Your Questions

Q: Dr. Eppley, I am inquiring about septal perforation repair. I haven’t touched cocaine in years, but unfortunately, my perforation has grown. It’s between the size of a pencil eraser and a dime. I’m crushed and afraid and want it repaired. So far, it’s still standing (my nose) and I want to keep it that way. I read most traditional surgeries do not succeed but stem cell is working for larger holes. Can you help?

A: While it is true that the larger a septal perforation is, the lower is its success rate. But that does not mean that a septal perforation repair can not be successful, it is just that they are not easy and are often performed poorly. When talking about ‘stem cell therapy’, which is not really clinically available and is a misrepresentation of what is available ( injection options include autologous fat injection which coincidentally may contain some stem cells or platelet-rich plasma (PRP) which is a platelet conecntrate), such injections are not a method by themselves that can heal a septal perforation. Any such injections can be used as a concomitant treatment with conventional surgical techniques. PRP injections are what is used in septal perforation repair. It is important to realize that whether PRP injections are used before or during septal perforation repair, there is no medical evidence that proves septal perforation repairs are more effective because it is used. But because it is a natural extract from the patient, there is no harm in using it. In short, the use of PRP injections in septal perforation repair is largely based on the hope that the platelet concentrate may help in some fashion with the healing problem of a known difficult internal nasal problem.

The best approach for septal perforation repair is from above through an open rhinoplasty. This allows mucosal flaps to be raised on both sides and a PDS plate combined with temporalis fascia and a cartilage graft to be properly placed and covered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in temporal reduction surgery.  I was wondering if a complete reduction of my temporal muscle (including the non skin bearing part) was possible? And if so would it only require a surgical procedure? Or also a botox injection on top of that? Thank you very much for your time.

A: When you speak of complete temporal reduction of the muscle I am deducing from your description that you mean both the anterior and posterior temporal areas. The anterior temporal region is the skin bearing portion of the temporal muscle to the side of the eye that extends a few centimeters back into the temporal hairline. This temporal area can not be reduced surgically due to its thickness and location. It is treated by Botox injections to shrink down its size. The posterior temporal region extends behind the anterior area the whole way to the back of the head. The larger by surface area but thinner posterior temporal muscle area can be surgical reduced very effectively. Thus, surgical temporal reduction refers to the posterior area  above the ears while injectable temporal reduction refers to the anterior region closer to the side of the eye.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in heel pad fat injections. I had a bad experience with an inexperienced podiatrist. He had given me cortisone injections to the heel pad for fasciitis. Unfortunately the outcome made my condition worse and I have lost most of the fat pad in my left heel. I am very active person and to be left like this at 35 is very depressing. Is there any hope? I don’t know if this requires an orthopedic surgeon instead. Please let me know what you suggest.

A: I believe you are correct in that heel pad fat injections would be the best approach to your heel pad atrophy. The normally tight heel pad which is weight bearing is a difficult place for fat grafts to take. But fat is a natural graft material and between the fat cells, fibroblasts and stem cells it is likely that some heel fat pad thickness restoration can be obtained. For many heel pad problems, it is surprising that more podiatrists do not embrace the use of platelet rich plasma (PRP) and fat injections. These tissue extracts from patients offer a more natural approach to many pain and tissue inflammation problems without any of the side effects of steroid injections.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about orbital asymmetry surgery. I suffered a zygomatico-maxillary complex (ZMC) fracture six months ago and have since had noticeable asymmetry of the orbits. The right orbit (injured side), is now noticeably higher than the left orbit. The right orbit was slightly higher than the left prior to the injury, but not to the current degree seen in the attached image. The medial portion of the eye is at an upward slant compared to the left eye which is more level.

A: Such orbital asymmetry would suggest an impaction type ZMC fracture. This could create an inward translocation of the inferior orbital rim/zygomatic body. This would then cause a buckling of the orbital floor upward, creating the changes you see now. But the etiology of these changes is best assessed by a 3D CT scan which would clearly show whether any asymmetry exists between the two orbital floors.  If orbital floor asymmetry exists then lowering of the raised part of the orbital floor may be beneficial as an orbital asymmetry surgery. This could be done through a lower blepharoplasty incision to allow complete access to the entire orbital floor.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation. I am a male and I would like to know whether it is possible to increase the slope of the forehead given that the thickness of the frontal bone allows for it. I have high temples, so the roundness of my forehead is displeasing to me. While my forehead does slope backwards slightly it is quite round, whereas I would like a ‘sharper’ look. Thank you for your time.

