Your Questions

Q: Dr. Eppley, I know rhinoplasty involves a lot of different surgical steps that affect the outcome of the surgery. But there must be different types of rhinoplasties based on whether you change just one part of the nose or different parts. I am trying to figure out what type of rhinoplasty is best for me. 

A: You are correct in your assumption that rhinoplasty involves a lot of different steps and no one rhinoplasty is exactly the same as the other. But there are some basic types of rhinoplasty which affect not only what part of the nose is being changed, but how long the operation lasts and how the length of recovery. I like to think of rhinoplasty as involving three different types which can be described as follows.

Type 1. This is a true tip rhinoplasty where the work lis imited to just the lower alar cartilages. No nasal bone or middle vault cartlaginous work is needed. Also there is no internal septal or turbinate work done. A tip rhinoplasty would actually be done most commonly in revision work for tip asymmetry and/or an adjustment but may occasionally be done as an isolated primary rhinoplasty. This is the quickest recovery of all the rhinoplasties. For the obvious reason I like to call this a TIP RHINOPLASTY.

Type 2.  =  This involves work done to the ip and middle vault cartilages of the nose but does not involve nasal osteotomies. (breaking the nasal bones) It may involve some rasping or smoothing of the nasal bones for minor hump deformities. Septal grafts may be harvested but not overall septal straightening or turbinate reduction most of the time. This collection of nasal procedures I call a RHINOPLASTY.

Type 3.  This is a complete ‘overall’ of the entire nose. It is complete nasal work from the tip to the nasal bones including osteotomies. Always needed when there is a signifincant hump reduction. Will almost always include a straightening septoplasty, graft harvests and inferior turbinate reductions. Because of treating both the internal nasal breathing and external appearance, it is called a SEPTORHINOPLASTY. This will involve the longest recovery of all the rhinoplasties which often causes temporary undereye bruising and nasal congestion and stuffiness.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to possibly revise a scar from a surgery years ago that is 5-6 inches in length along the back right side of scalp up to above the right ear. I had cortisone injected into scar not long ago and it seems kind of depressed now.  The scar is covered by hair but I would like to shave my head as my hair is getting thinner and transplants are not really a goal at this time due to how thin the hair is becoming only making more problems. Any advice or consultations would be appreciated. 

A: The scalp scar you have appears as if it is from a hair transplant harvest procedure by its location and length. These scars can become visible when there is scar separation and the scalp hairs along the scar are not right up against each other. Wide scars are not going to be improved by steroid injections as that will not bring the edges any closer together. Rather it is donw what could be anticipated…creating a scar depression without narrowing the scar. The only way to improve your scalp scar is by excision of the non-hair bearing scar and bring the hair-bearing scalp skin edges closer together. Basically only a formal scalp scar revision will work.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was born with club feet. I had Achilles release surgery as a baby. I am now 25 and have been considering calf augmentation for a number of years.

A: Thank you for your iuquiry. It is quite common as you know that the associated calf on the clubfoot will have a smaller and more atrophic leg between the knee and ankle. While calf augmentation with an implant is a reasonable and standard approach for this problem, the unique issue with the ‘clubfoot calf’ is how tight the skin is around the calf area. This limits the size of the calf implant that can be placed and how much change (calf size increase) can actually be obtained. You can see that placing implants in a cosmetic calf concern where the skin and underlying soft tissues are soft and supple is quite different from that of a congenital calf deformity where the skin is more tight and less prone to stretch. It would be helpful to see pictures of your calfs and to know the actual circumferential measurement around the mid-portion of your calfs.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’m now thinking I want to move forward with doing cheek implants and picked out the style of implant I want but need to know it the implant is falls into the category of small, medium or large. It’s by spectrum design and is called( malar profile ) the nominal dimensions are 5.4×3.2×0.5. But it doesn’t say if its a medium implant or large and this is something that is important for me to know. Pls help. Thank You. 

A: To help answer your question, here is the schematic on that particular cheek implant style.

Profile Malar Implants
	Catalog Number	NOMINAL DIMENSIONS
		A	B	C
	S140-414S	4.6 cm	2.3 cm	0.4 cm
	S140-424S	5.1 cm	2.7 cm	0.5 cm
	S140-434S	5.4 cm	3.2 cm	0.5 cm
	S140-444S	5.7 cm	3.5 cm	0.5 cm
	Sizer set 900-014		Designed to enhance the entire malar region, this implant features thin tapered edges and provides a smooth transition to the malar prominence.

