Your Questions

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis,Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

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

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

Dr. Barry Eppley

Indianapolis, Indiana

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

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

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am a 27 year-old man currently looking for the best surgeon to carry out jawline and perhaps chin augmentation. I would love to get rod of this beard which I sue to camouflage my weak lower jaw. I have added you on Skype for a consult and have attached some pictures for your review.

A: I have done some imaging on your pictures. Yo do have a very short chin and high jaw angles. I don’t think a chin implant alone would suffice for the change that I have imaged. The concept of a sliding genioplasty with an overlay small square chin implant can create a 12 to 13mms of horizontal increase and add more squareness to your chin from the front view. Your jaw angles need vertical lengthening only with a minimal horizontal increase. All put together this should create a dramatic change in the jawline that will make you be able to dispense with the beard if you so desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 44 year old female. I weigh somewhere between 350 and 370lbs. I have spent many years with multiple medical problems. I currently have Crohn’s Disease, Diabetes (Insulin Pump), Fibromyalgia, Asthma, Underactive Thyroid, Pernicious anemia, CVID and Sleep apnea. Through the years, a strong use of steroids resulted in my right femur breaking. On my first surgery for the femur (Sep 2003), I developed MRSA. I spent the next 4 years constantly having surgeries and receiving vancomycin. In April 2007, the MRSA went dormant. This required removing all hardware from my leg. I currently have a lame right leg. I am wheel chair bound. It was after I permanently moved to a wheelchair that I began to gain weight. I am currently prednisone dependent and I must constantly watch for adrenal crisis. The steroids have greatly added to my weight. Since 2007, my weight has managed to stay around 350 – 360lbs. My skin in so thin and damaged from the steroid use that I have developed an extremely large pannicula. It is very large. On the right side of my body it hangs below the knee. On the left it hangs below the genital area. I develop ulcers in my stomach area. The ulcers often become large, oozy, painful and infected. I have had to take vancomycin to cure the infections. I have a location (at the end on the longest piece of pannicula) that receives inadequate blood flow and it has become hard like a rock. Additionally, I develop fungal infections. I had a C-section in 1999. The fungal infection seems to form on the scar and the infection spreads out. I develop open places along the C-section scar. These places itch and bleed. I am currently treating the fungal infection with a mixture of ketoconazole cream and Diaper rash cream. I also sprinkle a nyoxin powder on the fungal infection. The fungal infection is very difficult to treat. My Infection Disease Doctor and my Rheumatologist has suggested a Panniculectomy. Each doctor feels that it is important that I receive a Panniculectomy. The doctors said they feel a Panniuclectomy should be performed first and I should look at the gastric sleeve after I have healed. I have been unable to find a Doctor willing to perform this surgery. I know it is a high risk surgery. I am inquiring to find out if anyone in your facility has any experience with this surgery.

A:  Thank you for your inquiry. You are literally between a rock and a hard place. Your needed abdominal panniculectomy procedure is more than just high risk…it is virtually certain to have a 100% complication rate when it comes to wound healing. And that is not to mention your general medical condition which will require considerable after surgery management and is certain to have its own set of complications that could even include severe infection and death. Between the wound and your health complications I could easily see you sending a long time in the hospital. Whomever decides to take on your surgery has to do it with a team approach and be expectant of what is going to ensue. Your best bet is to have this done at a university-based hospital where there is a plastic surgery training program due to the need for a lot of doctors caring for you both during surgery and afterwards.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m 18 and 5’6 tall and weight 130. I was born with a big head. I’m so insecure about myself seeing everyone around me with a smaller head makes me depressed. I’m planning on having a head reduction if that even exists?? The top of my head is wide and long.I have a perfect idea on what parts of my skull can be removed in order for my head to look smaller. I’m also thinking that maybe my jaw makes my head look big as well so I’m guessing you could probably help me out?

