Your Questions

Q: Dr. Eppley, I had scar revision on my knee area. The surgery helped my scar to look thinner but there is still this image of a straight line cut. I had my operation last September 5, 2012. I am planning to undergo laser treatment for my scar. Can I have it done by December of same year?

A: While you certainly can treat your scar revision by laser resurfacing in the early months after a scar revision, I would not expect it to change how it looks. (like a residual straight line cut) Laser resurfacing is almost always perceived as if it is a ‘magic eraser’ but that is not how it works at all. Lasers do not have the capability to wipe away scars and often are overused and overhyped.

A scar, no matter how thin, is a full-thickness layer (most of the time) of abnormal tissue that is largely white and unpigmented tissue. Laser resurfacing removes a layer of the top of the scar but doing so will only reveal more of the scar. Only in the most superficial of scars can laser resurfacing reveal more normal underlying dermis which then can re-epithelize. Thus in full-thickness scars no improvement will be seen. And after surgical scar excision, your scar is most certainly full-thickness.

Dr. Barry Eppley

Indianapolis,Indiana

Q: Dr. Eppley, I am a 24 year-old guy looking out for skull reduction surgery. I have very wide skull especially above ears, also muscle over the portion is so hard and overdeveloped it is creating very absurd symmetry. I don’t want to have Botox reduction as it is temporary solution hence looking for permanent solution through reduction surgery. Can you please tell me is it possible to reduced muscle to large extent? Also I want skull side to be reduced to some extent. I am looking for narrow skull with vertical indentation. I feel very upset and depressed because of this. Please advise me as soon as possible. Really looking forward for your help.

A: You are correct in assuming that the full area above your ears is as much temporalis muscle as it is bone. Temporal bones are often quite thin so even though they may protrude they can not be reduced very much, usually no more than a few millimeters Muscle reduction is the primary tissue to reduce for narrowing/thinning. Reducing the temporalis muscle is a combination of muscle release and muscle resection. The temporalis muscle is a very large fan-shaped muscle that  extends from above the zygomatic arch up to thue anterior temporal line at the top of the skull as well as back to the occipital region. To do temporalis muscle reduction, the enture muscle is released from its origins for the lateral orbit up and across the skull. A central wedge of kmuscle is then taken. Much of the reduction ultimately comes from the contraction and atrophy of the muscle which can take up to six months after surgery to be fully realized. Because it is a muscle of mastication and inserts into the lower jaw, expect some temporart restriction and soreness with mouth opening after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had chin and cheek computer imaging done to show me what the effects of this surgery would be on my face. I notice in looking at the images that there is some asymmetry with one side being different than the other. Is this what I can expect from the outcome of the surgery?

A: There are some basic concepts of computer imaging in plastic surgery that are important for every patient who undergoes it for any procedure to understand. First, the quality of computer imaging is only as good as that of the original pictures. In your case, you provided the pictures which were not of great quality.  (slightly blurry and out of focus) When these pictures are magnified for imaging, the quality is not good enough to create very good detail. Second, computer imaging is designed to serve as a method of  communication so the patient and the surgeon can see if they are on the same page, it is not intended to be an exact replica or a guarantee of the result. Contrary to popular perception, there is no computer that does the imaging. It may be done on the computer but ultimately it is the hand of the operator (often using Photoshop) that is creating what he/she thinks the effects will be from the surgery. That is the reason it is called ‘computer prediction imaging’…it is a prediction not an assured result. Third and most important, Plastic Surgery is not Photoshop. The body does not respond to trauma and healing like pixels do on a computer screen.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, does the mandibular angle implant bond to the bone through time?  Or is it just the screws that hold it in place for the rest of my life?

A: There is no synthetic facial implant materials that truly bond to the bone in the truest sense of the word. Bonding denotes an actual bone ingrowth and attachment to the underlying bone without the interface of scar, much like a dental implant where bone bonds directly to the metal. That does not happen with either silicone or Medpor materials.