You can think of the four options as Small, Medium, Large, and Extra Large.  Therefore what you inquiring about is S140-434S which would be considered a large implant. As you can see by this dimensional chart on cheek implants is that the thicknesses don’t differ that much but the surface area that they cover do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am finished having children and my body is a wreck. I have tried to get back close to my pre-pregancy body, but it is not happening. I want to have a Mommy Makeover procedure but my husband says I am just not working at it hard enough. When is a good age to have it done?

A: The effects that pregancy has on a woman’s body are largely irreversible by natural efforts for many women. Loose or separated abdominal muscles (rectus diastasis) can not be made to fuse back together by any amount of abdominal situps. Abdominal skin that has been stretched out and partially torn (stretch marks) can not have elasticity restored by situps, creams or weight loss. Breasts that have lost volume and sag can not be lifted up by chest exercises or alleged skin tightening creams. The onething a women can do is lose her pregnancy weight but all other changes require outside help

A so-called Mommy Makeover procedure, which combines breast augmentation with or without a lift and some form of a tummy tuck with or without liposuction, can be done at almost any age. But, by far, the majority of these procedures are done between the ages of 35 to 50. This is an age range where women are done having children and have proven to themselves that diet and exercise just can’t get the body improvement they desire. But age alone is not the only criteria. As long as one is finished breastfeeding, a Mommy Makeover can be done as soon as three to six months after one’s last pregancy.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read most of the material on your website relative to skull reduction. I have a disproportionately large head and face compared to my body. If you burr my head, how many months it will take before I can see a result? Because I assume in this kind of operations you get lots of swelling and you don’t see a result right away. So, the head will look bigger before starting to look smaller. Most importantly, I am an active person and work out every single day (aerobic, elliptical, walks). For this kind of surgery, how many weeks should I take off from the work out? And what is the worst that can happen if I work out 10 days post op, for instance? Thanks

A: While the scalp will swell after any skull reshaping procedure (the bone doesn’t), it usually takes about three weeks before the initial results start to become apparent. It will take up to three months to see the final result. There is harm in returning to working out whenever you feel comfortable, even if it just 10 days after surgery. You can not hurt the surgical result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in silicone malar cheek implants and wanted a dramatic look to change the shape of my flat face. I for sure want to get a medium size implant and was wondering if a 3mm falls in that category or if a 4mm is considered a medium? Thank you.

A: The determination of size is but one consideration in the selection of a cheek implant. It would be equally important to select the style or shape of cheek implant that works best for your face and could create the look you are after. But back to size, a cheek implant’s size has numerous dimensions of which thickness is but just one of them. Generally as the thickness of the implant increases so does the height and width of it as well. (total surface area that it covers) Whether a 3mm thick cheek implant would be considered a ‘medium’ would depend on what cheek implant style you are talking about. For some silicone cheek implants such as the malar shell, 3mms in thickness would be considered an intermediate sized implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, This is for the nasal sill area and I am specifically interested in the cartilage injections to augment the sills which were removed in a bullhorn liplift. Will the injectable cartilage work for this indication? I would like to take care of that first since it can be done under local. What would be the price for cartilage injection in the sill area?

 The other procedure for premax augmentation don’t you also use mersilene mesh to augment that area or do you just use rib? I think rib might be better anyway except I would be afraid of warping.

A: If your goal is to try and stretch out skin in the nostril sill area, I don’t think this will work with any form of subcutaneous augmentation. It may provide a push but I can’t see how that will make up for lost skin along the nostril sill. In addition, placing injectable cartilage can not be done under local anesthesia. While the injections could be done under local, the cartilage must be harvested usually from the nasal septum which is not a local procedure. One simple way to easily prove whether an injectable approach will worko is to first have a temporary filler like Juevderm or Radiesse injected and see if that works. If it is successful then you can move forward with injecting cartilage.

Mersilene mesh can certainly be used for premaxillary augmentation just as rib can. I would have no concerns about rib warping as that is a function of how it is harvested so it is easy problem to avoid in an enbloc augmentation application.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am looking to improve my weak jawline. It is weak not only in the front but all the way to the back. I guess I was just borne with a small underdeveloped jaw. It makes me look very unmasculine and I would like to improve that as I think it would make my life better. I have read about implants that are used for the jawline but it is not clear to me whether I would need custom implants or not.

