Your Questions

Q: Dr. Eppley, I have contacted you in the past about questions I had regarding indentations I have on my skull, and about fixing them with a cranioplasty. You responded by telling me that I would require an open approach cranioplasty and the incision would be bilateral from ear to ear. Along with having a large indentations on my skull, I also am going bald. I am interested in getting a cranioplasty done by you and also am planning on getting a FUE hair restoration at some point.
My questions are:
1. If I was to get a FUE hair transplant/restoration would it be better to do it before or after the cranioplasty?
2. Would it make sense to do it after, so it mite be able to help cover the scar? or does it even matter?
3. Also can you diagnose what the name of the medical term/condition is that I have wrong with my skull by looking at the attached pictures I have here?

A: In answer to your questions, you would always want to do hair tranplantation AFTER a cranioplasty. This is because it would also give one the opportunity to place hair grafts along the scar should that be necessary. While this could always be done after, you would like to have that option during the initial FUE procedure. Usually that is not necessary but it is a theoretical option that you want to keep available given that bothi of these procedures are elective and can be done anytime in any order.

I believe what you have is a very incomplete form (microform expression) of bicoronal craniosynostosis. This is because you have deep indentations (like a constricting band) right along the exact location of the underlying original coronal suture locations.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, What is the difference between liposculpture And liposuction? I am 55 years old and scared of the skin sagging or wrinkling At my age with liposuction, I would love my inner thighs, knees and saddlebags gone forever.

A: On the one hand, the difference between liposuction and liposculpture is largely one of marketing. The term liposculpture implies a greater degree of finesse and precision than the historic term of liposuction . As a result some doctors use this term for any form of liposuction because it simply sounds better. That does not necessarily mean, however, that it is or that the body is truly sculpted. Conversely, if applied to the right situation, the term liposculpture may have some real meaning. The right situation in my experience is when one is doing smaller areas of fat reduction using smaller cannulas where getting a more precise result and truly creating a visible contour change occurs. In short, liposuction implies large volume fat reductions where a simple size change occurs. (i.e., a full abdomen) Liposculpture implies smaller and more precise volumes of fat removed to create curved contour changes. (i.e., neck, knees)

Based on your age and areas of concern, however, these liposuction concepts are not what is important for you. You are appropriately concerned about what will happen to your skin at your age with any form of liposuction. The effects of liposuction on the overlying skin change based on the area being treated. I would not be concerned about the knees as skin never sags in this area no matter how much fat is removed at any age. Conversely, the inner thighs are a treacherous area for irregularities and skin sag at any age. I would approach the inner thighs with modest fat removal or none at all. If any significant skin sag exists now you would be better off with some form of an inner thigh lift if you want to go that far. As for the saddle bag area, this is a good area to treat but the key is to not remove too much fat as skin sag as some irregularities will occur with too much deflation. You may also have to accept some negative changes in the skin in the saddle bags no matter how much fat is removed.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, how much do jaw implants cost roughly? If someone already has a decent jawline but would like to enhance it would that cost be less as opposed to someone who needs a lot of work done?

A: The main difference between the cost of jaw implants, and I will assume you mean combined chin and jaw angle implants, is whether off-the-shelf implants can be used or whether custom ones have to be designed and made. Since you already have a decent jawline and ‘only need a little work’, I will assume standard chin and jaw angle implants can be successfully used. There are differences in these types of implants and the materials from which they are made and this also affects cost. But I will make the assumption that silicone chin and jaw angle implants can be used. Using those inmplants, the total cost of chin and jaw angle augmentation would be around $ 6500.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had fat injections done under my eyes to correct some hollowing that I naturally had a month ago. I understand that there is still some swelling, but the areas around my eyes that were injected with fat have become really lumpy and uneven. Is there anything that can be done about this? I have tried massaging the area but there doesn’t seem to be much difference.