What does ultimately stabilize and maintain a facial implant into a secure position is the development of a surrounding layer of scar known as a capsule. This takes several months to form a solid capsule around the implant. So the primary purpose of implant screw fixation is to maintain the desired position until a good capsule forms. Medpor material does develop a more robust capsule formation than silicone but early implant stability can only be completely assured by screw fixation as that still takes time to develop. Medpor material also has a much higher frictional resistance (which is also why it is much harder to insert and usually needs bigger incisions) so this may help a little with early implant stability. But that is not enough for me to rely exclusively on this material property. Silicone has little frictional resistance and pocket development alone does not provide assurance that implant migration/mobility will not happen after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a large bump on my forehead that has bothered me all my life. I am a 25 year-old man and this kind of gives me a ‘horned’ appearance. What are my options for getting rid of it? I have attached some pictures from different angles and it becomes really prominent when I raise my eyebrows and put wrinkles on my forehead.

A: Thank you for sending all your photos. The involved forehead area is quote distinct and, interestingly, does not allow any wrinkles to form across it. I suspect that is from the effect of pressure where the overlying forehead tissues are being pushed out more. The cause of this forehead ‘bump’ most likely is just a thicker area of forehead bone but I would always confirm that with a simple lateral skull x-ray before operating on it for burring reduction. This bump is moderately large so the issue is one of surgical access. I would definitely not make a hairline (pretrichial incision) because your hairline, like most males, does not appear stable for the long-term. The endoscopic approach could work but that also placed a sagittal (vertical) incision behind the hairline, that once again, may not prove stable. I think the best and most direct approach would be to use a horizontal forehead wrinkle line. This would also provide access to get the greatest amount of assured bony reduction which is obviously the intent of the operation. This form of frontal skull reshaping is actually very simple with minimal recovery, it is just all about how to get in to do it and where to ideally place an incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a gummy smile. I would like to see what options are out there to correct this issue. I have attached pictures of me smiling and not smiling for you to see how much gummy smile I have.

A: Thank you for sending your pictures. The first thing I can say is that you are not a candidate for any bone surgery (maxillary impaction) for your gummy smile (thank heavens) as one has to have lip incompetence at rest…which you do not. Therefore, any effort for improvement in your gummy smile has to be directed towards soft tissue management. While there are internal soft tissue lengthening procedures which will have long-term benefits, your long upper lip (skin between your nose and upper lip) poses some concerns. One has to be careful that you don’t fix the gummy smile but then also lengthen the upper lip. (may not be a good trade-off) The good news is that there is a test before doing the procedure to see how the result of the surgery might work. That is Botox. A few units of Botox (generally 2 – 4 units per side) on each side of the nose will simulate the effects of a muscle release and mucosal lengthening. if you like the result of the Botox injections, you can just continue with the Botox (much less units and cost than the typical injection sessions done in the forehead which are usually 20 to 30 units) or then proceed for the surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had buccal fat removal upon the misleading instruction of a doctor . Now my cheeks look sunken and dented. After reading your article “Contemporary Cheek Enhancement – Malar and Submalar Zone Considerations”, I have the following questions which are consistently suffering me.:

1. Will the removal of buccal fat pad lead to great fat loss (lipoatrophy)? e.g. due to loss of the supporting fat. I just found myself look like dying.

2. I guess the doctor just removed the whole fat pad, which was not told to me. May I know if there are any suggestions for repair with the least potential risks? I consider fat grafting, but it seems so unpredictable. Do fillers like Juvederm or Artefill work in my case?

I will move US next year and I think surgeons of US are better. Wish you can save me out of this. Thanks a million for your great help!

A: Buccal fat removal can be beneficial for facial reshaping in the properly selected patient, such as someone with a very thick and round face with full tissues. But in the wrong type of patient or if too aggressively done it can result in a gaunt overresected look. I suspect by your description you fit into the latter category. In answer to your questions:

1) I do not know how far out from surgery you are. But if you are six months or more after surgery, the result you see is likely stable. The degree of surgically-induced ‘lipoatrophy’ that you see could be worsened with additional weight loss or further facial fat loss with progressive aging. Whether this occurs or not depends on your facial type.

2)  Synthetic injectable fillers is certainly a simple albeit a short-term fix. I would not rule out injectable fat grafting. Its volume retention results may be unpredictable but the cheek  is one of the best areas on the face for fat transplant survival. Other options include submalar implants placed intraorally and even dermal-fat grafts placed through a limited facelift incision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am very excited about my upcoming breast augmentation procedure. I am sending you some photos of the breasts in which I DO like and some in which I DONT~ let me know your thoughts when you get the chance. I want a round high full look but I don’t want the implants to go too far to the sides and I don’t ant a big gap between my breasts.

