Your Questions

Q: Dr. Eppley, I am interested in a rhinoplasty. I am 50 years old and was originally born with cleft lip and palate. I have had two previous rhinoplasties for my cleft nose, the last being over a decade ago. I have never really liked the results and was hoping to have one more go at it in my older years. Just recently had a consultation about my nose with  a  surgeon who is basically a cosmetic surgeon. He looked me in the face and said  that due to my anatomy and blood supply, his major concern was that he wasn’t sure if he could correct anything. His concern was necrosis. I have great blood supply and have never heard of that possible complication before. As a matter of fact that remark caused me to realize that I needed an expert in cleft nose deformities. Please tell me what you think.

A: While open rhinoplasty always has the potential for nasal tip skin necrosis, this would be a very rare problem. The surgeon would have been better to say ‘I am not interested in doing your nose’, ‘this is hard and not worth my effort’ or even ‘this is beyond my skill level’ but the idea that the blood supply to your nose is compromised and can’t be operated on is not a valid biologic concept. If that were true, the vast majority of revisional rhinoplasties would never be done, not withstanding the secondary cleft rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’d like to inquire about getting injectable fillers under my eyes. What product do you use, what are the risks and what does it cost? What is the general satisfaction with patients having this procedure. I am excited about having it done but also nervous since it is around the eyes.

A: Under eye hollows, tear troughs and malar creases are becoming a popular treatment site for injectable fillers. When done well they can provide significant visual improvement of problems areas that previously were only treatable by surgery. For under the eye hollows, I generally use Juvederm placed with a microcannula technique. This usually eliminates any risk of bruising. The biggest concern in injecting under the eyes is that it is not overdone and that it is as smooth as possible. This means that it is injected down at the bone level along the infraorbital rim Of all the facial areas to treat with injectable fillers, this requires the most careful and skilled technique and a comfort zone with the surrounding orbital anatomy. The biggest risk is lumpiness or unevenness of the lower eyelids. The cost of treatment, which will usually last a year or more is around $550.

Q: Dr. Eppley, I am interested in getting facial implants and am gathering information about getting plastic surgery. My intention is to improve my facial features with facial implants and cosmetic plastic surgery. I would like to get your professional impression and advice to enhance my look. 

The areas that I would like to improve are: 

– Jawline. I think I have an elongated face. So, I am looking for a more square and strong jaw.

– Cheeks and Eye Hollows. I am starting to notice some eye hollows. I think I do not have a strong features in this area, they are somehow “flat”. At this time, it is not bad, but I believe with time they will get more pronounced. 

– Upper Eyelids. I notice that I have extra skin on my eyes lids, especially on my left eye.

–  Any suggestions to make the face more aesthetically balanced and harmonious with the rest of the face.

Concerns:

– I am concerned about the scars and the surgery around the eyes. I do not mind internal scars but external incisions concern me.

– What is the material used for the facial implants? I read about Silicone, Medpor and Gore-Tex. I would like to know your impressions about these materials, and their pros and cons, and why you use ones over the others.

– Asymmetry, implant shifting and/or misplacement (due to position, scarring, etc.)

– Final look. I would like to look natural and not “done”. 

– Revisions. What is your policy in case of revisions?

– Complications during and/or after surgery. What is your policy in case of complications during the surgery and/or after the surgery? nerve damage?, secondary effects?, responsibility, cost, etc.

– Bone erosion with implants over time. What is going to happen with the implants when I get older. I am 30 years old at this time. What is going to happen with the implants and the bones when I am 85-90 years old? the implant, the screw, the bone. Is there any research done about this? 

Ideal:

– I can imagine you have heard this before, but I would like to get the “model” look. Strong, symmetrical, pleasing features. I attached some photos of some ideal looks, by all means I don’t want to look exactly like a specific “celebrity” or “model”, it is just an idea of the look I am looking for. 

Questions:

– Could you provide me with your professional impressions about the surgery/ies that I will be benefiting from, their related costs and results?

– Do you provide any imaging about the possible results. I attached photos of my face in different angles. 

– What are the difference between conventional and custom designed implants? what are their costs?

– How long will I have to stay in Indianapolis after the surgery? 

– When would I be able to return to my normal life work, exercise, being in public, etc?

– How much discomfort should I be expecting in the surgery?

A: I have done some computer imaging on your face for the various facial implants for the following procedures:

1) Square chin augmentation

2) Vertical lengthening as a well as width expansion jaw angle implants

3) Cheek implants

4) Fat injections to the lower eye hollows/tear troughs

In answer to your questions:

CONCERNS

– there would be no external incision with fat injections

– implants would be silicone, best because of better shapes and easily reversible or modifieable

– all implants would be screwed into place

– natural comes from not using too big of implants, particularly when multiple implants are being used.