A: Facial augmentation can be done by a variety of implant approaches which fundamentally breakdown into off-the-shelf, semi-custom, or custom. Off-the shelf implants mean what is currently available in the catalog that the manufacturers have available and can ship with arrival in 1 to 2 days. A semi-custom implant approach means using what is available off-the shelf but modifying them during surgery to fit the patient’s anatomy and their aesthetic desires. Like off-the-shelf implants, they can be ordered and arrive in 1 to 2 days. A custom facial  implant approach is very unique because the implants are made off the patient’s model made from a 3-D CT scan either by hand or computer-generated. These take a certain amount of time to manufacture, which at the minimum is three weeks from when the patient gets their CT scan done locally.

To make the determination of which implant approach needs to be done for any particular patient I use computer imaging to get a feel for the magnitude of facial implant volume and changes that is needed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, do you do injectable cartilage? Can this be used to give support in the nostril sill area? My sills were partially removed from a bullhorn lip lift and I thought the cartilage injections might rebuild the area. Dr. Onor Emrol in Istanbul says the injectable cartilage can be used in this area but I can’t really travel that far and he doesn’t do phone consults. I have scarring at the base of the nose loss of nostril support from the liplift and the sills were partially removed due to where the incision was placed. Also can the injectable cartilage be used to do premaxillary augmentation. I want to move forward the nasolabial angle. The nasolabial angle is now caved in due to being scarred down from the liplift and I need to increase the angle push it away from my face.

A:  I have done numerous diced cartilage grafts, whether it is by injection or with a rolled graft fabrication in fascia or surgicel collagen material. The key questions are whether such cartilage grafts will work for your two indications and what volume is needed. From a premaxillary/paranasal augmentation standpoint, the issue with using cartilage is the volume of donor material needed. The septum will not have enough material to create enough push to make a visible difference in these areas. To get good volume, a lower rib donor source is needed where a good bloc can be removed and used. Whether one dices up the cartilage or injection below the skin and places it at the bony level in a carved form just like a synthetic paranasal-premaxillary implants is a matter for further discussion. From a nasal sill standpoint, the septum or ear will offer enough material to dice and injected beneath the scarred nasal sill area. While this will not replace lost skin that was removed from the lip lift, it will provide subcutaneous volume to push out on the area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got the gummy smile by V-shape process in Asia one year ago. It did not work for me. It looks like as before surgery. Can I get the new process for gummy smile in (Lip reposition method) again?

A: Even though you have had an unsuccessful V-Y upper lip mucosal advancement, you can proceed with further efforts at improving the gummy smile. I have found that while the V-Y mucosal procedure is a part of gummy smile surgery, it alone is not enough for a sustained correction. Elevator muscle release and a lowering vestibuloplasty must also be incorporated into the surgery for a sustained improvement. Your other option is to do Botox injections in the paranasal area. With just a few units of Botox, the muscle is relaxed and you will have less lip elevation for the duration of the drug’s effect. (4 months)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I wanted to send you a couple pictures to see what you might suggest. I have a very narrow jaw and a pointy, long chin. I would like to have it reduced in length, though I’m not sure what else would be necessary for my jaw to look proportionate. Thank you for your time.

A: Thank you for sending your pictures. There is no question that a vertical chin reduction osteotomy would be very helpful for your chin. The unique part about your vertical chin reduction, because of your very steep mandibular plane angle, is that the back part of the osteotomy behind the bony cut must be reduced (leveled) as well. Otherwise the chin will be vertically reduced but you will end up with a ‘box’ look to the chin as there would not be a smooth transition along the jawline between the end of the osteotomy and the rest of the jawline as it heads back to the angles. I have done some predictive imaging to show what the potential changes could look like. Based on these predictions I see no need to alter your jaw angle area even though they are high. They could be lowered with implants but I am afraid this will make your entire lower face ‘too heavy’ even though it may be better from a jawline perspective. For now I have not imaged such changes but can if you desire.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to ask a rhinoplasty question. Since my primary motivation for getting any work done is to improve my smile. In a rhinoplasty where you reduce the nasal spine as we discussed, would there be a possible side effect of lengthening the distance between the nose and mouth? In my imagination, by eliminating some of the protruding cartilage in that area, the tissue and skin that currently exists there would be pulled back into that void, thus pulling up the lip slightly. However, I’m not sure if that’s even how the anatomy works. Is the tissue anchored to that area and would it need to re-anchor itself or would it just drape down further, thus lengthening the lip?