A: As I mentioned during our consult and as a general breast augmentation comment, breast implants mainly accentuate or magnify the exiting anatomy (positive or negative) of one’s natural breasts. The most perfect breast augmentation results typically occur in those women who have good breast anatomy  to work with, albeit smaller than they want. (good breast skin with the existing mounds high up on the chest, spaced close together and with the nipples centered on the mounds pointed straight forward) You have three ‘negatives’ that must be understood/managed in trying to reach the best result possible, moderate breast sagging, low and outwardly pointing nipples and widely spaced breast mounds.

The spacing between the breast mounds and a high very round upper pole look is purely related to volume and projection of the implant. While we had discussed 375cc high projection silicone  gel implants, your desired pictures suggest that more volume than that would be needed to expand the mound properly. If all we do is use implant volume to mainly expand the upper and inner poles, the nipple position will be driven further down which will not be completely negated by the nipple lifts. Therefore I think a slightly higeher volume like 435cc will be needed. Also although the nipple lifts will help, they will not end up perfectly centered on the mounds without a vertical breast lift…which I would not do in you for scar concerns. Any persistent or undesired low nipple position can be managed by a secondary additional nipplel ift down the road if desired when the tissues have relaxed and more upward movement may again be possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for an experienced surgeon to preform gynecomastia surgery. I have hard tissue build up under the nipples caused from weight lifting supplements. I have a muscular body but I am self conscious about taking my shirt off and people staring at my nipples.

A: Supplement-induced gynecomastia is an increasingly common type of gynecomastia that I see. The patient type is very typical having a fairly lean and more athletic type body with the localized development of hard nodules underneath and around the nipples. It is a very glandular-type restricted mainly to under and around the areolas. While it may feel small, it can be quite surprising as to the actual size of the masses when they are removed. (often being 2 to 3X bigger than what they feel like) Because of the firm tissue quality, these areolar gynecomastias are best removed through a lower areolar incision. Peripheral liposuction is rarely needed and direct excision of all hard tissue back to normal soft fatty tissue is done. Drains may or may not be used depending on the size of the excision. A chest compression wrap is important should be worn for up to two weeks after surgery. It would be important to avoid strenuous chest exercises/lifting for 3 to 4 weeks after surgery to prevent a fluid build-up which can convert to scar tissue creating a partial return of a mass effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had silicone 4.5mm Malar implants place 9 years ago. I have never been happy with the implant look after placement due to their large size but have been scared of the unpredictable result if they were removed. (i.e. facial sagging) Unfortunately I developed an infection due to a facial injury and need them removed. I am wondering if you could tell me if preforming a soft tissue suspension typically works in these circumstances and how long (days/weeks) does a soft tissue suspension takes to “set” per say. Also is there anything that can be worn on the outside of the face to help hold the tissie up while its healing ie tape or a surgical mask? Thank you for your time answering my questions.

A: Because a cheek implant (actually any implant in the body) creates a circumferential capsular lining which is very smooth and avascular, implant removal leaves two sides of the smooth capsule to collapse together. Because of the soft tissue expansion caused by the implant and the fact the cheek bone is like a rock ledge on the side of a cliff, removal of the implants has the definite potential for the outer cheek tissue to slide down off the cheekbone as the smooth surfaces of the capsule will not stick together, resulting in post-implant removal cheek sagging. Whether this is a significant risk for any cheek implant removal patient depends on numerous factors such as the size of the original implant, the prominence/angle of the cheekbone and the existing quality and looseness of the overlying cheek soft tissues.

To prevent or manage the risk of cheek sagging after implant removal, there are various strategies. One intraoral approach is to either suture the two sides of the implant capsule together with some permanent sutures (sliding the outer cheek tissue up as high on the bone as possible) or to replace the implant with the Endotine cheek lift device to provide uplifting support. Extraoral or external strategies can be done with either a transcutaneous lower eyelid approach to cheek soft tissue suspension or en endoscopic temporal or scalp approach to elevating the cheek tissues. Which approach is based would be based on the degree of cheek soft tissue sagging a patient has. If it is a pure preventative approach then use either of the intraoral technques. If cheek sagging is evident even with cheek implants in place, then an external approach would produce a better result with cheek implant removal.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am 26 years old and have a really flat area at the back of my head. I am very self-conscious about this since I was 18.I want to kill myself to get rid of this pain. You would be my last hope. Please let me know if there is any way that I can fix this for a cosmetic purpose. Can something be implanted at the back of my head? I have attached a picture with my hair wet so you can see what is bothering me.