– we have a complete page of the revision policy which you would get to read before surgery.

– bone erosion is a non-issue. The implants will look the same decades from now as they will one year after surgery.

IDEAL

– you are correct in assuming that every male who wants this kind of surgery wants the ‘male model’ look. Those who have a chance to come close to that look have to have thinner faces and some decent underlying facial bone structure…you are the uncommon one that actually fulfills these criteria.

QUESTIONS

– I have attached some imaging predictions for your review. I will have my assistant pass along the costs to you in a day or two.

– you should be fine with standard implants. Custom implants are always ideal but at the additional costs of $7500 they had better provide a real difference…which in your case they do not.

– 2 to 3 days, all based on how you feel.

– that is based on how you feel and look, somewhere between 10 and 21 days after surgery.

– jaw angle implants provide the most discomfort, the other procedures are much less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did an upper and lower jaw surgery five months ago. Unfortunately a genioplasty with bone graft was also done. See before and after X-rays attached. I’m very happy with my upper and lower jaw surgery but not the genioplasty with bone graft because now I’m unable to close my lower lip without forcing the lips together. It looks like the lower lip is being pulled down.

 Is it possible to redo the genioplasty so Im able to close my mouth more easily. The secondary problem is that my face also look too long now. I added some before and after X rays. Is it possible to recut the bone and slid it back upwards half the distance it was slid downwards?. Or is it better to remove the bone graft and make the chin as it was originally?

A: Given that it has been nearly six months from the original procedure, there is no concern at this point about revisiting the genioplasty site. You can simply redo the genioplasty and either remove entirely the length that was added by the bone graft or shorten to whatever vertical distance you want. It is just as straightforward to do it either way.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 19 year old considering a buccal lipectomy and wondering if I am a good candidate for it. I feel that there is some roundness to my cheeks that make the lower half of my face disproportionate to the upper half. I was wondering if the procedure would benefit me or if it wouldn’t make much of a difference. And if it does, whether I might not look too gaunt. I’ve seen a lot of regrets online but I wonder if it’s just a vocal minority. Thanks for the opportunity to gain some nice insight! Truly appreciated.

A: In looking at your your pictures and your young age, you would not be a good candidate for a buccal lipectomy procedure. While the initial result would meet your objectives, the long-term of it in your case would leave you looking gaunt and end up along with those that you have read that has regrets online. It is not that a buccal lipectomy is a bad procedure, as it can be very effective and successful in the right patient, but your face is not one of them. You do not have a ‘fat face’ or even a round face. Your level of fat lipodystrophy is very modest and the buccal lipectomy is too aggressive for your facial fat concerns.

In addition, where your facial fat concerns are is actually below of where the buccal fat pad actually is. It is situated just under the cheekbone and not down by the side of the mouth.

If you were to consider any facial thinning procedure, perioral mound liposuction is a better choice as it helps reduce the fat thickness at the lower end of the cheek and is a procedure that cannot really be overdone and has no long-term ‘gaunt face’ consequences.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had fat injection breast augmentation done six months that had a lot of problems afterward. There was drainage from under the left breast for three weeks after the procedure. I was put on antibiotics to treat it but was told the rubbing of my bra on it was the cause. Then a month later my right breast developed a large painful lump that turned out to be an abscess which required more antibiotics and needle drainage. I am now left with one breast bigger than the other and one of them is lumpy. The doctor now wants to do the procedure again but this time using the Brava device. Will this make a difference and make it more likely that the fat grafts will take? My doctor is an ObGyn who specializes in cosmetic surgery but my first experience has now made me nervous.

A: Unlike breast implants, the use of fat injections for breast augmentation is not an assured outcome. As you know and have experienced, the take of injected fat is subject to a wide variety of factors not all of which is completely understood. The take of injected fat is highly dependent on the harvesting, method of preparation and the injection technique. While the injection of fat seems like, just like the liposuction of fat, successful results ultimately depend on surgeon experience and attention to technique details.

The concept of using the Brava device is a good initial approach for small breasts with a tight skin envelope. Whether that would have been advised for your first fat grafting surgery is now irrelevant but should probably be considered for any second stage. But it is important to remember that the Brava device is an adjunctive procedure to prepare the recipient breast bed, it is not the magical solution or a substitute for adhering to sound fat graft harvest, preparation and injection principles.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, I am an Asian female who is 27 years old and want to have a more narrow face. I’m interested in jaw reduction, chin reduction(v-line) and cheekbone reduction surgeries. What are the possibilities of side-effects such as nerve damage and sagging skin? Is it possible to do all 3 surgeries at once?