A: Your question is a good one. Theoretically by removing the nasal spine, your assumption is most likely correct that the tissue should be pulled back up into the removed area potentially lifting the lip somewhat. In reality, probably very little lip lift actually occurs. There have been a few reported instances where lips have lengthened as a result but that is not something that I have ever seen. One would not, however, try to anchor the tissues to the removed nasal spine area as that may potentially cause a tethering/tightness when one smiles. It is much better to let the area heal naturally rather than try to treat a potential problem which may never occur…and in the process create a whole new one.

The way I view your rhinoplasty, and is the reverse of the the concern of upper lip lengthening, is that the rhinoplasty is potentially setting up a subnasal lip. So whatever happens to the lip length (particularly if there is some lengthening) does not matter because you likely moving on to a lip lift anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you do tummy tucks scheduled and coordinated with a hysterectomy. What the cost would be and how much of a cost savings would it be. I am not only looking into having them done at the same time for cost savings (insurance will pay for the hysterectomy but NOT the tummy tuck) but for combining recovery time as well. Can a lower body lift (instead of a tummy tuck) be combined with the hysterectomy? A little info on me.  I am a 40 year old female, about 20 months post op from bariatric surgery. I have lost about 160 to 165 lbs and now weigh about 167 and weight has pretty much stabilized the last 4 to 6 months. I am 5’3″ and happy at the weight I am at now, but the hanging excess skin is really bothering me, in the way, clothes don’t fit right, it gets sweaty under the fold, and it is very uncomfortable. Thank you for you any information you can provide me and for your time.

A: Congratulations on your successful weight loss! Either a tummy tuck or a circumferential body lift can be performed at the same time as a hysterectomy. This is an historically common combined abdominal procedure. Besides the obvious benefit of one single combined recovery, the only key question is how do the economics work out. Since you will be paying out of your pocket for either a tummy tuck or a body lift, the question is what is the OR and anesthesia cost if done in a hospital with the hysterectomy compared to it being done separately in an independent surgery center? (the plastic surgeon’s fee would be the same at either location) Many patients would assume they are similar but that is often mistaken. Either location of the surgery should be priced out so you can see the difference between your fees. If the difference is small, then one should have the body contouring procedure done at the same time as the hysterectomy. But if the difference in significant (thousands of dollars) that may give one pause as to whether it should be done separately. You may ponder as to why there would ever be a difference between the two locations (hospital vs surgery center), the answer is simple….overhead and efficiency.

I will have my assistant calculate those specific costs between the two locations for just one of the procedures (tummy tuck) so we can see how different or similar those costs would be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very long chin that completely throws off the rest of my features. I live in Arizona and can’t seem to find a good MD in the California/Arizona area. I wanted to know if you could recommend someone for the procedure, or if not, suggest the feasibility of going out there for the procedure. What would be the downtime/ballpark costs for vertical reduction in the chin length? Thank you for your help.

A: Thank you for your inquiry. It sounds like you need a vertical reduction wedge chin osteotomy.  As a ballpark range, the cost of a chin osteotomy is around $6500. We have many patients that come in for surgery from all over the world so this is a common experience for us. You may also feel free to send me some pictures of your face for my assessment to determine your suitability for this procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, about a year ago I received a blow to the head from the rear causing a depressed skull fracture. The fractured skull segments were removed and replaced with a titanium material.  But there is the emergence of the head of the screws now seen through the scalp. Are there other ways to patche skull defects without these materials?

A: It is very common when scalp swelling goes down over time that the metal mesh and screwheads become apparent through the skin on skull reconstructive surgery. This is particularly evident in the forehead although it can be seen all over the scalp. In some cases, just the screws can be removed and leave the titanium mesh behind. But if one wants to remove all metal material, the titanium can be removed and replaced with a skull reshaping bone cement that will leave a smooth surface and no risk of visibility through the scalp.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how large of breast implants can I get? I know that most women don’t want to look like they have had breast implants but I do. I want a very round and very full look to them. I have a good breast shape 34C with no sagging but they look very small. I don’t know what extreme breast augmentation means but I think that is what I mean. I have had several consultations and I have tried on various sizers. (Mentor sizing system) The plastic surgeons I saw said they would not put in more than 500cc but I like the 650ccs the best. Is this too much for me? if I like the look why won’t they do it?