A:  I often have patients come to my Indianapolis plastic surgery center asking me how to get a smaller head. Unfortunately, the reality is that the concept of skull reduction for a larger head is limited as it is simply not possible to make a big head much smaller. From your statement that your jaw is what makes your head look big, it suggests to me that your jaw is currently small or recessed. With that in mind, I would suggest that you consider a jaw enhancement procedure as opposed to skull reshaping surgery, as making the jaw bigger and more defined is a much more attainable goal. I would need to see pictures of your face/head to determine what, if anything, can be done to improve your perception of a skull-face disproportion.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, Hello, I am inquiring about laser surgery stretch mark removal. I have abdominal stretch marks just above and below the belly button due to pregnancy and I wanted to know what could possibly be done about this. I would also want information on pricing. Thanks very much!

A:  Thank you for your inquiry. As much as I would like to tell you that ‘laser stretch mark removal’ is a real entity, it is not. Lasers can be used to treat stretch marks and there may be some improvement, but the concept of complete removal of their appearance is not currently possible. Stretch marks represensent partial tears in the dermis of the skin and, once such injured, the skin can never be restored to normal skin again. It is not possible to regenerate the lost thickness of the dermis which is why they are wide and somewhat depressed. I would need to see some pictures of your periumbilical area to see if laser treatments would be of any benefit at all.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  I have an infected chin implant and would like to have the implant replaced at the same time if it  would prevent ptosis. Aesthetically, I am very satisfied with the implant. The only reason I am having it removed is because of the infection. Its just that my surgeon was saying (which I guess is the standard procedure) to wait four months to have it replaced. He said that he would do the replacement implant through the skin. What about replacing it and using antibiotic beads to reduce risk of reinfection? Is that possible or recommendable? Should I replace it with another medpor or silicone implant?  Really for efficiency purposes it would be great if I could get it replaced in one surgery instead of two. Thank you.

A: one important question is why did this chin implant get infected so late after placement? This is important to know because you want to be able to avoid re-creating the very problem that caused it in the first place. My suspicion is that a large medpor implant placed through the mouth may have resulted in tissue thinning intraorally. That would be most evident if there were drainage holes from inside the mouth. In this scenario, it would be best to remove it from below, excise and close the intraoral tracks and secure a new implant as low on the chin bone as possible.  The replacement should likely be a non-porous chin implant if you can get a replacement that has similar dimensions to what you have now. Do you know the catalog # and/or description and size of the implant you have in now. (there are only so many styles in Medpor…contoured two-piece, RZ extended (round or square) or two-piece chin) I am not opposed to an immediate Medpor replacement as it does have the potential to be infused with a Vancomycin solution. The antibiotic bead concept is an old one from Orthoopedic surgery using impregnanted PMMA beads. But the dimension of these beads, while good for a hip or knee, are too big for the chin area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am ready to get my infected chin implan removed but since it is my face I want to make sure I’m getting the most qualified person to do it. If you were in my place are there any particular questions or concerns that I should make sure my surgeon has dealt with to reduce risk of nerve damage, ptosis since it is a pretty large implant? The implant was placed through the mouth. Also have you ever used hyperbaric oxygen therapy? Could it help reduce post operation healing time? How many work days would I need to take off to be able to return to work? Would you use any head dress?

A: In theory , any surgeon that places chin implants should be able to remove them. The issue that you need to be aware of, particularly since this is a big implant and you are removing it from inside the mouth and are not replacing it, is the high likelihood that chin ptosis will result. (sagging of chin tissues off of the bone since that are now stretched)You will likely need a simultaneous muscle resuspension done at the same time to avoid this potential aesthetic problem. There is no benefit to hyperbaric oxygen (HBO) therapy in surgical removing an infected chin implant. HBO has benefit in irradiated tissues where the native blood supply is compromised. If the muscle is resuspended to the bone, there is no need for a chin dressing afterwards. A chin dressing is not going to prevent chin soft tissue sagging anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, have a medpor chin implant that I have had since 2008. It has become infected. I am taking antibiotics and soon I will have it removed. I don’t think my surgeon has ever removed a medpor chin implant. In your opinion is it too risky to have someone how hasn’t removed one before perform this surgery? How many medpor chin implants have you removed? Thank you.