A: Your forehead augmentation desire is possible and would be best done by a custom forehead implant made from a 3D CT scan of you.  This is the best way to get the angularity and sharpness in the implant that would be needed to create the outward forehead effect. The limiting factor in any forehead augmentation procedure is not the thickness of the frontal bone but the stretch allowed by the overlying forehead skin and soft tissues. I have yet to see this potential soft tissue limitation, however, be an issue in any forehead augmentation procedure that I have ever done. Most forehead augmentation needs rarely exceed 10mms in thickness and are often less than that amount.

Dr. Barry Eppley

Indianapolis, Indiana

Dr. Eppley, I’m having a LeFort 1 and bilateral split sagittal osteotomy to widen my upper arch and move it forward and rotate it clockwise and to straighten my lower jaw, and correct an underbite. But since I’m going through the trouble of this surgery and its difficult recovery, I’ve been thinking about how I might as well make the results better. In an ideal world, I’d love to have a more prominent and masculine jaw angle and jaw line. My surgeon is considering combining the surgery with a sliding genioplasty. From what I understand, together these surgeries could improve my chin but not necessarily my jaw angle. 

My two questions are: 1) have you had any patients who had a wrap around custom jaw implant (or even just jaw angle implants) done at the same time as a LeFort/BSS osteotomies? and 2) how long would one need to wait after surgery before considering implants? Thanks for your help.

A: It is not advised that a wrap around custom jaw implant be placed at the same time as a sagittal split mandibular ramus osteotomy. Placing a custom jaw implant over a newly made sagittal split osteotomy site may adversely affect bone healing. One should wait six months after orthognathic surgery to consider placing a custom jaw implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been bothered as I’ve aged that I’ve lost the ability to show my teeth when I smile. Would you recommend any lip procedure to improve this, considering I already have a short upper lip and would likely not be a candidate for a lip lift or an internal lip lift? I was also curious regarding the suggestion of a mucosal or vermilion-mucosal reduction to someone on RealSelf. Thank you for your time and consideration.

A: If tooth show is the main perioral aging issue and a subnasal lip lift is not an option, then a horizontal vermilion smile reduction would be an option. If the maxilla came forward in an orthognathic procedure that would also improve the amount of tooth show. But removing a strip of vermilion at the lower edge of the smile line is the most effective method to expose more upper tooth show.

But in looking at your pictures, particularly when you smile, you actually have an upper lip deformity known as a double upper lip. This is an excess roll of mucosa that hangs down significantly when you smile and the upper lip is stretched out. Resection of the redundant or excessive upper lip mucosa is what is needed for a double upper lip reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Two years ago, I had a septoplasty procedure with turbinate reduction due to a diagnosis of moderate sleep apnea. It turns out my septum was severely deviated, essentially blocking air at the back of one nostril. Shortly after surgery, I could breathe and smell things much better. Soon thereafter, everything has returned to pre-operative functionality, if not even worse. The surgeon I went to is an ENT physician, and refused to do rhinoplasty. I was advised by physicians later that a rhinoplasty procedure likely would have improved my nasal function significantly, simply by lifting the tip slightly. Would I be a candidate? I am concerned, because others have told me it’s a jaw issue and I would need orthognathic surgery.

A: The rhinoplasty procedure that you refer is two-fold and relates to the only two external (outer) nasal procedures that are known to improve nasal airway flow, spreader grafts of the middle vault and tip rotation. While both may be able to improve nasal airflow I would have no confidence that they would substantially improve sleep apnea. The only facial procedure that can reliably improve sleep apnea are jaw procedures that pull the face forward, particularly the lower jaw with the attachment of the base of the tongue, to open the posterior airway. But given the magnitude of orthognathic surgery it is understandable why other effort (nasal surgery) may be on interest to explore first.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to have a facelift done while I am in surgery for removal of my thyroid. i would also like to have my breasts lifted. It would seem to make the most sense to do all of these procedures at the same time.