A: Having a flat back of the head is an aesthetic issue, not a problem that causes pain. While skull expansion can be done, I would nto expect it to emotional pain about the deformity but not actual physical pain. The key about building up the back of the head (occipital cranioplasty) is knowing the exact location where you want the skull expanded and a realistic assessment of how much expansion can be achieved. The limiting factor in skull expansion is always how much stretching of the scalp skin can be done. To some degree that is partially controlled by how much of a scalp incision a patient is willing to allow to be done. I have done some initial estimation of a result (attached imaging) although I am not clear where you see the need for the exact location of the correction of the flat back of the head. This imaging is just an initiation for further discussion about what you want to achieve.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 29 year old female that received liposuction in 2009 to the outer and inner thigh area because of stubborn fat that was left after a weight loss.. Immediately afterwards I had “banana rolls” or a double butt line that has gotten worse throughout the years. Plastic surgeons in my area said I would most likely need an incision to fix the problem but did not feel comfortable performing that sort of procedure. This deformity has prevented me from feeling confident. No matter how much I exercise the line stays the same. I cannot wear shorts, or a bikini bottom for that matter, and even jeans don’t fit properly anymore. I hide my backside from my boyfriend constantly. Your website gave me hope that the problem could one day be fixed. This would give me back the confidence I once did. Thank you for your time.

A: There is a difference between a double butt line and a true banana roll deformity. It is a matter of how much loose skin exists along the infragluteal crease. A banana roll has a skin overhang of varying degrees with an indistinct lower gluteal crease. It can only be treated by a skin excision and tuck, known as a lower buttock lift. A double butt line is a skin indentation, not necessarily a skin excess issue. It could be treated by either skin excision or fat injection, although the skin excision would be more effective. I would like to see a side profile view of your buttock to have a better idea of the buttock profile and the depth of the indentation.

A decision to do a corrective buttock lift is about accepting the aesthetic trade-off of a fine line scar instead of a double butt line. Either one is not perfect and it is just a choice of which one thinks looks better.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in seeing what the jaw angle implants could do, as I feel that I have very little definition of my jawbone (it’s almost just a continuation of my neck). I would especially be interested in seeing what some width (towards the back of my jaw) could do. I would like to have my overall look be feminine and not too harsh. I am really happy with the imaging results for my nose and chin. Would the jaw implants be a continuation of the chin implant or separate? Does it sit directly on the jawbone, or can you feel from touching the face that it’s an “implant”? I’m assuming the results would be permanent as well, and wouldn’t need to be replaced. Thanks so much for your time.

A: Jaw angle implants had width to the back part of the jaw over the masseter muscle area.  The implants sit under the muscle on the bone. Because the tissues are quite thick in this area, it is not possible to really feel jaw angle implants from the outside. Like other facial implants, they are permanent. They are separate implants from that of the chin, unless custom implants are made to create one smooth continuous jawline from one side to the other. (I do not feel you need this approach) The key to jaw angle implants in most females is to not overdo the width. Most women don’t need more than 3 to 5mms width expansion to have improvement but still keep a feminine facial appearance.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m a 21 year-old female with a frontal bone that is raised higher than the parietal bone in my skull which appears to be flat. I’ve developed really bad anxiety over the issue and refuse to wear my hair in any other hairstyle than a bun on top of my head to conceal my odd head shape. I have also developed really intense habits over the years which include examining my head side on in mirrors up to twenty times a day, taking photos of my head regularly, and constantly touching my head and I really wish to be rid of this paranoia and live my life without worrying about what my head looks like. I’ve considered looking in to getting some form of implant inserted over the parietal bone on my skull to raise it higher than the front region and I was wondering how much this procedure would cost, what risks are involved with this procedure, and what materials are used as a form of implant and do they pose a risk of rupturing? Thank you in advance for your help, I really appreciate it.