A: Fat injections are notorious for irregularities in the lower eyelid area. While they can look and feel smooth in the first weeks after surgery, any irregularities become apparent as all swelling subsides. And irregularities are the norm not the exception. This is because fat injections, unlike synthetic injectable fillers, are not linear and smooth as they are injected. Fat is more ‘clumpy’ and as a result does not come out of the injection port in a completely smooth fashion. The goods news is that your fat injections are in a state of healing and this is not the final result. This would be a different story if it was 6 months from now. You have to massage and knead them fairly firmly. You need to work the lumpy areas against the underlying infraorbital bone, pressing on them to try and flatten them out. This is a process in evolution whose final result in terms of smoothness will not fully evident until 3 months out from surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, my question is regarding your last article about cranioplasty. Near the end you include the following statement: “The limiting factor is that the narrow skull beyond the temporal lines can not be augmented with material as it is covered with temporalis muscle.” I’m considering having a cranioplasty for enlargement (aesthetic reasons, exclusively) and you are my first option to having the procedure done but I would like to have the aforementioned area enlarged as well as all the others. I would like to know if there’s a solution for this.

A: The normal anatomy of the skull is that under the scalp across the top (between the temporal lines) is only bone while at the sides there is a layer of relatively thick temporalis muscle under which the bone lies. Whether it is a cranioplasty that involves temporal skull augmentation or bone reduction, the temporalis muscle must be considered and managed. There are two basic approaches when extending skull augmentation beyond the temporal lines down along the sides. The first approach is to leave the muscle alone and merely place the material on top of the temporalis fascia. When so doing, it is critical to feather the material to a very tapered edge to avoid a palpable or visible edge demarcation. This approach is best used when the amount of material/augmentation that needs to extend beyonf the temporal line is minimal. When more substantial augmentation is needed that extends further down into the temporal region, a submuscular approach is used. The upper edges of the muscle are released and the material is placed undeneath it. The key to this approach is that the muscle must be resuspended back up over the material to the temporal line as much as possible. This is done by suturing the upper edge of the temporalis fascia to the material as close as possible to the original temporal line.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a craniotomy for an aneurysm over a year ago with radiation. This has left me with many effects from facial nerve paralysis. It has affected my face from the brow the whole down to the neck with a facial droop. I have attached pictures for your assessment. When I lay down my right eye does close which it did not do for quite awhile. The only movement I have on my right temple is a slight lift of the inner tip of the eyebrow. When I try to wrinkle my brow it goes slightly past center but it curves downward. The corner of my mouth was much further down than now. Originally there was no movement at all. I am now able to turn the corner up and the area of movement still seems to be increasing.

A: Thanks for sending your pictures. What they indicate to me is the following:

The frontal branch of the facial nerve is gone which is why the eyebrow does not lift up. As long as the eyebrow has not drifted lower than the opposite normal left side, I would not do any procedure for it. (i.e., browlift)

It is good news that the upper eyelid does now nearly close. As long as it closes completely when you lay down, I would not place a gold weight in the upper eyelid which is the normal treatment for a partial or slow closing upper eyelid.

The lower eyelid, as previously mentioned, needs a procedure which will help it considerably. It needs to be lifted and tightened up against the eyeball. To achieve this more is need to be done than just a traditional lateral canthoplasty. (tightening the lateral canthal tendon at the corner of the eye. That procedure needs to be combined with a fascial sling (harvested from the temporalis fascia) that would be placed from one corner of the eye to the other, much like a clothesline. Together this is the most effective method for lower eyelid tightening and resuspension.

The right face and lower corner of the mouth appears to be in some state of gradual improvement although it is probably not realistic to think that completely normal mouth movement will ever occur. However,, as long as it is improving, I may defer any type of static corner of mouth resuspension until later although that is still up for further evaluation.

The entire right facial droop may be treated with a complete facial resuspension (facelift) on the affected side. That is certainly reasonable to do at anytime. This may be combined with a corner of the mouth lift, both of which will not negatively impact any ongoing facial nerve recovery.