A: Understandably the concept of combining a facelift, breast lifts and a thyroidectomy would seem to make the most sense from a surgical and recovery efficiency standpoint. And to a large degree it is. However, the hurdles to overcome to put this surgical combination together are substantial. The first is to check with your thyroid surgeon to make sure he/she would be comfortable in doing so. Plastic surgeons are comfortable doing a large number of procedures at the same time, but many non-plastic surgeons are not. Then there is finding the surgeons who are willing to do so and have their schedules find a mutual operative date. Equally, if not more importantly, then there is the cost of trying to do cosmetic surgery in a hospital where the thyroidectomy would almost assuredly have to be performed. The costs of cosmetic surgery, such as lengthy procedures as a facelift, in a hospital are often substantially higher than what they would be in a outpatient or private surgery center. These hurdles are not impossible to overcome but will be challenging. It may be far easier to have your thyroidectomy done first and then the facelift and breast lifts done separately days to a week later.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rib removal surgery for waistline narrowing. I am 30 years old, 5’2” 135 lbs with a 29  inch waist. I have breast implants and have had 2 fat transfers to my hips and buttocks. My waist may look smaller in these photos because I have added fat to my hips. When I was at my thinnest (125lbs) my waist was 26 inches. I feel I naturally have a very wide upper body. If I do proceed with the rib removal, am I obliged to wear the corset 24/7 for the rest of my life as I saw someone on TV doing? Any chance this would affect future pregnancies?

A: Rib removal surgery does NOT require wearing a corset or any form of wrap around support beyond the initial healing period of a few weeks after surgery. (because it will feel better if you do right after surgery) The patient and TV episode to whom you refer was waist training and that involves the long-term use of a corset. That is the exception and not the rule in rib removal surgery. This surgery would not affect the ability to get pregnant or carry a baby to term.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had this jawline augmentation morph done by a person who claims to do plastic surgery morph predictions, and I was wondering if this really is realistic and if I can look like this by any surgery necessary to achieve it. It is basically my ideal result if I could get it, but I want to know if it really is possible. (if anything, i would like to go even further)

Also, and this may be a bit ‘out there’, but would it even be possible to find a man with great facial bone structure and get him to get the 3D CT scan, then you can match my facial bones and jawline with his to make the implants so I would have a jawline augmentation to look like him afterwards?

A: I do think that type of jawline augmentation result is possible. It can only be done with a custom jawline implant designed by a surgeon who has done a lot of them who would know the dimensions to make that type of ‘extreme’ jawline augmentation result. It is not realistic to use someone else’s 3D CT scan as there are other factors involved in how one looks than just their bone structure. And no one is going to expose themselves to radiation for someone else’s benefit.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very excited about finding your webpage, discovered by searching for ways/methods to remove/hide my two bulging temple veins/arteries. They are very prominent, especially when in the sun, after exercise, after an alcoholic beverage, in a hot room, or after a salt-enriched meal. Been dealing with these for 15 years and I am ready to just pull them out. I am bald and shave the rest of my head, so their prominence is highly noticeable and “causing a complex” doesn’t begin to describe the frustration and discomfort in my life . After seeing the explanation of the temporal augmentation process, with the photo of the man’s head with the incision and implant on is temple, I have a few questions. I am curious if the temporal augmentation implant can be placed in between the temple arteries and the skin? Thus putting a shield over the vein and permanently keeping it masked to never be seen again. If yes, you have answered my prayers. If yes, how big is the incision? Thank you for any information that can help me.

A: In eliminating or decreasing the appearance of temporal arteries, you can not put any implant between them and the skin for a number of reasons including risk of arterial rupture, visibility of the implant’s outline through the skin and the length of the incision needed to place them. In theory one could use that ‘camouflage’ approach with fat injections but I doubt that would be very effective and would create its own lumpy appearance issues. The proven treatment for prominent temporal arteries is multiple point temporal artery ligation that is done through several very small incisions. Temporal artery ligation is a procedure done under local anesthesia in the office after tracing out the pathway of the prominent temporal arteries.