A: Skull augmentation of the parietal/occipital bone can be easily done. Please send me a few of the pictures you have taken so I can see exactly the area and how much augmentation needs to be done.  This is skull augmentation surgery done with materials like PMMA and hydroxypatite bone cement that are placed and molded on top of the deficient bone area. These materials are solid and will never rupture or become displaced. It is actually a very straightforward procedure and it is just a matter of getting the right volume in the right area to create the desired effect. It does require a incision somewhere on the scalp to achieve it but for women with good hair density this is never a scar problem. It is done as an outpatient procedure under general anesthesia. The recovery is very quick and you would be fully functional in just a few days.

Once i receive the photos so I can assess the problem, then we can provide a cost for the skull augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want more angularity to my face. I want high cheekbones, a stronger jaw, an enhanced chin, and possibly removing fat from around my mouth. Do you this will give me what I want? I have attached pictures so you can show me what this may look like after.

A:I have done some imaging on the photos you have sent. Your photos are not the best quality for imaging (poor resolution, fuzzy) but I think they will illustrate the point.

To improve your facial shape, I believe you have correctly identified the structures to consider changing. Your face is somewhat vertically short and lacks keys points of angular definition. From a chin standpoint, you need vertical lengthening as well as increased horizontal projection. Unless one uses a custom implant, the chin can only be lengthened by a sliding genioplasty, it can be brought forward at the same time. I am estimating that you need 7mms of vertical lengthening and up to 9mms of horizontal projection increase. You may also benefit from jaw angle augmentation but your pictures are not good enough to do useful imaging for that evaluation. You would also benefit my higher cheekbones using implants and some perioral liposuction to remove some fat around your mouth area. I Have attached some imaging of these potential results, keeping in mind the limited nature of the quality of the original photographs.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, the question is that I have a flat head. I mean the back of my head is very flat and it really bothers me so that I can’t have short hair. I look very funny or deformed if my hair is too short, what can I do about it? I went through your webside and saw a lot of people had the same problem and you answered their questions. But one thing if i do the surgery I dont care about the scar, but will the surgery effect my hair growth?

A: Skull reshaping surgery and the use of scalp or coronal incisions will not affect your hair growth. The scalp is incredibly thick, around 1.5 to 2 cms for many people. The hair follicles reside in the upper 5 – 7mms of the dermis of the skin and protrude just below it into the subcutaneous fat. They are easy to see and it is important in surgical technique to avoid injuring them. (no use of cautery in making the incision, meticulous skin closure)The point being is that there is a low of tissue between the bone work and where the hair follicles live. The only issue of any potential hair loss is right around the incision not anywhere elese.The issue, therefore, for any patient is acceptance of a scar from the incision not one of hair growth.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  my first pregnancy was one very big baby for my little body. My stomach was completely stretched out like a big balloon. It got so big at the top of my stomach that it fractured the end of my sternum. It now sticks out and I am told it is called the xiphoid bone. Whatever it is called it now sticks out a little but but what is really bothersome is tht it moves around. and hurts when I stretch too much or bend over. I want to get a tummy tuck and was wondering if this could be fixed at the same time. However while researching the topic I couldn’t find anywhere that the two can be done together. You seem to be very creative and innovative so I was wondering if you could repair/remove it while performing a tummy tuck?

A: Fracturing of the xiphoid process from a large pregnancy is not a common problem but it certainly can happen. The xiphoid process is a small stick of bone that is attached to the end of the sternum which can become outwardly fractured with a consistent mass effect from below. Just because you did not find a simultaneous xiphoid process excision and tummy tuck on the internet does not mean that it is not done and I am certain many plastic surgeons have done them. It is easily done during a tummy tuck because at the upper end of the rectus fascial plication (muscle repair) sits the end of the sternum. So removal of the loose xiphoid process is easily done as it is right there. This does not lengthen the recovery or cause any prolonged pain after a tummy tuck.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  my jaw is small, not much of a jaw line, and have a slight receding chin. Wondering if an implant could achieve a balanced/symmetrical look or if I should pursue Orthognathic Surgery. Interested in Rhinoplasty as well. How long would recovery time be? Would the implant be permanent?

A:In looking at your pictures, I see no evidence/reason to pursue orthognathic surgery. Such jaw surgery is only done when there is a major occlusal (bite) problem which I suspect you do not have. Your facial balance could be improved by chin implant augmentation only. Chin implants are permanent and will never need to be replaced. I have done some imaging of that result which is best seen in side profile. You may also benefit from jaw angle implants for increased lower facial width. But I will await your response to what a chin implant alone does for your jawline. From a nose standpoint, your tip and nostril area is larger the rest of your nose. (out of balance) A rhinoplasty that focuses on narrows the tip cartilages and nostrils with a slight dorsal reduction would make a better balanced nose. I have done some imaging of that potential result which is best seen in a front view.