A: The size of breast implants is, of course, a very personal choice and no one can tell you what you should like. That is up to you. But it is important to remember that it is a medical device and there are risks and potential complications with them. These potential adverse effects can become more apparent or likely when the implant ‘exceeds the tissues to support them.’  Thus size can make a difference in these risks. Exceeding the limits of breast tissue support can be simplistically thought of as violating the breast base diameter, the existing perimeter of your natural breast skin mound. This can be measured in centimeters as well as can the base width of an implant. (as implants get bigger so does it’s base width) If the implant base width stays within your natural breast base width, the implant will be well supported by the tissue attachments and have little risk of bottoming out (dropping) over time. When an implant’s width exceeds that of your natural breast base width, the tissue attachments are stretched and the risk of the implants dropping, going to the side excessively or otherwise losening their retention up on the chest wall will likely occur over time. This can be a difficult problem to fix later.

What your plastic surgeons are telling you, and some plastic surgeons absolutely will not violate this guideline, is that your size request is exceeding what is believed your breast tissues can support. This is likely what they mean by being ‘too big’. I tend not to be so rigid about this concept and will let patients choose the breast implant size they want. But I do advise them, like much of life, the choices we make today will always have future ramifications.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, The right side of my head (just above my ear when looking at me face on) buldges out about 5mm more than the left side. The left side looks perfect compared to the right. Would it be possible to reduce this ‘buldge’ and would the scar be noticeable? Thank you.

A: The simple answer to your questions is yes…and no. A 5 to 7mm reduction is what usually can be achieved in side of the head (temporo-parietal reduction). While most people think the reduction in this area of the skull is bony in nature, it is actually largely a muscular reduction. By releasing and shortening the posterior extension of the very large temporalis muscle, this will reduce the bulge on the side of head. (head reshaping) It is done through a fine line vertical incision over the thickest part of the bulge that is not longer than 4 to 4.5 cms in length. Usually this scar heals very well because the scalp incision is not under any tension. The noticeability of the scar would also depend on how one cuts their hair. If you shave your head I can not guarantee that the very fine line will not be seen.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I’ve been calling around Indianapolis trying to find a doctor that does Intradermal botox. It’s for oily skin and large pores. I think it is a newer procedure because a lot of places I called had never heard of it. Can you please give me some feedback on this? I really feel like this would help my skin very much. Thank you for your time.

A:  What you are talking about is the use of Botox to help control acne and/or oily skin. This is not new or anything magical about it. The concept was introduced years ago. It is simply putting Botox into the skin (intradermal) as opposed to under it. This is actually how Botox is used for armpit sweating, putting the injections into the skin where the sweat glands run through. The question is not whether it can be done but how effective it is in controlling oil gland production. In theory it sounds good but the requests to have it done are so few that I can’t tell you how effective it is most of the time. It is not a skin problem for which Botox is FDA-approved or ever been subjected to rigorous clinical trials. So in doing it one has to know it is uncharted territory for Botox use. (i.e., it might not work) When it comes to reducing pore size, I would say that Botox is not likely to be effective for that particular skin problem.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My face needs a vertical augmentation about 8mm and a horizontal one about 5mm or so. Yesterday I met a doctor in our area, he told me that with an Osteotomy surgery he can give it a nearly 2 to 3mm of vertical projection and about 3 to 4mm of horizontal projection, and above that level is impossible. He described that they cut a piece of my chin from its below, with a triangle section (kinda similar to a wedge I guess) and slide it forward and downward. I wanted to get your advice about how the surgery could be more efficient for me and how I can reach my desirable face.

A: You are referring to a sliding genioplasty procedure. The dimensional movements to which you have been told are far below what is possible. While I don’t know what your chin looks like, I would see no reason why you couldn’t have an 8mm vertical elongation and a 5 to 6mms horizontal advancement. Such movements are possible because of the use of specially designed chin plates that can be adjusted for a wide variety of chin movements to hold the bone in the desired position. I have no idea why you have been given those small chin movements as being what is possible. But to say that 8mm of length and 5 to 6mms of horizontal increase are impossible is not accurate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a 22 years old male and am interested in the orbital reshaping/brow bone reduction process. I had a procedure done a year ago, it was a frontal sinus reduction. This procedure didn’t really accomplish much. I didn’t stress to the doctor the type of results I was after. I guess looking back, I have myself to blame. I have attached pictures which show most of what I’m unhappy with… the somewhat uneven/large orbital rim. I would like to smooth that down to create a simple and more attractive looking eye area.