I would need to see some pictures of your prominent temporal arteries to see if temporal artery ligation would work for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a breast reduction question. Immediately after surgery when the dressings were taken off, my areola have a somewhat different size and shape. I know that my breasts will hange during the recovery period as the swelling goes down. I was wondering if my areolas would also change in shape and size as well? I knew there was a high possibility of them being different but I wasn’t sure if they just look a lot different in size now because they are still healing.

A: The areolas may change a bit but not a whole lot as the breast reduction heals. Areolas are usually a bit different after breast reduction surgery because they were not never really symmetric initially. While they are cut evenly using a ‘cookie cutter’ at 42mm in diameter during the first step in breast reduction surgery, the act of sewing them back to a new spot on the breast mound and the suturing rarely makes them as symmetric as the way they were initially cut out. I would wait six months and if the areolar size and shape is still an issue, adjustment of them can be done in the office under local anesthesia.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Can you please tell me if you perform buccal lipectomy and if so, how many he has performed? Thank you.

A: I have performed well over a 100 cases of buccal lipectomy procedures in the past twenty years. A buccal lipectomy surgery is very straightforward and uncomplicated to perform. There is no real risk to performing the procedure and I have only seen one infection in my 100 plus cases. (1% infection risk) I have not seen any cases of buccal nerve injury.

The key to a successful buccal lipectomy is one of patient selection. Determining who will and who will not benefit from the external facial change that the procedure can create has both short and long-term implications. The concern today with a buccal lipectomy is that it may result in facial gauntness as one ages. Since facial fat is lost as one ages, removal of the buccal fat pads in youth can result in a sunken face look decades later. This is why it should be only considered with caution in younger leaner people. It is ideally best done for patients that have fuller rounder faces who appear to be genetically predisposed to a natural rounder face

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wondering if you can help me…. I’m currently exploring my options. I have recently inquired about what surgery can be done to reduce the width of my head. Other doctors have suggested Botox and also an earfold treatment to pin my ears back. I’ve noticed on your site you do temporal reduction by removal of muscle. My hairline is thinning and I’d be concerned about the scars. A lot of the my width of my head is the muscle as I can move it upwards and see a huge change. I’ve pasted an extraction of part of your website… is this actually possible to do it from an incision behind the ear? I’ve attached a picture for you to review.

A: The most effective and quickest method of narrowing the sides of the head is a temporal reduction procedure where the posterior belly of the temporalis muscle is removed. While I initially developed the procedure using a small incision in the temporal hairline, more and more patients over the years who shaved their heads or had close cropped requested the temporal reduction procedure. It became necessary to find a completely ‘scarless’ way to do the temporal reduction procedure. Just like inserting temporal implants to widen the head, a temporal reduction procedure can also be done through a postauricular incision that sits right in the crease at the back of the ear.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I previously had a mini direct neck excision with a horizontal chin scar and a vertical scar extending about halfway to the Adams apple. I am 54 years old and had this procedure done to deal with loose skin from a previous chin reduction done ten years earlier. Is it possible to update this procedure into more of a direct neck lift? Is it possible to extend the scar a little more vertically to take up some lower neck slack?

A: Since you are already have partial direct necklift scars, there would be no reason why you could not extend the vertical portion lower. The lower end of a direct necklift is very effective at tightening loose skin above the adam’s apple. While it can be technically done, the only issue to be considered is how well the lower end of the direct necklift will do. In younger skin this lower end of the scar may not heal as well as the scars directly under the skin. While the risk of significant hypertrophic scarring from the lower end of the a direct necklift is low, it is a potential issue to be made aware.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young male (27 years old) who is self-diagnosed with sagittal craniosynostosis. I want to have sagittal crest reduction by a significant amount. (approximately 1.5cm) I know sagittal crest reduction is possible up to a maximum of 7mm. But if you suffer from sagittal craniosynostosis isn’t it logical to think that there is more sagittal crest bone and therefore more to reduce?