A: As you undoubtably know, narrowing of the Asian face by bone reduction is a common request and collection of procedures. All three facial bone reduction procedures are commonly done together including cheek bone reduction and jawline narrowing.  The most common side effect, albeit not a complication, is the protracted facial swelling (4 to 6 weeks) until you see the beginnings of the results of the procedure. Generally permanent nerve damage (sensory nerves, infraorbital and mental nerves) does not occur although there will be a period of some lip numbness. The bigger risk is with the mental nerve as the jawline reduction goes right beneath it and some stretch on the nerve does occur. Sagging skin is also not usually an issue either and this is more of a concern in the cheek area rather than the jawline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have cheek implants placed and had an infection after surgery. It was drained and reclosed, that was three months ago. While some of the cheek swelling has gone down there is a noticeable asymmetry between the two sides of my face. I had  a CT scan done which shows no ongoing abscess and my doctor wants to do liposuction on the cheek to try and make the two sides more even. This does not quote make sense to me. Can you review the CT scan and tell me what you think.

A: I have received your CT scans and reviewed them in detail. While I would agree with the radiologist’s report that there is no obvious abscess/large fluid collection, the scan does show some significant asymmetry in the cheek implant positions and there is an encapsulated area around the left cheek implant with the infection history. You can see in the attached cropped images of your CT scans to what I am referring. Knowing that you did not have significant facial asymmetry before surgery and you had an infection of one cheek implant with secondary manipulation, your current significant facial asymmetry can not be explained by a fatty tissue problem. If you were my patient with these similar findings, the only course of action I would recommend is to re-explore the left cheek implant, remove any scar tissue and either reposition or just leave out the implant and let the tissues settle down. I would not rule out the possibility that this is a chronic inflammatory reaction from an originally infected implant. What you do know is the opposite right cheek implant reflects what it should look like. Thus the facial asymmetry on the left side is implant-related in some fashion. It would have to prove to me otherwise.

Dr. Barry Eppley

Indianapolis, Indiana

 Q: Dr. Eppley, I am interested in getting cheek and paranasal implants. What is the best procedure to correct a deficient (flat) mid face? I’ve always hated my facial profile.  I have attached some photos which I realize probably are not the quality needed for computer imaging but I was hoping you would be able to gauge if and how you might be able to correct my facial features.

A: The photos you have sent show you smiling in both of them so they not only are not useful for computer imaging but have distorted the midface due to the soft tissues changes. Unfortunately if I can’t image them to see the visual change then  it is difficult to say such procedures are aesthetically productive…because what ultimately counts is what you think not what I think about the potential facial look change.

Having said that, cheek and paranasal implants are useful for improving the facial profile that has some midface deficiency…which may apply to you but smiling photos pull the soft tissue up (at least on the cheeks) and make them look fuller than they really might be. I can see the paranasal deficiency which smiling actually accentuates rather than improves.

So my incomplete assessment at this point suggests that you may be correct that your midface profile could be improved by these types of implant augmentations.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a lip advancement procedure that would make my upper lip at least equal to my lower lip. My lips are significantly out of proportion.  I have sent 3 pictures as references. Would you be willing to make such a drastic lip change to make them equal in size/appearance. I really would not be happy with the results if this outcome isn’t achievable. I live out of state and would have to fly in the night before the surgery and then fly out the day after. Would that cause any problems with the procedure and healing process. I am a very healthy 38 year old male with no health conditions. I have had anesthesia for a prior procedure. I am in the health field so I could perform most of the post care protocols. Thanks for your help.

A: Through a lip advancement your upper lip could be made almost even, if not completely even, to that of your lower lip. This is a procedure that could be performed under either local anesthesia (office) or IV sedation (procedure room) Many lip reshaping patients of mine come from afar so distance is not a concern in terms of healing or a cause of any after surgery problems. As you undoubtably know, the only issue with the lip advancement is the fine line scar along the vermilion border which is why it is not as commonly done in men as in women…although this does not mean the scar is any different. I don’t know of you are going to have upper lip hair or not after the procedure so the scar may or may not be of significant consideration.

Dr. Barry Eppley

Indianapolis Indiana

Q: Dr. Eppley, I need with a chin implant revision or a chin implant removal.  I had a chin implant done about 10 months ago and I am still experiencing numbness and a slightly crooked smile on the left side. The most alarming part is that smile does not “go down” as much as it used to. My smile feels tight and almost like I am fighting against my chin to smile. Am I just still recovering from the numbness or should I get it removed? I liked my smile before and now it is too small and strained looking…I have a round face and sometime’s I think the implant makes it look rounder (and not thinner/ more defined which is what I wanted). My entire lower left side was numb after surgery so it has come back significantly…but still so slow in 10 months. Do you have any suggestions?

