big infraorbital nerve is in the way) But due to cost considerations and that I nor you would be thrilled with making a lower eyelid incision, this ideal approach may not a good option for you. The other option is to pre-make a custom implant off of a 3-D scan and model, but again cost becomes a consideration with that approach as well.

With the ideal approach off the table, then we must look for using/modifying existing stock implants to achieve most of the cheek augmentation goals. One style of cheek implant, sometimes called the Malar II, augments the lateral orbital wall as well as cheek bone. It does not extend out onto the infraorbital rim to any degree which is its one limitation.

The other issue I would mention is that the use of these celebrity faces and pictures serve only as a direction that you want to go and that no cheek implant, even one custom made, will make you look exactly like them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got treated with Botox for migraines three months ago and it was not effective. It was done by a neurologist and when I asked why it did not work he said he did it in the “standard FDA” way by a band formation around the head, neck and forehead.  This is so disappointing and I paid around $3,000 to have it done.

A: That is certainly disappointing to hear not only because it did not work but because of the way it was done. There is no such thing as a ‘standard FDA’ way to do it. If that statement meant that it was done by using the clinical information and methods that was the basis for what made Botox approved for migraine treatment by the FDA, the ‘wrap around the head ‘ method was not it. Botox works for a select group of migraine patients who have identifiable peripheral trigger points in the frontal, temporal and occipital regions by both examination and history. It is these very specific points which are injected not in a random method. You may benefit by Botox injections if you have these trigger points so your lack of improvement is more likely due to that you are either not a good candidate or the injection approach was flawed.

Dr. Barry Eppley

Indianapolis, Indiana