A: Thank you for your inquiry. That is most unusual to develop an infection in a chin implant that has been in for years. Regardless, removal is the appropriate treatment now. I have removed/replaced numerous medpor facial implants over the years, most commonly the chin and jaw angle areas. Most of these have been for aesthetic purposes where they are well integrated into the tissues and can be challenging but successfully removed. I have done very few for infection reasons but they are always a little easier as they may not have ares that have a tight tissue bone due to the infection. I can not comment on whether your surgeon is up to the task in removing it but they should be prepared that it will not just slide or jump out like a silicone chin implant would.

The other issue you have to ponder is whether you want to do an immediate replacement or not. Some surgeons prefer to wait several months which is the standard approach while immediate replacement with a new chin implant can also be successful but with a slightly higher risk of recurrent infection. This can be successful because the infection is mostly in the porous material which, once removed, eliminates the primary source of the infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 82 years old and want to have a facelift. Am I too old for plastic surgery? I stopped smoking 25 years ago and I think I am in pretty good health. I do take blood pressure medication and have a pacemaker.

A:  Even though you are not at the typical age of most facelift patients, you can have elective plastic surgery done with several caveats. It would be critical to first talk to your cardiologist and get both their clearance and to find out what type of pacemaker you have.  A pacemaker needs to be demagnetized prior to surgery since the electrocautery used during a facelift will cause the pacemaker to malfunction. Whether this is best done in a hospital location or can safely be done in an outpatient surgery center is a judgment for your cardiologist. Your blood pressure must also be under excellent control before a facelift to decrease the risk of a hematoma after surgery. Lastly it would be important to have a type of facelift that produces a good improvement but also limits the surgical time to do it and has a fairly quick recovery. Facelift surgery needs to be adjusted for the unique needs of each patient and, at your age, the need for safety supercedes the degree of facial change.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, can you tell is there a way of reducing the excess skin between the eyes (glabella area) and what is the procedure for that? Only the skin, not the bone or fat. Will there be a big scar after the surgery? Thank you!

A: Some people will develop deep vertical furrows between the eyebrows, also known as the glabellar area. These are the result of extreme muscle action of the glabellar musculature. These furrows can become so deep and excessive that in some people they will appear as actual rolls or vertical folds of skin. While Botox is the standard treatment for glabellar furrows, it will have little effect in reducing these glabellar skin rolls. I have actually done excisions of select vertical glabellar skin rolls. While this does create a dramatic flattening of the glabellar area, and one can also perform muscle excision at the inner eyebrows to create a more permanent Botox-like effect, it does result in a prominent scar if one has thicker type skin. (which is almost always in whom these skin rolls exist) In each and every case, I have needed to do subsequent scar revisions for an improvement in their appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  growing up I have been called all sorts of names, but the one I hated the most was flat head. I eventually grew my hair out as an adult and spiked it out or make it poofy in the back. I never thought it was possible to get your skull reshaped until I came upon reading your page, and taking a look at a couple of your operations. My head is flat posterior parietal to the occipital bone. I’m an Asian male, and not everyone has it, but it’s highly common in our race, but I absolutely hate it. I been wondering about the price of operation, and maybe consider it in the future. I have many times down myself into seeking this operation, or even research about it. I have a couple pictures of my head to show, but not sure where to put picture attachment. Please respond back, thank you.

A:  Thank you for your inquiry. About one-third of the patients that I perform surgery on for correction of a flat back of the head in one area or the other are of Asian descent. So I recognize the ethnic component to it. I would be happy to review any pictures of your head which you can attach as a reply to this e-mail. The typical cost range for an occipital skull augmentation procedure would be in the $7500 to $9500 range depending upon the volume of material needed and the time to do the procedure.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, here are a few photos of my necklift result. You can see that the results of my traditional neck lift were not bad, just not as well as I hoped for. I do have the lateral scar under my chin and scars behind my ears so my surgeon did tighten my skin. As I mentioned I do have a sharper jaw line and thinner neck but not quite the neck angle I expected. If I place my thumb in the crook of my neck and slightly pull the loose skin to one side, it looks exactly the way I wanted my surgery to turn out. If that can be achieved by a direct neck lift then I would consider that option. Can you tell me what that runs price wise and is it common enough that most surgeons would be adept at that procedure?