The right temporal area is sunken in due to the effect of the combined craniotomy and radiation, which has caused the temporalis muscle to shrink or atrophy. This is a very common effect from this exact neurosurgical procedure. The temporal area could be built back up using a variety of techniques which would depend on the dimensions of the volume lost. I can not tell exactly from the pictures to give you a better idea on how that would be done yet.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am wondering if I want to do Ulthera and laser hair removal laser at the same time in the same area? The area is my temples to my outer eyes or upper cheek bone. Is that dangerous?

A: While the energies used for Ulthera and laser hair removal is different, their effects are the same…heating up tissues under the skin. Given that both technologies generate considerable heat, I would not do the both during the same treatment as you risk creating a burn injury. There is no benefit in taking this risk for cosmetic enhancements. These two skin treatments should be spaced at least a week apart to avoid this skin damage risk. While they should not be done together, their effects are somewhat synergistic if they are not staged too far apart. The heat creation form both will help create a better skin tightening effect than if Ulthera was just done alone. It is also theoretically possible that the heat from Ulthera may help inhibit hair growth as well.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am 42 years old and had a tummy tuck two years ago after my third and final child. While I had some rather dramatic improvement and am pleases with the overall result, there is one area that still remains problematic. I have this persistent swelling between my tummy tuck scar and the pubic bone. It has never gone down completely and I don’t understand why. It sticks out in dresses and tight pants like a bulge and is a visible ledge if I try and wear a swimsuit. What can I do to get rid of this swelling?

A: What you have is not swelling and is a not uncommon finding for some patients after a tummy tuck. It is residual fat in the pubic mound area that is below the effect of a tummy tuck. The tummy tuck scar in most patients becomes the narrowest part of the waistline and can look like a constricting band above the puffy pubic mound. Sometimes this is recognized before the tummy tuck and its reduction by liposuction done at the same time. In others, it becomes obvious after a tummy tuck. It can be very effectively reduced with a small liposuction procedure. (pubic mound liposuction)

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had one of those TV-advertised facelift procedures last year. Having had it done under local anesthesia of which I would not go through again or every recommend, but that is a different story. What I am considerably bothered by are the scars in front of my ears and that my earlobes are pulled down. They never bothered to mention that either of these two issues could ever occur after surgery. I have read that my ear problem is known as pixie ears. What can be done to fix them?

A: The pixie ear deformity occurs after a facelift due to inadequacies in how the procedure was performed. This is what can happen when all the lifting of the skin flaps is supported by the lower part of the ear. Not to soon after surgery the tension on the non-cartilaginous earlobe will result in it being pulled down creating what has been described as a martian or pixie ear deformity. Poorly placed scars in front of the ear and the distorted earlobes often happen from those poorly trained in facelift surgery who does not understand the basic principles of the operation.

There are two basic approaches to correcting the pixie ear deformity. A simple release of the ear and shortening of the earlobe can be done but this will leave a small vertical scar below the earlobe. The other alternative is to readvance the facial skin flaps (repeat facelift to some degree) and tuck the scar up under the released earlobe as well as behind the tragus of the ear. This will reposition all scars into more aesthetic locations which should have been the result of your first facelift procedure.

Q: Dr. Eppley, I had porex cheek implants implanted then removed a year later. It has been about 8 months since the removal and I look ok and do not have any sagging, however, I do have excess scar tissue that is built up on the bone of the cheek. It is not that bad (meaning hard to see without feeling the face) but it is quite lumpy in some spots (especially on the one side) and I would like it reduced if possible. I heard steroid injections work well, but not sure. Your opinions? I am a 27 year old male. No other plastic surgery or intention for future surgery. Thanks!

A: What you are referring to as scar tissue is the residual capsule left after removal of the cheek implants. In most cases, much of that capsular scar tissue will resorb over time but it may well over a year for maximal absorption. While steroids are commonly used for scar issues, most of that is done at the more superficial skin level where control of placement of the steroids can be visually done. While steroids could be injected deep into your cheeks, I would not do it because you have no assurance as to exactly where it is being placed. Indiscriminate use of steroids can be associated with fat tissue loss and tissue thinning. Given that your scar problem is not visible, I would not risk potentially creating another problem that may turn out to be just as bothersome or worse than what you have now. You are better off to live with what you have, no matter how it eventually turns out.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had gastric bypass surgery, and my breasts have flattened out and sag now but so far my actual cup size hasn’t altered all that much. I need a consultation to see what can be done to improve the look and shape of my breast. They have been large my whole life so I definitely do not want larger breasts at all.