A: In reality, having a sagittal crest from a limited form of sagittal craniosynostosis may or may not make the bone along its midline length thicker. That speculation can be answered by a CT scan in which the bone thickness can be directly seen and measured. However, I doubt very much the bone is thick enough that would allow a sagittal crest skull reduction of 15mms. Having done many sagittal crest skull reduction procedures, I have not found them to be extraordinarily thick or substantially thicker than that of the surrounding skull bone. Usually they are in the order of 5mm to 7mms thicker before the inner cranial table is seen and/or violated.

When one thinks they need as much as over a centimeter of sagittal crest bone skull reduction done, they may likely be suffering from a parasagittal deficiency along side the sagittal crest as well. In these cases the best treatment is a combined sagittal crest reduction and bilateral parasagittal bone augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a glabellar implant. My interest in glabellar augmentation is that as I have had rhinoplasty and fat graft to forehead but my glabellar region is flat in comparison. I would be interested in knowing whether it looks natural when raising eyebrows and facial movement? Is there a visible border from the implant? Also what is the recovery time?

A: While glabellar augmentation can be done by a variety of materials and techiques, the most successful method is a custom glabellar implant made from the patient’s 3D CT scan. Since the glabella is a broad-based region that is like a diamond shape, it is best to have it custom made so that it blends smoothly to the surrounding bone and would have no visible or palpable edges. It is placed in the subperiosteal plane from an endoscopic scalp technique so it does interfere with any eyebrow or forehead movements. The glabellar implant is placed through a small scalp incision after the subperiosteal pocket has been made using the endoscope. The recovery time is very quick with limited swelling that should largely be resolved in a week after the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in Perioral mound liposuction. I received Perlane to the corners of of my mouth and they have never been the same. I know the product is gone, but nonetheless the bulges remain. I do not know if they are fat, scar tissue or simply excess soft tissue, but I have these convex mounds on either side of my mouth which are less than attractive. I hate them and want them gone. They age me more than any other facial area.

A: Thank you for sending your pictures. Despite your lean face you do have very discrete convex mounds at the sides of your mouth. I could not tell you what composes them or how effectively they can be eradicated. But I do know that the only procedure that has any chance of reducing them would be small cannula perioral mound liposuction. This can be performed under local anesthesia or IV sedation. This is a small procedure that has a short recovery. Because of swelling and the small size of the perioral mounds, perioral mound liposuction can take several months to see the final result. I will have my assistant followup with you tomorrow to pass along the cost of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. I want to change the shape of my face. I have a long and thin face which I do not like. I have attached pictures of model faces that I do like. I can not really tell what is different about them from mine. I just can’t point my finger on what it is or what I need for facial reshaping surgery.  

A: Thank you for sending all of your own pictures for consideration for facial reshaping surgery and that of faces that you like. All of the faces you like the same differences from yours…their cheeks are much fuller and wider, the chin is vertically shorter and they have more pronounced jaw angles/width. Your face, attractive as it is (although not to you) is longer and thinner. Your ideal face is wider and shorter. To make your face more like your ideal the following three facial reshaping procedures would be needed. Cheek augmentation using implants to substantially widen and increase the apple cheek effect. Your chin could be made vertically shorter by an intraoral vertical reduction bony genioplasty. Thirdly, jaw angle implants would be needed to widen your jawline. The facial reshaping change you seek is… long and thin to shorter and wider.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a general question regarding jaw angle implants. I’m currently trying to decide whether to choose silicone or medpor material for jaw angle implants augmentation. I’m trying to create sharp, square, chiseled angularity more than just adding width. I’m getting differing opinions whether silicone is able to do this as effectively as Medpor. I’d really like to go with silicone (particularly a custom silicone implant) due to ease of removal and no tissue ingrowth, but I’m worried the result would be less angular and more soft, such as in the photo I’ve attached (notice how it’s more of a U shape than a sharp V). I’ve read some claims that because Medpor is a harder, firmer material, it creates much better angularity for those seeking a sharper jawline. Basically my question is, if I were to opt for a custom silicone jaw implant, would it able to create just as sharp jawline edges as Medpor material would, or will silicone always looks a little softer? 