I would anticipate that recovery, from a return to work and not obviously looking like you have had surgery, would be 7 to 10 days. It would take the final shape and form of the nose and chin up to 3 months after surgery to have subtle changes in swelling to resolve and to see the true final result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, when using diced cartilage graft for nose augmentation do you overgraft to compensate for potential resorption?  Did you use a columellar strut on your nasal augmentations and do you do anything for wide and flared nostrils? In some rib graft rhinoplasty results, the nose looks pinched. I have read that some doctors place two extra grafts on each side of  the nose giving the frontal view a very nice look to it. What are these grafts and how are they done? While I love the idea of diced cartilage mainly because there is less chance of warping, I am concerned that there would not be enough build up to achieve the height that I desire with this. In addition, my rib graft rhinoplasties that I see have a tip that is bulbous and not sharp. I would like a much pointier and defined tip. I feel like this is one of the biggest flaws I keep seeing over and over in the before and after results that I have seen on asian ethnicity patients. It seems as if the surgeons augmented the bridge and completely forgot the tip.

A: In answer to your questions:

1) In looking/suspecting the degree of augmentation that you want from your rhinoplasty, I would ‘overgraft’ as much as possible. The limiting factor in any augmentation rhinoplasty is what the skin will accomodate (how much can it be stretched) and how much recoil (deformational elastic limit) the skin will do. The thicker the skin, the greater the elastic recoil will be. (push back) This is what leads to resorption of cartilage more than any other factor.

2) Columellar struts are used in every augmentation rhinoplasty. The length of the columellar strut and its stiffness (thickness) depends on how much nasal tip lengthening is needed. Most non-Caucasian rhinoplasties need and get nostril narrowing as part of their rhinoplasty.

3) There is no question that whole rib grafts are going to give more of a push on the skin and resist recoil than any diced cartilage graft. Given the result you are showing, a whole rib graft would need to be used as that is pushing it to the limits of what the skin can tolerate. What you are referring to as ‘side grafts’ are known as lower alar rim grafts, sometimes called batten grafts. (although this is not technically correct) They are placed obliquely to the rib graft at the nasal tip. This adds expansion/fullness to the lower alar cartilages so that when the tip gets significcantly elevated, it is not like a tent pole sticking out of the top of the tent. (pinched look)

4) What you are seeing in the tip is more often a conservative approach to tip projection/stress, rather than ignoring the refinement of the tip area. You have to remember that when you significantly push the tip up in an open rhinoplasty, the tip skin over the graft has very little blood supply. There is a real risk of tip skin necrosis after surgery, a disastrous event in rhinoplasty. There are well documented cases of it happening and I have seen it with a bone graft many years ago. In your type of nose, the columella is very short. Once you push up the tip area with rib grafting, the open rhinoplasty incision must be closed. If the rib graft is too high, one can not close the columellar incision. Pulling the tip skin down pushes the partially devascularized nasal tip skin tight over the graft. This is where the risk of tip skin death is and the blood supply may get cut off. This is an important issue to recognize during surgery as a sharp point on the end of the rib graft, if the skin is too tight, will cause this problem to occur. It is far better to have a more rounded end of the rib graft and not too tight of columellar skin closure over it to avoid this nightmare of a problem. This is the likely biologic explanation for some of the nasal tip results you are seeing.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have found your website to be very helpful.  I was wondering if I could please make an inquiry on an important personal matter. My son is now 5 years old. He had a laceration in his scalp when he was 3, and the stitches were made by an emergency room doctor (not plastic surgeon). Attached please find several pictures of my son’s scar. Would a scar revision or hair transplant be viable options for us to consider for him? Any thoughts which you may have would be truly valued and appreciated!