A: You are describing symptoms of a chin implant that is too ‘big’. The feeling of tightness in the chin and the stiffness from it is either due to a very tight pocket or an implant that is a little too big for the tissues. The fact that your chin looks rounder also indicated that it is ill-shaped for a female which should have more of a triangular-shape and not rounded like the implant that is in there. Given that you had the chin augmentation procedure for a reason, I would suggest a chin implant revision rather than a chin implant removal. The implant needs to removed, reshaped and then repositioned rather than just throwing away the entire effort. You did not say which way the chin implant was put in (intraoral vs. submental) but I am going to guess it was placed intraorally which can often be a source of these type of symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead reduction/hairline advancement surgery. I am a 20 year old female, and I wanted to ask about forehead recontouring. I would like to know more information. I am self-conscious about my forehead as it curves/bulges outwardly. I’m not sure if this is applicable to this, but I have included a picture to get a better opinion.  I also want my hairline lowered. Will a tissue expander be needed?

A: The success of frontal hairline advancement depends on the tightness of one’s scalp and how much forward movement of the hairline one desires. If the scalp has some looseness and the amount of hairline advancement in not greater than 10 to 15mms, then a scalp expander will not usually be needed. Although I have seen some patients whose scalp is so tight that is barely moves even with full release.

A hairline lowering will help but will not get rid of the bulge appearance completely. The two procedures are often done together for maximal effect.

Based on this profile picture you have sent, I think your rounder forehead can be made flatter. The relevant question is how much? Generally up to 4 or 5mms can be taken from the most central prominent area. But I alway check a simple skull x-ray first to see how thick the bone is in that area.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My son needs skull reshaping surgery. He is currently six yearrs old and will turn seven later this year. I have many concerns for my son. My son has never had a hair cut in his entire life. I braid his hair down in efforts to try to disguise the deformity located on the right side of his head. We are African-American and one day, after my son graduates from college, he will need to be appropriate to interview for jobs. No one will want to hire my son with braids in his hair. He needs to be able to cut his hair and wear suits proudly.  Also, both his grandfather and father are bald. What happens to my son if his hair pattern follows in that same direction? When my son was born, his head shape was absolutely perfect. I want my son to be able to fit in with society and not be ashamed or judged on his deformity. My son is an innocent child and if there were anyway I could take his place I would. Please help us.

A: Skull reshaping surgery by an onlay cranioplasty is most commonly performed for flat areas on the back of the head. I am assuming that his flatness is on one side of his head in the back of his head. Such a skull deformity is very amenable to being built up by an onlay cranioplasty procedure by putting material on top of the bone. This does require a scalp incision to do it, located more to the back of his head. He does not have to shave his head or unbraid his hair to do it. In fact, having braids in his hair is the best hair management for the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about the injectable, minimally invasive cranioplasty skull reshaping procedure that you mention on your website. I am in my 50s and considering shaving my head after years of trying to deal with cosmetic issues related to thinning. I have been reluctant to do so due to an uneven flat spot on the back of head until I happened upon your site that describes ways to correct it.

A: The pure injectable cranioplasty skull reshaping approach has largely been abandoned due to an inability to get it completely smooth throughout the augmented area. That has been modified to a ‘minimal incision’ cranioplasty with a small incision about 2 to 3cms long. With this more open approach the material can be placed and then more carefully smoothed at the edges so there is not a step-off between the cranioplasty material and the natural bone. This can be a very good procedure as long as the size of the skull flattening is not too big.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to know if I can have a non-surgical rhinoplasty for temporary basis. At the moment I do not have sufficient funds to afford a rhinoplasty. Will there be dying of the skin or problems with the skin if I do this. Do you think i can have this procedure based on my nasal anatomy. Please let me know thanks.