A: The answer to your question about jaw angle implants is two-fold. First, regardless of implant shape, not every patient has a good chance of developing a sharp angular jawline. The only patients who will do so are those with thinner lean faces with little fat. Men that have fuller and rounder faces with more fat will fail to develop much definition. (as illustrated in the example you have shown) Thus one’s own tissues must be taken into consideration. Second, your selection of a silicone material for jaw angle implants would be best in my experience for the reasons you have mentioned. But the only assured way to get the most angular result is to have the implants custom made. Otherwise you take your chances with performed  jaw angle shapes and sizes. As an aside the slightly firmer feel of Medpor does not give it increased angularity. It is the implant’s shape that determines the external change not the implant’s material composition.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had two abdominal surgeries. The first was a hepatic bypass and the last one was a partial hepatectomy. My last surgery was complicated with infection at the organ level as well as an incisional hernia. The surgeon plans to surgically repair the hernia in May or June of 2016. I am interested in having a tummy tuck at the same time. I am not sure if I am a candidate or not. Would need to know if the two surgeries can be done at the same time.

A: The question you ask about a concurrent tummy tuck done at the same time as an abdominal wall reconstruction (hernia repair) is determined based on the consideration of multiple issues. First I would have to see pictures of your abdomen to determine the tissue excess and the location of your current abdominal scars. The location of certain abdominal scars may preclude or at least potentially complicate healing of the tummy tuck incision. Secondly, you would have to be in good medical health (which I would assume you would be for a hernia repair), on no immunosuppression drugs and be a non-smoker. I would need to know more about your medical history. Lastly there is the economics of doing a cosmetic surgery procedure in a hospital. While many patients think that most of the cost of the surgery would be covered by insurance because one is already asleep and having surgery, that is not the case. Hospitals are well aware of what is being done and will hold the patient accountable for the time and costs of the tummy tuck surgery, including OR costs and anesthesia, up front.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting closer to making a decision about extra large pectoral implants. I currently have Implantech’s Power Flex Pectoral Implants. (ACPI-4, 17.6 x 13.4 x 3.2cms) I am looking for something much larger, particularly in projection…hopefully at least double or much larger with greater upper fullness and deeper separation/cleavage. I know my pecs will be out of proportion to the rest of my body but that is OK. ou sid I could get pectoral implants as large as possible that would fit in the tissue pocket. How would you be able to judge their maximum size. Didn’t you say you had used custom implants as big as 6.5 cms projection? Thank you so much for your kind attention to this matter.

A: When designing custom pectoral implants, several considerations go into considering their dimensions based on the restrictions of the submuscular implant pocket. First and foremost you have indwelling implants which have created a solid surrounding capsule. Unlike submuscular breast implants, the capsule of pectoral implants is harder to release much because of the limited access from the remote axillary incision from which the implants were initially inserted. The one area that most needs to be released is the sternal or medial edge of the pocket as well as the superior edge of the pocket since this is where you need the most expansion with new pectoral implants.  Because you have the Powerflex pectoral implants (ACPI) that are more oblong rather than rectangular (PowerFlex II, ACPI2), your greatest area of ‘aesthetic’ deficiency is closer to the sternum. Any new pectoral implants must have a shape that is more like the PowerFlex II rather than the PowerFlex I that you have now.

Changing the height and width of your indwelling pectoral implants to 19 cms x 14.5 cms would be what I would advice. Any increase in pectoral implant surface area is going to come in the sternal side. Unlike the height and width of the existing pocket the ability to stretch the projection is more generous. Thus doubling their projection should not be a problem from a tissue stretch standpoint.

The only issue that bears consideration, and a possible limiting factor, is the insertion process of  large custom pectoral implants. Pectoral implants are inserted through an axillary incision and are done so because they are folded onto themselves. The thicker the implant becomes the harder it is to roll it (fold in half) for insertion. This is why in very large pectoral implants the concept of double stacking implants rather than one single large implant is often considered.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I wanted to ask, in a Lefort 1 osteotomy, is it possible to lengthen the nose along with that part of the maxilla. Part of my problem with my midface is a nose that is short vertically compared to the distance between eye to eye horizontally. So is it possible to lengthen the nose within the Lefort 1 osteotomy? I am asking because I saw this Lefort 1 osteotomy example, and wanted to know if the bone grafts also applied to lengthening the nose vertically? And if so, by how much?