A:  While I have no idea what you looked like before your traditional necklift, those results look very good to me and are about the best you could have hoped for. Because of potential hairline and beard skin distortions and the heaviness of male facial skin, it is usually not possible to have a very sharp or close to 90 degree neck angle. To have thought otherwise suggests a fundamental misunderstanding in the preoperative consultation/education process.

A direct necklift can make that final change into a sharper neck angle if one has some tolerance for a midline neck scar in the depth of the neck angle area. Whether you would have a favorable scar depends on how tight the skin is in that area. Loose neck skin in the older male when a wattle is present heals remarkably well. Tight skin in a middle-aged male may be at higher risk for hypertrophic scarring.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I have a question about necklift procedures. I am a 49 year old white male at 6’1″ and 230 in fairly good health. I had a neck lift 6 months ago to correct jowling and a progressively poor neckline. The liposuction reduced the circumference of my neck and sharpened my jaw line to my satisfaction. However it did not restore a better neck angle to my expectations. My surgeon is a very talented surgeon but he did not remove any neck skin and I think that might have improved the results. I cut and pasted the paragraph below from your webpage commentary. It sounds like you may use skin removal as a standard part of the overall necklift for best results. Is that common? If so why wouldn’t my surgeon have used it? Can I now have neck skin removal done as a stand alone procedure? If so what is the name of that specific procedure and what would it cost?

“In rare cases of the much older male (usually greater than 65) who has a large neck waddle and does not want or can not undergo a significant operation, the direct neck lift can be an option. Rather than using any incisions around the ears, the loose skin is cut out directly in the neck. This produces a pretty significant change that offers a much more limited recovery. And can be a consideration if the man can accept a scar running vertically down from the chin to the adam’s apple. Surprisingly that scar can heal very nicely due to it being in beard skin which scars less than non-beard skin most of the time.”

A: The question about your ‘necklift’ procedure is did you have skin removed through standard facelift incisions? If so, some call this a facelift while others call it a necklift. A facelift in a male typcially never gives the refinement in the neck angle like one sees in a female because the tissue are heavier and thicker and a less chised neck angle results. If you did not have skin removed through a facelift approach (incisions around the ears) then I am not surprised that simply defatting the neck, while making it less full, did not change the neck angle.

Directly excising neck skin, aka the direct necklift, while very effective is reserved for the older male who needs neck skin removed but does not want the greater complexity of a facelift operation even though it places the scar is a much more favorable location.

I would be happy to review pictures of your neck (side view most favorable) to see what your options may be at this point.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was wondering whether you performed any surgical procedures for the lengthening of a short upper lip without the use of injectables or fillers etc. I have been trying to find such a procedure for quite some time and have so far been unsuccessful.

I was wondering whether there was any way to lengthen the upper lip by approx. 6-7 mm, since when at rest most of my teeth are visible. Could you please let me know if you perform such a procedure and if such a result is achievable or if you are aware of any other surgeons who may be able to help me. Many thanks.

A: I suspect you are talking about correction of a gummy smile. There are no procedures that can add skin to the upper lip or lengthen it from the outside. Thus there is a reason you have not been successful in your search. There are procedures done on the inside of the upper lip where the vestibule is lowered (lengthening vestibuloplasty), thus pulling done (lengthening) the lip so some degree. It may also be that you have vertical maxillary excess (too much vertical upper jaw bone) that may also be the culprit in your case.

I would need to see some pictures of your face/lips, at rest and when smiling, to have a better idea as to whether this approach may be helpful for you.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I was wondering approximately what cost I could expect for a nipple reduction? Breast size is 32B and nipples are nearly an inch long and half inch wide.  Because of their size, they are heavy and sag.The only thing I would be interested in would be a simple width/length reduction of the nipple and nothing with the breast or areola size.  I would also like to retain as much feeling as possible.  Thanks!