A: With your weight loss, you undoubtably have lost some breast tissue volume or they would have not have flattened out and sagged. For a good breast shape, you simply have too much skin for the amount of breast tissue volume that you now have. A full breast lift does not remove any breast tissue but rather only the amount of skin needed to lift and reshape your breasts to a restored position back up on your chest wall. With that the nipple is moved up considerably to a central position on the respositioned breast mound. Interestingly, most breast lifts will actually make the breasts look smaller and never larger. But by your own description, you would not be offended if your breasts do look somewhat smaller. The only negative aspect of a breast lift is that there will be scars. These will be the classic anchor or inverted T scars that are typical of a full breast lift or a traditional breast reduction surgery.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I would like to have an otoplasty done for my protruding ears. But I have seen numerous otoplasty results on the internet on doctor’s websites and many of them look overdone to me. The middle part of the ear seems to be pulled back too far and the upper and lower parts of the ear still stick out. Can I get an otoplasty performed in which the ear is closer to the side of head but it is smooth from top to bottom?

A: The setting back of the ear through cartilage reshaping (otoplasty) is as much an art as it is a science. And how much setback a patient desires does vary with each individual case. It is important to have a good understanding before surgery as to how much setback you consider to be adequate or even too much. Many of the untoward otoplasty results to which you refer is not the result of how the cartilage was repositioned but by a lack of setting back the earlobe at the same time. The earlobe has no cartilage in it and is thus not affected by any cartilage suturing. It is an often forgotten part of an otoplasty and can make the middle part of the ear look like it is pulled back too far if it is not changed. In those protruding ear patients that also have an earlobe that angles out (and many do) it is important to set the earlobe back at the same time as the cartilage to ensure that the outer helical rim is a smooth line.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had saline breast implants placed under the muscle 11 years ago. While I know they have not ruptured, they seem to be less full and firm that they used to be. Is it possible that they are slowly leaking saline but without a rupture. Do saline implants get weaker over time and more likely to rupture? Are they more fragile now and more prone to rupture? Should I stop doing strenuous physical activities?

A: Your breast implant experience and questions are common. Many augmented breasts, although not all, over time will feel softer and less full years later. This is not the result of something going on inside the implants but rather what has happened on the outside. The pressure of breast implants over time will cause the loss of some breast tissue between the implant and the skin. This is known as pressure atrophy. With the loss of some breast tissue, the breasts will feel softer and less firm. With saline implants, the breasts may really feel loose and ripply as there is no longer as much tissue between the implant and the skin to act as a cushioning buffer…and this then reveals the more rippled surface of a saline implant.

The second part of your question is actually true. The shell or bag of a breast implant does get weaker over time, no different than any other manmade device. The constant stretching of the bag does over time create flaws or weak spots in the silastic shell which will eventually lead to a spot of rupture. While this is inevitable, there is no reason to stop doing any type of physical activity that you enjoy. This is not different than one stopping driving so their car tires will never wear out.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am now 10 weeks after cheek implant removal. Implants were removed because of infection and incorrect asymmetry. I am now thinking of getting Sculptra, Radiesse or Juvederm but am getting different answers as to how long I should wait to get the injections after removal. I still have some fluid, swelling and lip numbness after 10 weeks post op. My implants were put in October 2 and removed November 2, so they were only in for one month. I am very concerned about my health and healing from this and want to wait long enough to make sure the filler injections are safe. But my face looks worse than it did before the implants. Your expertise is very much appreciated!!