A: Thank you for sending your pictures. Knowing that you went through a major frontal sinus reduction procedure, there must have been some miscommunication as to your outcomes. While I don’t know what you looked like before, my assumption is that what was achieved was some high frontal sinus/brow setback. But you were as much interested in the lower frontal and lateral setback as well. In your previous procedure, do you know how it was done? Was the bone taken off and put back with small plates and screws, wires etc?? That may have an impact on how well further reduction can be by hardware being in the way, scar tissue, etc. There is also the issue of how much bone along the orbital rim can be reduced without entering the frontal sinus. This is the value of the frontal sinus osteotomy technique which overcomes this limitation. Orbital rim reshaping/brow bone reduction is more of a burring technique although some features of an osteotomy technique can be incorporated into it.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been getting injectable fillers placed in the bridge of my nose to hide a small nasal bump that I have. It works quite well but doesn’t last as long as I would like. I am thinking that injecting fat may be better since it can be permanent. Has this ever been done before?

A: To no surprise, injecting fat into the nose is not new or novel. Like synthetic injectable fillers, fat grafting can be an option to change the shape of the nose for those that do not want to undergo surgery…in very carefully selected patients. As has been proven with the use of synthetic fillers, injections are for adding volume in nasal deformities that benefit from augmentation. This is primarily useful in deficient areas in the upper nose where a hump or pseudohump deformity may exist. It can also be useful for those that want a higher radix area for the same reason. (camouflage a small hump) There are also selective tip or bridge depressions which may also be helped by the injection of small amounts of fat droplets.

While fat can be injected into the nose, it is important to realize that it behaves differently than a cartilage graft or an implant. Because it is soft, it is prone to recoil pressure from the tight overlying skin. Thus it is more prone to resorption, distortion and migration from the injected site.  It is best injected into a tight pocket as exists in a pure injection technique rather than as part of an open rhinoplasty.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have been looking at your web site for over a week now and I believe I have finally found a perfect plastic surgeon for my problem with my forehead. I’m 58 years old in fairly good health. I’ve had car accident long time ago when I was about 20 years old, which left a scar running vertically in the middle of my forehead. It looks like a thick vein coming down in the middle of my forehead. Also due to scarring (swelling like) there are 2 shallow bulging just above both of my eye brows. What do you think needs to be done to make for a smoother and level forehead?

A: It certainly sounds like you have a depressed scar that runs down the middle of the forehead, which is not surprising with long scars that run perpendicular to the relaxed skin tension lines in the forehead. The smaller two bulges to which you refer could be either your native brow ridges (which have become more prominent due to the depressed scar/bone) or they may be extra bone formations. (periosteal reactions to the original injury) I would have to see photographs to answer that part of your forehead issue better. But let us assume this is what the forehead issues are. In this case, a scar revision of the entire forehead length can be done and the bony prominences reduced through this open exposure. It may also be necessary to do a little buildup of the bone underneath the scar will a little bone cement to help make the bony part of the forehead smooth across the original injury area.  (forehead contouring) But this would await what is found during surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had a lower elliptical buttock lift in late December.  It looks similar to the procedure that is shown on your website.  Is it normal to still have swelling around and below the incisions 3 months later?  My PS says yes, but I would like a second opinion.  The ‘swelling’ is significant to the point that it looks like a ‘banana roll’ on the back of my thigh, below the incision and buttock crease.  Can you comment?  Any information would be appreciated.  Thanks.

A: All I can say is that this has not been my experience with the lower buttock lift. From what I have observed there usually is very little swelling with this procedure and a quick recovery. The only long term issue is how well does the scar do and the stability of its location. I would suspect that this is more related to the amount of tissue removed rather than swelling at this point.  The very act of sitting on it and the lack of any tissue undermining done in a lower buttock lift limits how much swelling can occur and how long it persists. But this comment is made without seeing pictures of what you look like so this is just speculation for now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 21 year old guy with a big jaw and a long chin. Also my jaw line is low which gives me a long face. What’s the best and the safest thing for me to do? Should I go for a jaw line reduction surgery and a chin reduction surgery as well? Are they safe? I have attached some pictures of my jaw from different angles.