A: The best type of nose for a non-surgical or injectable rhinoplasty is the patient with a small to moderate-sized dorsal hump. This provides a perfect place to place an injectable material above the hump in the upper nasal bridge or nasion area. By so doing the hump is camouflaged as the dorsal line is straightened from the tip of the nose up to just below the eyebrows. Your nose is the perfect candidate for it as you fulfill this anatomic criteriua. I have attached some imaging which shows what the result would look like. The  only question is what type of injectable filler to use of which they are a large number of choices. I would chose one of the longer acting ones like Radiesse or Juvederm XC which should last about a year. This is done in the office under topical anesthesia and takes about 10 mnutes to perform…which is why the procedure has earned the name of injectable rhinoplasty or ‘lunchtime’ rhinoplasty.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need acne scar revision surgery. I have large deep acne scars. I have tried four sessions of Ematrix…a waste of a lot of money. Didn’t even remove some red blotching which they said it would remove. Have been to other plastic surgeons and they wanted to either fill or sent me to some other laser type skin care people. Subcision seem to be my only hope. I understand you perform this kind of acne scar revision procedure. Please contact me with any info on this procedure.

A: Acne scars can be difficult scar improvement problems but it is important to match the acne scar type with the most appropriate procedure to have any hope for a visible change. Subcision works best in those acne scars that are deep but broad-based. Using a fine needle, the skin under the depression is cut or released. Some simply let blood fill in space that was released or one can place injected fat into it. I am of the injected fat approach as a spacer is ultimately needed to prevent the skin from just scarring back down as it heals. Deep acne scars that have a more narrow base (ice-pick type) are better treated by complete excision of the total scar and then closed to level it out. Many acne scar patients need a combination of excision and subcision/fat injections as their acne scar types are variable. When the acne scar revisions are more than just a few, the entire procedure is best done in the operating room under some form of anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need scar revision or some type of treatment on two stomach scars that are pretty bad. When I was a baby I had surgery where an incision was made across my stomach. As I grew and have gotten older (I am 24 years old now) it has  grown increasingly worse in the way it looks. It is stuck down to my muscles and has made a big groove across my stomach. The surrounding skin has grown up around and over it and the top part hangs over the scar. I also have a lower stomach below my belly button which runs up and down and it is very discolored. That scar needs to be lightened. Attached are some pictures of my scars.

A: Scar revision is frequently beneficial for abdominal scars from prior pediatric surgery procedures done as an infant or child. The ‘infant surgery’ abdominal scar is exactly what I would have predicted to see. They all look like that when done very early life, the scar adheres down and the fat grows around it creating this classic appearance. It needs to be completely cut out, released and put back together as a fine line scar that is level with the surrounding skin.

While the lower vertical abdominal scar has a different origin and is not stuck down to the abdominal wall, there is no non-surgical therapy that is going to lighten the scar. Like the upper abdominal scar, it needs to be cut out and reclosed into a fine line scar to remove its dark discoloration.

t would obviously make the most sense to do scar revision on both abdominal scars at the same time during the same procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the true recovery time from a tummy tuck? In my consultation, the plastic surgeon said around two weeks. But I have read online that it can be as long as six to eight weeks. What is the truth? I am a nurse in a hospital and work in an Oncology unit. I don’t lift patients but I am up and down all the time and constantly running around. 

A: The concept of recovery can mean different things to different people and understanding what that is is of great importance in a tummy tuck…where the recovery should never be underestimated and often is. The concept of a two week recovery from a tummy tuck is not a realistic one. While you may be up and around the house and doing many normal activities, that is too early to feel comfortable doing strenuous activities. Work for many people is strenuous even though it may not seem so until one is less than 100%. Short of lifting, constantly having to be up and down is a very strenuous activity to be doing just a few weeks from a tummy tuck. A more realistic approach would be to consider going back half-time, if possible, the third week after surgery and then going back full-time by a month after the tummy tuck. This will allow you to ease your way back into work. While some people will not have this luxury for recovery time and simply have to go back after two weeks (and suffer through it), a three to four week approach as described is going to be a lot better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, if I get silicone breast implants will I be able to breastfeed? If I get pregnant after breast augmentation should I first check and see if the implants are ruptured before breastfeeding? If the implants are ruptured can I breastfeed or do I need to get the implants out immediately or can I let my son self wean??

A:  You taken taken the classic ‘can I breastfeed with implants’ question to every conceivable scenario. Most breast implants today are placed under the pectoralis muscle well below the glandular breast tissue. As a result there is no interference with milk production or breast feeding. If you have no symptoms suspicious of an implant rupture (pain, change in breast shape) I see no reason to get an ultrasound, mammogram or MRI before breastfeeding, In addition, the implants are contained within a surrounding scar capsule so even if there was an implant rupture there should be no silicone in the milk ducts. However, in the event that you have a rupture and are breast feeding, I would suggest that you do not breast-feed until you have had the rupture evaluated by a board-certified plastic surgeon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a rhinoplasty to help with my congenital nose deformity from cleft lip and palate. I am a healthy 60 year female and my speech is fine. But my nose has never been right and until I read your writings on my problem I did not realize that it is a cartilage memory problem. This seems like it might be a magical solution and I hope you are the magician.