A:  Your question about scars is the scalp is a common one. What makes scalp scars noticeable is the lack of any hair. Even slight scar widening in the scalp is noticeable because of the lack of hair. The question then becomes how best to get the scar area covered with hair. While hair transplants would seem like a logical approach, they are a secondary choice for most scalp scars. Hair transplants take very poorly into scar tissue so their success rate is very low. In extremely small scars, a strip hair transplant rather than single follicular units would be more successful because the poorly vascularized scar tissue is being removed. But the far simpler approach is to recruit normal scalp and hair tissue from around the scar. In other words, scar excision and scalp advancement and closure. The scalp can be mobilized significantly and most linear scalp scars should be approached in this way. Your son’s scar is a good example of where scar revision by excision would work well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 37 years old and although I still have a fairly young looking face, I am beginning to develop a few bothersome issues. I am beginning to get some marionette lines and the very beginnings of jowling. I have tried some injectable fillers to improve these issues and all they did was make my face look bottom heavy. I have read about mini-facelifts and jowl lifts which sound like more of what I need given the problem. What are the advantages/disadvantages of having this type of facelift at my age? I prefer to take a preventative approach and address issues before they become too big. But will starting early make me look unnatural?

A:  While the concept of a facelift historically seems inconceivable at your age, today’s facelifts are not your mother’s facelifts so to speak. Contemporary facial rejuvenation procedures, and facelifts in particular, are tailored to the magnitude of the problem rather than a standard cookie cutter approach. In essence, small early aging problems merit a more limited facelift, more advanced aging issues need a more complete and extensive facelift approach. Although you are young, appearance and need are more important criteria than a chronological number. There are numerous advantages to early intervention…everything is smaller from the scope of the surgery to recovery to cost. Early facelifts actually create a more natural look because the changes are less dramatic than when a facelift is done at an older age.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, what is the best way to correct skin discoloration above upper lip and to fix lines?

A: Both hyperpigmentation and vertical wrinkles line of the upper lip are challenging problems. There is no ‘one best way’ or one single method that will work for every women afflicted with these lip concerns.

Upper lip hyperpigmentation is common and it is important to be aware any known causes of it such as birth control pills and pregnancy. Topical bleaching creams, chemical peels and pulsed light therapies (BBL) are the most common methods we use. In many cases we have to try or use several of them to get a lightening effect.

Upper lip wrinkles can be by injectable fillers and fractional laser resurfacing. Injectable fillers is best for those that are present right at the vermilion-cutaneous (pink of lip with skin) border. Laser resurfacing is better for lip lines that go well above the vermilion-cutaneous border into the lip skin. In some cases, both methods can be used for lip augmentation and wrinkle reduction. It is best not to think of ‘fixing’ the lip lines since there is no permanent cure for them. They can be treated and reduced but never gotten rid of forever with any treatment. They are caused by the sphincteric action of the lips and, unless one is not planning to move their mouth again, they will eventually reform.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I researched and read many articles and visited many websites before I had my Bullhorn procedure performed. Unfortunately, I don’t believe my plastic surgeon had much experience with the procedure. At first he removed an eliptical piece of skin inside the nostril (“italian lip lift”) which did nothing to decrease the distance nor pout the lip. (my mouth is tiny, lips were thin and philtrum long)  Next about 5 months later, he did the bullhorn… he did not ever carefully review my anatomy, measure any important distances, nor did he take enough tissue… again, no improvement. Then, 4 months later (late August 2012) he performed the Bullhorn again and I had to inform him that the normal distance between the base and vermillion should be 5-7mm.. my result: right side of my lip droops… on the left the sutures were placed within the nostril, on the left they were not. also, i do not know what he did with the muscle.. I’ll have to get my op report. I know stiffness is expected, but what I don’t know is if I can smile at all. When I do, my smile seems to be distorted a bit.. but I know it’s early. I feel stitches deep and I don’t want to pull them. I would appreciate your feedback, I think I need a second post op opinion, but most doctors don’t want to become involved especially so soon after surgery. However, I am concerned because I also had a facelift with this doctor and I believe it was overcorrected.. can’t move my upper cheeks and have constant swelling and pain around my eyes. Very weird, almost like I can not squint!