A: I will have my assistant forward that cost information to you. Most likely the cost will be around $1500. There are two different techniques for nipple reduction. The one that is the most effective at length reduction also runs the greatest risk of some loss of feeling. The nipple reduction technique that preserves the most sensation is the one that will produce a more limited amount of length reduction. No nipple reduction technique is very effective at reducing the diameter of the base of the nipple.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a swelling on my right side of the head, and I noticed it 8-9 months ago. Yesterday I was in the hospital took computer tomography, and it showed that I have osteoma on my skull. So, mine is on my skull, but the pics shows that it can be insight the skull too  (not sure though). So, I talk to the doctor, and he says it should be removed. He suggested surgery as it can grow. What I don’t like doctor says they gonna remove first two layers of the skull. My bump is 3.5 x 3.5cm in diameters and 1.5cms in height.  So, doctor says he will remove 5×5 in diameters, and two layers of the skull, and then to fill in the hollow created due to the clearing away of the extra growth by cement. These all horrifies me. The thing is I don’t have any symptoms, I mean I never had head injury, don’t have head aches, nothing. So, can you please advise how you do this kind of surgery and how much it will cost me with you. If you need I can send my CT. Thank you in advance

A: Thank you for your inquiry. The question is whether your osteoma should be burred down or excised and replaced by bone cement. (as you your surgeon has suggested) Admittedly if I was a patient I would be a lot more interested in the burring approach, particularly for an asymptomatic osteoma. Please send me some pictures of your head showing that area and the CT scan for my assessment. Then I can give you a more fully informed opinion. But if the osteoma has no intracranial expansion, I would choose the burring reduction skull reshaping approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I like what I see, much more “chiseled” appearing. Would it be unnecessary to or insensible to increase the length of my chin to make it sort of protruding? I’ve always found that to be appealing/masculine. I know people get chin reductions to avoid that, but I’ve always liked that. If not, I feel that I see some flaw in my chin/jaw line that stands out to me. I’ve always wanted a stronger jaw/chin, maybe overly strong, beyond typical. Maybe it is my jaw? Would you recommend a possible jaw implant along with the rhinoplasty and chin implant? Do you think this would match my desired traits? I desire an angular sort of jaw, with a square appearing and strong chin, and my nose looks great after, but is there a way that it could be made that you couldn’t see the bottom of my nose? Its always made me self conscious that the bottom of my nose has been visible when i am looking at someone. I am sorry I’m asking so much, I just want to make sure that I am 100% pleased with the procedure and I want to get as much done at once as possible by the same person and you seem to know exactly what I want.

A: When it comes to vertical lengthening of the chin, that can not be done with an implant by more than few millilmeters. It would require a chin osteotomy or a custom chin implant to do that which, although can be done, adds to the cost of the procedure. I would just use a square chin implant of 9mms augmentation and position low on the chin bone so that is some degree of vertical lengthening. I believe that will more than suffice.

The trifecta of jaw angle implants and a chin augmentation are the best way to create a chiseled jawline. The key question in jaw angle implants is whether they should just be of the lateral augmentation type (just adds with to the jaw angle) or whether they should be of the vertical lengthening type with variable amounts of width addition. What most men who seek the chiseled jawline look need is the latter, some vertical lengthening and width addition to create a sharper and more defined jaw angle at the back of the jaw.

Your nose is slightly over rotated (tip up too high). The tip could be rotated downard to some degree using septal extension and tip only grafts during your rhinoplasty.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’ve seen a lot of photographs and I’m completely amused by the results of the surgeries you have performed. I’m 20 years old female and I’m very interested in chin reduction surgery as I feel that it makes my face too long and also when I smile or speak the muscle/soft tissue protrudes hence this makes it look even larger. I was wondering if I could send you some photographs of my chin so that you could consult me on what could be done to improve my appearance. I have attached photos of my chin and also the result that I would like ( using photoshop) Could you please tell me if it is even realistic to get such result from a chin reduction surgery and how it could be done.

A: Thank you for sending your imaged pictures of the desired result. Your chin concerns are that the center area if long and include both the vertical length of the bone and a soft tissue underhang. To achieve your result, which in my experience is very possible, requires a submentoplasty approach to your chin reduction. From an incision underneath the chin, the center bone could be burred down and smoothed into the sides and the soft tissue overhang could be removed and tucked up.

Dr. Barry Eppley

Indianapolis, Indiana