A: Correction of the cleft nose is a particularly challenging rhinoplasty procedure as the anatomy is far from normal. Such a nose appears deviated or twisted from the nasal bones down to the tip. The tip is most noteworthy as it is usually bulbous with thicker skin and deviated towards the non-clefted side. Part of this is due to the twisted septum internally which swings away towards the normal side pulling the tip with it. Trying to correct can be difficult and this where the role of cartilage memory comes into play. But the other major component is the nostril on the cleft side. It is deformed because it has a lack of adequate tissue support. The lower alar cartilage is slumped as it is weak and lacks the amount of cartilage on the other side. In addition the skin is deficient further contributing to the shape distortion. (which also makes it difficult to get a shape like the opposite side)

I will assume you have had some prior rhinoplasty work, perhaps years ago, and substantial efforts were made in the tip area. In my rhinoplasty experience, the cleft tip needs considerable support added including a columellar strut, spreader graft on the cleft side and an alar rim and batten graft above the cleft nostril.

If only improving the nostril shape to correct the amount of nostril retraction/asymmetry, I would just do a composite ear cartilage-skin graft to roll down the retracted nostril edge.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw angle reduction surgery last year. I told the surgeon I wanted my jaw slightly slimmer, but I said I wanted to keep the same shape and definition of my jaw.  However, there does not seem to be any difference in the width of my jaw, but unfortunately my jaw angle slopes now, whereas before I had a nice defined jaw angle. I didn’t want to lose the jaw angle, just some of the width. From the front I look basically the same, although I had been hoping for a slightly slimmer lower face, but from the side and 3/4 view of my face, I have lost my nice jaw angle definition, which was what I wanted to keep. Was what I was requesting impossible? Thank you in advance for any insight you can provide. 

A: I can not tell you whether what you were asking was impossible as I have no idea what your face looked like before your surgery or looked like now. But I can give you some insight about jaw angle reduction. There are two basic techniques and they are done differently. Width reduction of the jaw angle is done by removing the outer cortex of the bone, either by a split osteotomy or burring reduction. Amputation of the jaw angle removes the tip of it, which make reduce width but will also shorten it vertically as well. What technique you had done is unknown to me but it sounds from the result that it may have been more of an amputation approach.

Whatever the jaw angle reduction technique that is decided on before surgery, it is first necessary to see an x-ray of the jaw angles to see how much flare they have and its thickness. That information will help determine if the procedure, regardless of the proper technique, actually has a chance to make a visible difference. This would be of particular importance in the width reduction jaw angle approach as the thickness of the bone determines whether enough can be removed to justify the effort.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in rhinoplasty but think I may need more.  I’m trying to find a way to make my side profile look nice and pretty. I hate my nose as its quite large and has a small bump on it therefore I really want rhinoplasty. I also have a small slanted forehead and small chin so it looks like my face goes into a point at my nose. What would be best to change this? Please help, many thanks.

A: By your description, your three main side profile features have an imbalance. Your nose is too big and the forehead and chin is too small, creating the profile that you dislike. In trying to figure out what procedures you may need that creates the best change, it would be important to do some computer imaging. The procedures of rhinoplasty and chin and forehead augmentation must be looked at individually as well as in comboantion to see which creates the best change. It probably goes without saying that all three create the greatest profile improvement  but do you really need them all. I suspect that the rhinoplasty and chin augmentation alone may be sufficient and produce the best return on the effort but that remains to be proven by the imaging predictions. Please send me a side profile picture at your convenience to help you make that determination.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in facial reshaping. I am a 27 year old Asian-American female who, through some weight gain and with late puberty, have developed to me what is a foreign look which has caused me great distress. My objective with plastic surgery is to look all-American. I want a natural look, I don’t want it to look like I got plastic surgery at all. I noticed that my eyes grew higher on my head and slightly closer together. I grew a slight bump on my nose and my cheekbones grew flatter and higher on my head.  I have gained weight intentionally to fill out of my face because I felt I looked too hollow. The changes have been about a mm but it bothers me considerably. I feel like I am in someone else’s face and it has changed my life for the worse. I am attaching some photos of the way I look now as well as a couple of photos of the way I looked before when I was in college. I am also attaching photos of how generally how I want to look. The biggest objective is that I want to look American, because I am. I am thinking of having my eyes and cheekbones literally moved lower and wider to give it a feminine and youthful look. I have noticed that male to female surgeries don’t look believable if the distance is still too long between the eyes and mouth.  Please let me know what procedures you recommend.  I am thinking of cheek implants, nose job, and eyelid surgery too? I really need plastic surgery for the life I want to live.