A: I would agree that complete healing should take place before you place any injectable fillers, even though the tissue plane where they will be placed is differngt from that were the implants were. That would be a minimum of three months. But a better barometer rather than just raw time is when the cheeks are no longer tender and any signs of numbness has completely dissipated. In short, don’t do fillers until your cheeks feel completely normal again.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had jaw augmentation and a little lipo in the neck area…It was performed 2 weeks ago today….I can’t move my bottom lip in a downward motion which means I can’t smile….I still have a great deal of swelling although significantly less…Is this nerve damage permanent or could the swelling have something to do with it.Your advice would be greatly appreciated as I am very nervous. Thank you. It was performed by a very reputable surgeon but none the less I now bad outcomes can happen to anyone.

A: What you have is weakness of the marginal mandibular nerve branch of the facial nerves. This tiny nerve branch, which supplies the depressor muscle of the lower lips, crosses over the jawline on the side of the chin. It is not really at risk from the jaw (chin) augmentation since that is down at the bone level which is deeper. It is at risk from liposuction of the jowls particularly if liposuction is done at or above the jawline which is exactly where the nerve runs. Nerve injury from liposuction , because it is a blunt instrument, does not cut the nerve but bruises it. This may make it weak for a period of time (unable to lower lip) but recovery almost always occur. Nerve recovery does not parallel swelling reduction, however, and usually takes much longer. In most cases llike yours, full functional nerve recovery can take up to three months or longer. Given that there is no other treatment, patience is all you can do for it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like some information about breast augmentation re: price of inital consultation and surgery fees. Also, I am currently breastfeeding but am weaning and plan to be done within the next week or two. I would have to have the surgery between the end of March or before mid April due to when I can take vacation from work. How long does the surgeon require to be done breastfeeding before doing the surgery? I’ve researched and it looks like a lot say a minimum of 6 weeks? Thank you for your time.

A: The issue of when to undergo breast augmentation after breastfeeding is a relatively common question and there is no real exact timetable. Delaying having breast implants placed until after breastfeeding is based on having a non-engorged breast (so one can estimate breast implant size better) and having an increased risk of infection due to breast milk leaking onto the surgical field. Thus the key questions are how quickly does the breast deflate and assume its normal deflated size and when does the milk production dry up. Once can see that will vary tremendously for many women. I feel that breast size reduction is more important than absolute cessation of milk production, since I do not use nipple incisions and the nipples can be covered with sterile shields (dressings) during surgery. Therefore, I do find the general estimate of six weeks after breastfeeding to be a reasonable schedule to undergo breast augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am really interested in a new procedure called “Fractora Firm”. Do you do that and if not, do you know anyone in the state of IN or surrounding states who does? This would be much less costly than a facelift.

A: The procedure or technology behind the Fractora Firm is radiofrequency (RF) energy driven into the skin to creatre a mild firming or skin toning effect. What has caught your attention to it most likely is its recent appearance on the Dr. Oz show. The use of RF and a variety of other energies (ultrasound, pulsed light, galvanic electrical currents, etc) to try and improve sagging skin is not new. Over the past decade there have been a slew of these energy-driven technologies, all of whom capture media attention as they have become available for patient use. They capture the public’s attention due to the widespread concern of sagging facial tissues as one ages and the hope that it will avoid the need for a ‘facelift’.

It would be a far reach to consider it or any similar technology as a replacement or substitute for what a surgical facelift does. Calling it a non-surgical facelift is a marketing concept not a clinical reality of what actually happens. It is better to think of it as a skin toning or firming method not a sagging tissue lifting method. As a result it is best used on younger patients with early signs of facial aging such as a small amount of jowling or just a little loose neck skin. It is not for someone who has more moderate to advanced facial aging with really evident jowls and a neck wattle. Its success, therefore, is highly dependent on proper patient selection.

What is also not evident on the Dr. Oz show is that Factora Firm requires multiple treatments, usually 4 to 6 treatments spaced a week or so apart, to get the optimal facial toning effect. Thus the cost is not really $300 (as stated on the show and the website) but $1200 to $1800 for a series of treatments. Whether that cost and the effect that it creates is a better value than a ‘facelift’ would depend on the degree of facial aging that one has. If one does not really need a facelift then it is a good treatment that may be worth the cost. If one really needs a surgical facelift, then such treatments are a poor value.