A: Thank you for sending your pictures. You do have a most unusual pattern of jaw hypertrophy that I have ever seen with excessive horizontal chin projection and jaw angle protrusion. It would be very help to see some x-rays (even a panorex would be useful) to confirm that the bulges at the jaw angles are primarily bone and not masseteric muscle hypertrophy. But let us assume that these are all bony protrusions, they could be reduced through intraoral approaches by burring reduction of the chin projection and an osteotomy/saw reduction of the lateral jaw angle protrusions. These are not only safe but the only jaw surgery options you have for their reduction. If the vertical length of the chin is felt to be too long, then a vertical reduction osteotomy could be performed by the horizontal burring reduction. But it would be important to manage the then excessive chin soft tissues that would result from the reduction of the bony support. I would performed suture suspension of the soft tissues to the reduced chin size.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have had a lap band for about 5 years and I have lost about 90 pounds and basically kept it off give or take an occasional 5 to 8 pounds. I would very much like to get rid of the remaining skin and fat in my stomach and upper torso area. I am searching for a surgeon who has quite a bit of experience with these procedures. I was planning on a local plastic surgeon do it but he is moving out of state and is booked solid. I only know of one other Dr. in this area who has extensive experience in this procedure on drastic weight loss, however, I do not choose to have him do this for me. I have consulted and been examined by my initial plastic surgeon about one year ago and he approved me for the surgery. I just was not quite ready at the time. I am now.  I am 66 years old. I am very active and always have been and am in very good health.
I would like to know if you are accepting patients from central Illinois, and if this is something that we can talk about the possibilities and the possible concerns of my not living in your area. I will likely have to self-pay, since my insurance company was approached as to if I would be covered for this procedure, and I was denied. They feel that it is cosmetic and not a necessity. Therefore I would also like to be informed of the cost involved. I would also like to have my breasts lifted and was wondering if it is possible to do both surgeries at the same time and the cost of that procedure as well. I think you in advance for your time and consideration.

A: Congratulations are your weight loss and, equally importantly, the ability to have maintained it. With a near 100 lb weight, you undoubtably have many of the typical findings that one would expect with  a resultant abdominal pannus and significant breast sagging. While I would ultimately need to see some pictures  of you to confirm your exact surgical needs, having done a lot of extreme weight loss patients (bariatric plastic surgery) over the years I can envision with some certainty as to your needs… an extended tummy tuck and full (type 4) breast lifts. It is very common to do both of those procedures together and it is safe to do so.

I have patients that come from all over the world for a variety of procedures so we are very familiar with how to handle patients from afar and can accurately foresee their needs and how they must be accomodated from afar. Doing a tummy tuck and a breast lift in a 66 year-old from afar would need to be done as an overnight procedure in our facility. The extent of the procedure (it is surprisingly not that painful) and your age mandates overnight observation for your medical safety. Whether you would then go directly home the next morning or stay just one more night in a local hotel is an issue to be discussed and also based on how you feel. You would go home with abdominal drains (you would have breast drains but those would be removed the next day) and those would need to stay in for 10 days at which time you would come back to have them removed. We follow all of our patients carefully using e-mail, photographs and texting, available 24/7, to handle any questions or needs. Thus you may be far away but are electronically just a click of a button close. All incision are taped so you have to provide no care to them and can shower with 48 hours, getting all tapes wet without any concerns about doing so.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 21 year-old transsexual male. (female to male) I have been on hormones for a year and a half and my face has changed in sufficient ways. However, I still lack much masculinity in my facial features, and the bones don’t face drastic changes at my age. I also know that I have a bulbous tip to my nose and a weak chin. I have been considering plastic surgery not only for aesthetic reasons, but for the more masculine appearance I could gain from it. My goal isn’t to correct the flaws in my facial balance as much as it is to “masculinize” it. A strong chin, a strong straighter tipped nose would be my goals. I am wondering if you think you could achieve what I am asking of you. I can send pictures and you could give me your input. I will send them from different angles, completely neutral appearing. Thank you for your help in this matter.

A: As a general statement about facial gender transformation, it is usually easier to make a face appear more masculine than more feminine. This is because augmentation of the facial bones, usually by implants, can produce a more noticeable change than trying to reduce the size of any facial bone. This, of course, depends on the facial bone structure that one has to work with but augmentation by millimeters will always be greater than what bone reduction in millimeters can be achieved.