A: I would to make a few general comments about your facial surgery objectives. First you are going to need to set some realistic objectives. There is no plastic surgery that is going to make you look ‘All-American’. You have Asian features, and while there may be some room for softening, you are always going to look Asian. Secondly, you have thick tissues and thick skin. Every American female face pictures that you have shown has much thinner skin and softer features due to a completely different facial bone structure.. While I realize those may be examples, I do not want you to think your facial features can ever be as refined as theirs…you simply have different tissue thickness which only allow for some moderate changes at best.

While there is some facial changes that can be done, those have to be understood in the context of what may be achievable. This issue up front is more more important than what procedures to do…for within lies the key element of whether any patient will be happy after their plastic surgery operation. Some facial reshaping changes can be made but they will not have a facial transformation effect. They will only improve upon the basic appearance of your face.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, My concern is my facial asymmetry. My one side of my face did not develop normally, my left eye sets lower than the right.  Also my left cheek bone is under developed.  I want to know if it can be corrected. I have attached some pictures so you can see what I mean by one side of my face being different than the other.

A: Thank you for sending your pictures. You have a left-sided form of facial asymmetry due to some underdevelopment of various facial structures. This is probably a minor variant of hemifacial microsomia. I can see in looking at your pictures you have some orbital dystopia (lower eye socket) with malar (cheekbone) hypoplasia as well as some chin asymmetry. (shift towards the underdeveloped left side) The best treatment approach would be orbital floor augmentation, medial z-plasty canthoplasty, cheek augmentation and a chin straightening genioplasty. But probably what bothers you the most is the cheek-eye area which is what you see and look at the most.

I believe the eye and cheek area could be significantly improved but I wouldn’t use the term ‘correction’ as that implies they could be made perfectly normal which they can’t can’t. It is just a question of how close to normal can they be made.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considered having an armlift for my bat wings. I have looked at a lot of scars from that surgery and most of them are underwhelming. I hate my batwings but am worried that I might hate the scar to remove them just as much. Some of the armlift scars seem to be quite long, often crossing the elbow and down past the armpit. Does every armlift scar have to be that long? Do you have any pictures of really good looking armlift scars?

A: The length of the arm lift scar can be shortened or lengthened as the patient desires although, in some cases, that may affect how much improvement is seen. It is also important to understand that with varying degrees of bat wing problems the skin excess may cross the shoulder and elbow joint areas, particularly in the bariatric or massive weight loss patient.

When it comes to the scar for the armlift, one has to approach it as the worst case scenario..as you never know in anyone how well it would do. In looking at our people’s photographs, one has to understand that is them and may not signify at all what may happen in you. Even if you saw a great arm lift scar on another person, that should not be the motivation to undergo the surgery…as you are banking on that will happen in you. You should make your decision for surgery based on ‘typical’ or ‘average’ results, not the best that has happened. If you look at an airlift scar and think it looks terrible, then this surgery is not for you. If you look at an arm lift scar, wish it looked better than that but still think that trade-off is better than having batwings, then it is a good operation for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a full breast reduction when I was a later teenager. I am now 36 years old) Now that I am older and with time my remaining breast tissue has fallen and is saggy. I would like to now have a breast lift to reshape them and give them more of a perky appearance. My original plastic surgeon has since retired and office records are no longer available. One plastic surgeon I consulted with said he said he would be worried about doing a second lift after the reduction. I have read from other plastic surgeons that a lift with a small implant is safe and will help. Is this a worrisome procedure after having a reduction? I would be open to a small implant but ideally would like to be the same size, just rounder. I’d love to be able to go bra less. Is this possible?

A: It is not rare to have a breast reduction done when someone is young that wants augmentation or a lift many years laters. It is perfectly safe to do a breast lift now using the same scars from the original breast reduction. The blood supply to the nipple through the central breast tissue pedicle will be undisturbed. It would be similarly safe to place an implant under the muscle which is beneath the overlying breast tissue mound. The role of the implant is to maintain upper pole fullness which a breast lift long-term will not do.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation/reconstruction for a congenital skull deformity. In terms of using cement on my forehead, by how much can we get an additional thickness there, i.e. what distance can we add to the flatness/deficiency? Why is it cement (on the forehead)  instead of a prefabricated implant? I have a very rough terrain of the forehead. In our opinion the implant’s inner side would hide all the problems beneath, but the cement treatment might be not creating a proper elliptical smoothness unlike an implant should do. Correct us please if we are wrong, it is just to dispel our concerns.