In my practice, we offer a similar non-surgical treatment to Factora Firma using RF energy (Exilis) combined with more superficial fractional laser resurfacing for skin tightening and a mild amount of facial skin lifting. This combined treatment is superior because it combines heating up the underside of the skin (dermis) with a more superficial (epidermis) treatment. This produces the combined effect of skin tightening AND wrinkle reduction. For some patients a more intense single treatment is fine while others may be best served by lighter treatments done in a series.

I would be happy to review any pictures of you to determine whether you are best served by considering a non-surgical RF skin tightening approach or whether something more surgical is more appropriate. While every patient wants to avoid surgery and their associated costs and recovery, most patients would also like to avoid throwing their money away on a treatment concept that never had a chance to achieve what they wanted.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a very active 28 year old man who has both a scar and bump at the top of my forehead. They have both bothered me for years. I have been meaning to contact your office for quite some time, but have been a little hesitant. I would like to learn more about my options. I guess we can discuss everything in more detail once we make contact. I tried to take the best pictures possible to make out my concerns. I took one with a ruler just to give you an ideas of the length of the scar, its about half an inch long. You can semi make out the bump I’m concerned about, the high point of it is around the location of the scar. I look forward to hearing from you.

A: Thank you for sending your pictures. I can see the forehead bump which I view as more prominent and obvious than the small scar. The scar can be used for incisional access to burr down the forehead bone bump. The real question is whether the concomitant revision done on the forehead scar would end up much better after it healed. This is because of two factors, your ethnicity with darker pigment (which notoriously scars poorly) and that there would be some stretching of the skin edges for the bone bone burring. (which could potentially cause the scar to hyperpigment or widen after healing)

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I had fat from my hip added to the left side of my face. I had a hollow side due to radiation, it’s been about 7 to 8 years since I had this done. And the fat has dropped and looks terrible, what can I do about this? It sticks out and hangs down.

A: You undoubtably had a dermal-fat graft taken to reconstruct the soft tissue atrophy on one side of your face due to the radiation. While dermal-fat grafts are an excellent means of subcutaneous fat reconstruction, they are notorious for ‘sliding off the face’ or falling down to the jowls if they are not anchored securely to the cheek bone and along the zygomatic arch bone. What could be done now is a resuspension of the dermal-fat graft back into the desired position with permanent sutures. This would be very similar to the original procedure to place the graft minus the harvest site. It is, in essence, like a one-sided facelift procedure. It is clear that the dermal-fat graft has taken  but it probably developed descent before it completely healed, thus falling down to the jowl line.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 35 years old. I had a child nearly 18 years ago. I have excess skin and stretch marks. I would like to consider getting a tummy tuck. My chief concern is down time and cost involved. I am recently divorced and self conscious about my looks. But worried about going through plastic surgery.

A: The thought of elective plastic surgery is certainly scary for most people, particularly an operation like a tummy tuck. Such a procedure, while making a dramatic improvement in one’s stomach and waistline area that is not achieveable by any other means for someone with excessive abdominal skin, requires a commitment of both time and resources. It is not for the faint-hearted and there is no easy or simple way to do it.  The bigger the change, particulalry on the body, the mopre of everything it takes to do it. The best way to think about it is that you will need three weeks to have an adequate recovery and total costs would be in the range of $7500 to $8500. Those two basic considerations are good screening tools to determine if you should move forward with taking your desire for a tummy tuck to the next level of an actual in-office consultatiobn.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had augmentation rhinoplasty to build up  my bridge a and bilateral spreader graft to widen my nose. I am not sure the use of ear cartilage was appropriate for my wants. I wanted my radix to tip slightly augmented and my Dr. used ear cartilage. I never had an over done rhino before either it was a just tip work on my first. I just decided I wanted a more masculine nose. I am looking for some answers about a possible third rhinoplasty yikes. I have never had cartilage taken out of my nose. I am 25 year old caucasian male. I am looking for a surgeon who works well with rib grafts.