A: While diagrams and actual LeFort I osteotomy down fractures (vertical lengthening) do show the pyriform aperture (nasal base) being opened up and/or bone grafted, this will not vertically lengthen the nose. The shape of the external nose is largely controlled by the cartilaginous support system. (septum, upper and lower alar cartilages) This to vertically lengthening the nose cartilage grafts must be placed on TOP of the existing cartilage support. Nothing done underneath it will lengthen the external nose shape. In fact, vertical lengthening of the midface will actually create a relatively greater deficiency of the nose, more of a potentially saddle dorsal line appearance rather than the opposite effect which you desire.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a chin reduction three weeks ago. My chin always made me feel self conscious because I felt it was too long and wide for my face. Also, I had a dimple in the center of my chin that also really bothered me. My surgeon preformed a sliding genioplasty and shortened by chin 5mm. I was also concerned of the width of my chin after surgery so he tapered the sides of my jaw/chin to create a more narrow appearance.

I understand that there is considerable swelling still but I am so unhappy with how I look at this point I can’t even leave my house. The first thing I noticed was instead of dimple being in the middle of my chin, it’s at the very bottom and looks much deeper. I thought my dimple would be greatly diminished if not gone. This is what he told me. Also, my chin looks incredibly round. I feel like he should have addressed my skin and tissue instead of just addressing the bone alone. The sides where he burred to make it more narrow have this big hard knot or bulge on each side. What is this? When I smile I feel like I look awful. My lower lip looks thinner and is still numb. My lips when I smile look lopsided as well. I absolutely hate everything about my chin. I want a v shape appearance with my dimple gone or at least diminished. Now I feel like he made everything worse.

I want you to preform a revision but how long would I have to wait? I have included some pictures from 2 days ago. I would love to have a skype interview with you ASAP.

I appreciate your time and I look forward to hearing from you!

A: While I lack some specific information about your exact chin reduction surgery (type of osteotomy), I can tell you some very specific information about the recovery process from any type of reductive chin surgery. While three weeks seems like an eternity, the full recovery from chin reshaping takes a full three months, The swelling from chin osteotomies can be massive and, at three weeks, I would expect considerable chin distortion and roundness and it may not even be back to its normal size yet. Between resolution of the swelling AND soft tissue contraction back down to the smaller reshaped bone, it really does take a full three months. Other issues such as hard knots/spots, lip numbness and abnormal lip movement and smile are also normal at this point and will take the three months or longer to completely resolve.

If I am to interpret your pictures correctly, I believe some of them are before surgery (glasses) and the after surgery are those without. Based on these pictures I see a chin that do not considerable abnormally enlarged at this point after surgery.

From a chin dimple standpoint, No bony surgery is going to change the dimple. Its location may change because of the bone reduction but it will not go away. This is due to the fact that a chin dimple has a soft tissue etiology not a bone one. To decrease its appearance requires soft tissue management such as fat grafting.

The type of osteotomy used will determine whether a more v-shape will be the final result. This almost always requires a combined horizontal osteotomy and vertical ostectomy to achieve that change. I obviously have no idea what type of chin osteotomy was done in you although I am suspicious that it may have been a horizontal one only with some shaving on the sides. This does not usually work that well to effect that change. A simple panorex x-ray would answer that question.

Based on the chin osteotomy type and the presence of the chin dimple would determine whether staying the course until complete swelling has resolved would be best or whetehr earlier intervention would be more appropriate.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, For purely cosmetic reasons, I wanted to know if it was possible to lengthen my midface by performing a 1-2mm dual sided vertical ramus distraction of the mandible? Also a 1-2mm LeFort 1 osteotomy vertical elongation similar to the fashion of that provided in the attached photo that had featured the osteotomy and bone grafts. And if so, what would be the likely maximum cost after taxes and hospital bills?