A: The amount of expansion of any skull bone surface is based exclusively on how much the overlying scalp will stretch. How much the scalp can stretch is a function of many factors, including scar from prior surgery and an innate ‘looseness’ factor. As a general statement, skull expansion can achieve up to 25mm in thickness if a full coronal incision is used for access.

Forehead augmentation/reconstruction can be done very successfully, using either intraoperatively applied bone cements or prefabricated implants. One is not necessarily better than the other. A bone cement is an intraoperatively made putty froml iquid and powder components. It is applied as a putty to the bone surface and then shaped by hand to whatever external shape is needed. It has an intimate connection to every nook and cranny of the irregular bone surface as its outer surface is shaped into a smooth round/elliptical shape. Bone cements can be either of PMMA (acrylic) or hydroxyapatite (HA) compositions. Most large volume bone cement cranioplasties use PMMA due to its lower cost. A prefabricated skull/forehead implant is made from the patient’s 3D CT scan using computer designing software for its creation. It is then fabricated in a silicone material for implantation. It too will have a good fit to the underlying bone surface and an external shape of whatever is so designed. It is the costliest of all the alternatives due to the design process.

In short, your perception of the differences between a bone cement and prefabricated implant is not accurate. They are just different ways to get to the same place. They differ primarily, however, in the cost to do them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in perioral mound liposuction. I have a problem with fat pockets around the corners of the mouth. I’ve had buccal fat pad removal before, but it did not help at the right area. I also have some fat along my jaw line that I do not like. Do you think it is possible to perform microliposuction at those areas? And how drastic will the result be? Are there any complications with this surgery? Have you done this surgery many times?

A: I am not surprised that a buccal lumpectomy do not affect your area of concern as the large buccal fat pad or any of its arms does not extend downward toward the corner of the mouth and jawline. This area, as you have correctly pointed out, is known as the perioral mound area which is a subcutaneous layer of fat. (not like a well defined fat capsule like the buccal fat pad) I have done perioral mound liposuction numerous times. It is done with a very small cannula from a small incision inside the corners of the mouth. As there are no facial nerve branches in this area, one can aggressively liposuction it. It never produces a large amount of fat and often only a few ccd is obtained, but in the right patient, that can make for a noticeable thinning effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have an indented lower end of my sternum, I think it is called pectus excavatum. I have read about implants to fix but I don’t want a scar on my chest to put it in nor do I ever want any problems with an implant down the road. I was wondering if I was a good candidate for an injectable method of pectus excavatum repair. That seems perfect to me for my chest problem. I have attached some pictures.

A: Thank you for sending your pictures. You have a very discrete lower tail of the sternal depression or a limited pectus excavatum deformity.  It’s size and location is deal for an injectable form of pectus excavatum repair or sternal augmentation, the question is one of which material to use. The options include your own fat, hydroxyapatite granules or an hydroxyapatite cement. Having used all three for an injectable sternoplasty approach, I would opt for hydroxyapatite granules or fat. While I love injectable fat (and yes even you as a thin guy have enough to harvest) as it is both natural and will never created an abnormal contour problem, it is very prone to partial or complete resorption due to the tight attachment of the sternal tissues. The pressure of the tight overlying skin is the cause of fat atrophy/resorption. How much of the fat will take can not be precisely predicted before surgery. Hydroxyapatite granules can be injected, are very moldable (as they are granules), will not resorb, and have low risk of any contour/shape issue. Any of the bone cements (composed of hydroxyapatite) are great space fillers and are permanent but are very prone to being overfilled or having an irregular shape (as they set as a hard mass), thus requiring a revisional procedure for adjustment should that occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in minor skull reshaping. I would to have a point or bump at the crown of my head reduced. From what I have read, it is does not appear too big (tall) that it could not be adequately reduced based on the thickness of the skull bone. I have attached a front and side view picture of it. Now that I have lost my hair, what used to not be an issue has become one.

A: Thank you for sending your pictures. Your crown ‘point’ is very obvious and I have seen this very skull issue numerous times. Usually this can very successfully be burred down to be confluent with the surrounding skull contour. But because it is in the midline over the vertex of the skull it would be important before surgery to check a simple x-ray to determine the thickness of the skull in this area. I have seen a few times in taking this area down that the bone becomes quite thin and the dural lining of the brain is close by. While this is not dangerous, it would be important to know beforehand if an adequate reduction can be done so that the surgical effort would have been worth it. Also, as is the case in every male with elective or non-elective lack of hair, is the issue of the fine line scar to do the procedure. That small aesthetic trade-off must always be carefully considered.

Dr. Barry Eppley

Indianapolis, Indiana