A: My assumption  is that based on your description that the ear cartilage graft was used to build up the radix. But that has left you with more of a ‘scooped out ’ dorsum with too high of a radix and the rest of the dorsum too low or that the entire dorsum is now too high and more of a hump? When trying to build up the entire dorsum, I find it difficult to do that with a curved piece of cartilage that simply doesn’t have adequate shape for the complete dorsal line. But it is often used when a septal graft is not available and the concept of a rib graft seems too extreme. In a subsequent revisional rhinoplasty, the ear cartilage graft can be removed and replaced with a rib cartilage graft which offers a straighter piece that can be more assuredly shaped to the desired result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a deviated septum after getting a broken nose. I’ve dealt with this for about 12 years now and am working to becoming a chef and would like the full use of my nose as this would be a great plus for my job in getting my sense of smell back. The only allergy I have that I know of is I am allergic to Lortabs, If you would like to know more about me just ask I would like to know how much this would cost?

A: Septoplasty, the most recognized surgical name/procedure to improve an obstructed nasal airway, is just one aspect of nasal airway improvement. Straightening a deviated septum is often combined with inferior turbinate reductions as well as spreader grafts to the middle vault to open up the internal nasal valve. Whether one or all of these intranasal procedures are needed would depend on an internal nasal examination. What needs to be done will affect the time to do it and the subsequent cost. As a general cost guideline, a ‘septoplasty’ could cost anywhere from $2,500 to $ 4,000. In regards to your sense of smell, there is no guarantee that just because your nasal airway exchange improves that your smell will as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants in 1991…through the years they have shifted upward….more on the right, the right also is sore when applied pressure on it. I’m interested in having a revision.

A: All facial implants when placed ultimately form a layer of scar around them known as a capsule. This capsule not only envelopes the implant to separate it from the rest of the body but also serves to anchor or maintain the implant in its location. It is interesting as to why, years later, that the capsule somehow changes and allows the implant to change location even if it is only slightly. This is not unique to facial implants as it is seen in some breast implants as well as they bottom out or move too far to the side over time in some patients. What this indicates is that the interaction between implants and the body’s tissues is not just a static one. This is why I feel it is important to screw all facial implants into place when possible so implant micromotion and sliding around is not possible.

The question with your current indwelling cheek implants is whether they should be merely repositioned and secured with screws or replaced with new ones. That would depend on how you feel they look now and whether you have had any significant facial tissue sagging over them over their twenty years of implantation. Seeing some pictures of your face would be very helpful.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am an 37 Asian male with very prominent bulging eyes (I believe it is due to having a relatively flat skull with shallow eye sockets). From a side profile view, my eyes protrude farther than my nasal bridge. To my knowledge, I have never had Graves disease or any other eye condition other than myopia. I think it is simply a genetic aesthetic condition. But it seems to me that browbone augmentation could be an ideal way to reduce the prominence of my eyes. I can send you pictures I have taken of my eyes from different angles. I would like to know if I am a candidate for this surgery. Thank you!

A: What you are referring to is known as pseudoproptosis, the eyes appear to stick out because the surrounding bones are underdeveloped or not string enough. I think it is true that brow augmentation would be beneficial. But one may also consider lateral and inferior orbital rim augmentation as well (and maybe nasal augmentation) to provide a more complete orbito-malar augmentation to more effectively produce a less ‘bulging’ eye. This type of midfacial skeletal hypoplasia is very common in Asian patients as brow and forehead augmentation are frequent aesthetic procedures considered with this type of craniofacial skeletal development.

Q: Dr. Eppley, Is there a permanent solution for treatment of the hyperactive mentalis muscle? It manifests in a very subtle way, just on the right lower part of my chin, and instead of repeating injections on a semi-regular basis, I’m much more interested in finding a permanent method of altering this very slight irregularity. Thank you for your time.