In making a face more masculine the jawline is always of great importance. Whether it is just chin augmentation or a more complete jawline enhancement including jaw angle implants, one of the defining male features is a strong jawline. While the nose is not as important a male feature as the jawline, a nose and a rhinoplasty that creates a high dorsal line and a well defined tip goes along with a good jawline that makes a very masculine statement in profile. Computer imaging will show how much of a difference these changes can make in the appearance of your face.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I have a cheek dimple on one side that I would like deepened. I don’t know if this is possible. I have attached a few pictures of where it is located.

A: Thank you for sending your pictures. You have a very lowly positioned cheek dimple which is below the horizontal level of the corner of the mouth. As you may know, many cheek dimples are posiitoned higher on the face than yours. While such cheek dimples represent a split or bifurcation of the zygomaticus muscle, yours involves some defect in the buccinator muscle. The good news is that it is located in a very favorable position as it lies below the level of where the buccal branches of the facial nerve run through the face. (below a line drawn from the tragus of the ear to the corner of the mouth) Efforts at deepening your cheek dimple involves an incision inside the mouth right opposite where your cheek dimple is. Fat is removed from beneath the cheek dimple and a resorbable suture is placed through the skin and sewn down to the buccinator muscle to pull it inward further. This is done under local anesthesia and does involve some cheek swelling afterward. It would take up to 4 to 6 weeks to see how much dimple deepening may be obtained.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley,  It is getting closer to my surgery date in June. I have a few questions.  If I were to get abdominoplasty prior to getting my facial surgeries, (paranasal, premaxillary, chin tuck up and labiomental implant).  How long would I have to wait after I got my abdominoplasty before I could get my facial surgeries.  I went back to my old tummy tuck doctor from ten years ago and had him have a close look.  He said he wouldn’t tighten the muscle, he would only remove skin during a mini tuck.  I thought about trying to travel all the way to you and back with the seriousness, healing, and limitations of a tummy tuck and I am a little concerned about the travel distance. Would I have to wait a long time in between the two surgeries?

A:  I would agree with your old doctor, only skin should be removed. That is all you can do which is common after someone has had a tummy tuck previously. That is a much different postoperative experience than the first time because it is much more limited. There is a reason it is called a mini- because it is so much smaller in magnitude. The incision makes you think it is the same but it is far different.

But if you were going to space multiple facial implants and a mini-tummy tuck apart it is just an issue of recovery/travel between the two. I wouldn’t think more than a few weeks would be necessary either way.

When you have good lips like you do to start with (adequate vermilion) implants work really well. I am not sure how to answer how that would look without the submental tuck-up because I don’t think one really affects the other that much. I would say it would not look strange.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I got combined medpor orbital/cheek rim implant(with midface lift) and canthoplasty last year. The orbital rim and canthoplasty was supposed to fix my scleral show and negative vector. I still have the scleral show. I am not sure why. I am not sure if I still have negative vector. I like to get scleral show fixed. Can you tell me if you can fix the scleral show and what do you propose?

A: While there was aesthetic benefit to the concept of infra-orbital rim/cheek implants, they alone are not sufficient to ‘ drive up’ the horizontal level of the eyelid. To do so they would have to be extremely large and highly disproportionate to your face. It is a flawed concept that you can push from below and think that the lower eyelid will be pushed up. Such implants are protective but not curative of a lower eyelid problem. Given your natural state of a low horizontal eyelid with scleral show, I would not have expected a canthoplasty to produce significant elevation either. In theory one would think that the combination of the two would be effective but they usually aren’t for several reasons. First the problem in the lax natural lower eyelid with scleral show is that there is a vertical tissue deficiency in the eyelid. When this exists there is no amount of pushing and pulling that is going to overcome it and have a sustained result. Secondly, the need to make a subciliary (lower eyelid) incision and lower eyelid dissection for implant placement and the midface lift creates a lot of scar. This will have a natural tendency to pull the eyelid downs as it heals. Lastly, the space occupied by the implants actually fights against the midface lift often creating a zero sum gain…as your result indicates.

The problem that you have now is that the lower eyelid is scarred and is not easily going to be mobilized without the issue if postoperative scar contracture. What I would recommend is to first have some fat injections done to make the lower eyelid more supple and help replace scar tissue with more vascularized tissue. Then after three months you could have an eyelid procedure that would introduce an interpositional palatal or alloderm graft to the inner lamellar of the lower eyelid and an osseous-based canthoplasty that is more effective than just a simple tendon tightening.

Dr. Barry Eppley

Indianapolis,Indiana