A: What you are  seeking is vertical elongation of the maxillomandibular complex. If all that is needed is a few millimeters of vertical lengthening of the maxilla and mandible, there would be no reason to undergo any form of distraction. This can be done by using conventional orthognathic surgery operations such as a LeFort 1 osteotomy with interpositional bone grafting and a sagittal split osteotomy of the mandible. I would not do a LeFort 2 osteotomy as this is associated with an incraesed difficult factor that requires a coronal scalp incision to complete. Whatever aesthetic benefits that may come from a LeFort 1 osteotomy vs a LeFort 2 osteotomy, the added surgical risks and effort are not worth it. Such bimaxillary orthognathic surgery will cost in the range of $40,000 to $50,000 to undergo.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in tummy tuck surgery. Can you please tell me the cost of tummy tuck surgery in your practice? Also what is the recovery time from tummy tuck surgery?
A: Thank you for your inquiry. There are eight different types of tummy tucks with differing associated costs. I would need to see some pictures of your abdomen to give you a very specific cost figure. Most women are type 4 so I will have my assistant pass along the cost of that version to you. That may or may not be the type of tummy tuck that you need. There are three different levels of recovery and it depends on what you are defining as your recovery point. (up and about, back to work, working out, final recovery) Since full recovery from a tummy tuck takes a complete eight weeks, I am assuming you are referring to some level of incomplete recovery where you can get at least back to that type of activity. Working backwards then it would six weeks for working out/running, four weeks for any job that has a significant physical components to it, two weeks for a sit down job and seven to ten days to be more up and about.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I hope you will respond to my question. I am scheduled for temple augmentation with your designed temporal implant and was curious to know the recovery time? I have had cheek augmentation recently(2 months ago) and found the swelling stayed longer than anyone explained. Should I expect the same swelling with this implant? How long? Are there any photos of temple implant recovery?? Is this a new type of implant?

A: Since you are not my patient, my first answer to your temporal implant augmentation question is that these should really be answered by the surgeon you are trusting to do the procedure. He/she should be able to fully explain these questions if they have had experience with the procedure.

That being said, temporal implant recovery will be quicker than that of cheek implants. As you have now learned, full recovery from any type of facial skeletal augmentation will take a full two to three months. Your surgeon should have made that clear before your surgery. Any form of facial implant surgery always takes longer than any patient believes or is told. However since temporal implants are not a bone-based surgery but a muscle one, the recovery is much quicker with a faster resolution of swelling and to get to the point of seeing the final result.

Due to patent confidentiality, patient photos are not shared.

The temporal implant is not a new implant as defined by just coming out. It has been commercially available now for over three years.

Best of luck with your surgery,

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am interested surgical reduction of the occipital nob. I have a large bump on the bottom of the back of my head that causes constant pain and headaches. It hurts to sleep on it and wearing protective head wear at work is almost impossible. I have read that you do a reduction of the occipital knob. Is this strictly a cosmetic procedure or can it be deemed a medical issue for insurance coverage?

A: The occipital knob deformity is an abnormally large hump of bone at the bottom of the occipital bone in the midline. Why it develops more prominently in some men than others is not known. It has become more of an aesthetic issue today since more men shave their head or have very closely cropped hairstyles.

Tthe size of the bony knob can be a source of discomfort when flexing the head backwards or in certain headwear/headgear.  This is also where some of the neck muscles attach and the large hump of bone probably signals strong muscular attachments as well. The occipital knob can be reduced by burring it down through a small horizontal incision over it. This is a cosmetic procedure and not one covered by insurance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have two questions about rhinoplasty. First, is there any leeway in the 7 day recovery time? And the second one is I have seen that if you have trouble breathing, insurance may pay for some of the procedure. Is that true? I ask because my nose is a little crooked to the right and I feel like there is a big difference between the left and right side as far as breathing goes.Thanks.

A: Depending upon how one chooses to define recovery, only the first phase of a rhinoplasty is done at one week after surgery. That is when the nasal tapes and splints are removed. But that is far from when one has a full recovery from the procedure. But that is certainly the most obvious appearance part of it due to the external nasal dressing.

If one has breathing problems in which deranged anatomy is evident in a CT scan, then a predetermination with your insurance can be filed to see if they will pay for the functional or breathing part of the surgery. An insurance predetermination can not be filed without a recent CT scan report. The purpose of a predetermination letter is to provide your health insurance carrier with the information so they can determine if you qualify. But insurance does not cover any part of a rhinoplasty that changes the external shape of the nose.

Dr. Barry Eppley

Indianapolis, Indiana