A: The use of Botox is the easiest and most effective method for treating a hyperactive mentalis muscle. While it is not permanent, a few units skillfully placed works very well. It is possible to do a partial transection of the mentalis muscle through an intraoral approach and this may provide a more permanent solution.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25yr old male who was born with club foot. I went through life playing sports and excelling in every aspect. At this point in my life I am currently coming to a financial point to pursue a calf implant surgery. Can you please inform me of what the procedure is all about, how often it is performed, success rate, and cost. Thanks you for your time and I look forward to moving this process along!

A:  Calf augmentation can be done by either an implant or more recently fat injections. The more guaranteed method of permanent calf augmentation is with an implant. Calf implants, like all body implants, are made of a very soft and spongy solid silicone rubber material which feels very much like muscle tissue. It is inserted through a small incision in the back of the knee in an outpatient procedure done under general anesthesia. The procedure is most commonly done in body builders or non-athletes who feel that their calfs are just too small. The most challenging patient in my experience is the club foot patient because, not only is the calf too small but the surrounding skin is very tight. This makes the insertion of an adequately-sized calf implant more difficult and it will not be possible to match the circumferential size of the smaller calf to the larger one. The club foot patient must be willing to accept improvement in calf shape but an ideal result will not be achieved.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know which one of the two approaches for chin implant surgery is better, intraoral or submental incision? How do you avoid cutting the branch of the facial nerve. When you do the submental incision and how likely is it to injure this nerve by the submental incision?

A: There are advantages and dusadvantages to each chin implant approach. Neither one is necessarily ‘better’. Both are acceptable chin implant approaches and produce similar results if technically done well. The submental approach avoids the intraoral incision and the need for disinsertion of the mentalis muscle from the bone when coming from above and that may make the recovery process a little bit easier. The submental incision should have virtually no risk of injuring the marginal mandibular branch of the facial nerve. The course of that nerve lies way to the side of where the submental incision is and is in a much more superficial tissue plane than the subperiosteal approach to the chin bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, how long does it take to completely recover from liposuction? I had stomach, back, thigh and knee liposuction one week ago. I had a lot of initial swell and bruising and still do. I had lot of pain in first week, and my doctor told me I would be normal after one week but I am far from that. I still have pain, my body is sore, its hard to sit and sleep and I need to take pain medications to get any sleep. Certain areas of my stomach, leg and knees are numb. I can not go back to my work and I am very worried that I might not be able to do so even after 2 weeks from surgery?

A: While liposuction can produce some really significant body changes, the recovery is also equally significant for most patients. The concept that you would be fine in a week after almost any liposuction procedure sounds great in a marketing advertisement but is not based in reality. Everything that you have mentioned sounds exactly like what I would have predicted for just one week after surgery. While the next week will make some great strides in improvement and you will likely be able to go back to your work in another week, the true recovery from most liposuction procedures is closer to 3 weeks for being active again and up to 3 months to see the final contouring results.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came across your website in my search for 5fu injections. I have/had a cyst in my chin/jaw area last august. I have had it injected with cortisone/kenalog multiples times and it has helped but something is still there. I believe it is scar tissue because it’s hard and turning white. But because it never came to a head I’m not totally sure that theres nothing in there but scar tissue. So my question is this; are there any issues with having 5fu injections into a cyst or more likely a scar? Because I know cortisone has risks of fat atrophy and skin thinning. Does 5fu have any side effects like that? And also can you put 5fu in a scar that has had cortisone put into it? Thanks so much.

A: 5FU is not as significantly effective for scar reduction as steroids. This is also why is has none of the side effects of steriods and also why you will often see it combined with steroids for injectable scar therapies. It helps reduce the concentration of steroids needed to lessen their potential side effects as well as enhances the effects of 5FU. It works best in the early treatment of scar tissue formation. But it would not be an effective treatment for a true cyst. I am assuming that what you had may have been for cystic acne which is really an inflammatory condition so steroid injections would have been an appropriate treatment. But a true dermoid cyst is not going to go away long-term with any injectable scar therapy.

Dr. Barry Eppley

Indianapolis, Indiana