A: It is hard to make much of a usual comment when I don’t have pictures to review. Nor do I know exactly what was done during your last procedure in which the more conventional lip lift or bullhorn procedure was performed. The aesthetic result would not be my main concern right now, I would be more focused on the lip tightness and the difficulty with smiling. These are not usual postoperative findings even in the early stage. I have seen too many upper lip lifts where deep sutures were placed into the muscle or even down at the bone level…which is a mistake and should be corrected early before too much scar tissue forms.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I’ve had two procedures done 20 yrs ago. I don’t know the name of the procedure but I had a large amount of gums showing when I used to smile. They cut my upper jaw and raised it up, so I didn’t have the “gummy” smile. I then had my chin moved forward 11mm. I believe I have some underlying scar tissue from my upper jaw surgery underneath my cheeks. When I smile, my cheeks stand out and my face looks disproportionate. Can this be improved? Also my chin is still somewhat horizontally short. Can it be moved further forward again?

A: Your original surgery was a LeFort I or maxillary impaction to shorten the upper jaw and a sliding genioplasty to move the chin forward. The fullness that you have/feel in your cheeks is not really scar tissue per se. It is due to the release of the facial tissues made during the vestibular incision for your maxillary osteotomy. This causes some of the tissues and their muscular attachments to retract out to the sides into the cheeks, creating increased cheek fullness and what I call a ‘LeFort Look’ which is classic. This has long been recognized and is why at the completion of the maxillary bone surgery the vestibular incision is closed in a V-Y fashion to restore the midfacial tissues position. At this point in time after surgery, these tissues can not be respositioned. It may be possible to remove some of the buccal fat pad to reduce this fullness.

From a chin standpoint, osseous genioplasties or chin osteotomes can be repeated. The only complicating factor could be the fixation hardware used to secure the bone from the original surgery. Whether it was wires or plates and screws, these devices often get covered by bone healing and can be difficult to remove, hence blocking a good bone cut. Depending upon the indwelling hardware, it may be preferable to consider an implant rather than a repeat osteotomy. Whether chin implant or osteotomy should now be done can be determined by a simple x-ray, like a panorex, so the type of hardware in place can be seen.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am considering getting liposuction on my stomach and waistline but am curious how do you know how much fat to remove. In fact, why don’t or can’t you take all the fat that is there? I don’t want to you can just take it all? I have been searching for answer to this question but have not been able to find it.

A: Your question is actually a common one and comes in different versions. Most liposuction patients usually say just before surgery…’take as much fat as you want’…or…’feel free to keep going until none is left’. The answer is while it is possible to take much of the fat from any given area, it is not possible to physically remove all of the fat by liposuction. The way the instruments work make this impossible. The reality is you would not want to remove all the fat even if you could. Fat plays an important role between the skin and the underlying tissues that does beyond its commonly perceived metabolic role. Without fat your skin would stick right down to muscle and bone and not move when you move. The skin would be tethered, contracted and very unattractive as well. Just ask any patient who has ever had skin grafting for burn injuries. While they have a healed wound, they suffer from a loss of normal skin elasticity and flexibility. It is also important in liposuction to leave an adequate amount of fat on the underside of the skin to prevent the cosmetic deformities of irregularities and indentations, in other words to get a smooth result. There is an old plastic surgery saying in liposuction which is just as true today as whenever it was originally said…’it is just as important what you leave behind as what you take in liposuction.’

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I am really considering butt augmentation (but I’m nervous).  I am a 33 year old women, who was born with one leg longer than the other and mild scoliosis.  It was no problem in the begining because it was barely noticeable.  Now, however, my shorter leg is much bigger than the longer leg, and it has caused my butt cheeks to be very uneven.  My guess is they were probably uneven all along, but now it’s very noticeable.  I can’t buy jeans or pants because they are either too big on the small side or too tight on the big side, and it makes my butt that much more noticeable.  Anyway, my left butt cheek is bigger (meaning its more round and it hangs down longer) than my right butt cheek.  Before I get this fat transfer done, is there anything else I can do on my own (maybe exercise) that will even my butt out, or is surgery my only option?  And, if surgery is my only option, will that also change as years go by, because I will always have one leg longer than the other, that causes one to be more dominant? Thanks for your time.

A: There are no exercises or any other non-surgical methods that will change your buttock size.

When it comes to buttock asymmetry, there are two obvious approaches…make the smaller side bigger or the bigger side smaller. The bigger method usually involves fat injections to the buttocks and the smaller method involves a lower buttock tuck with or without liposuction. I do not have enough information to tell you which is the more reliable approach. It is also possible that a combination of the two may give you the overall best result. I would have to see photographs of your buttocks to better answer that question.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a long-time reader of your blog and it has been a terrific resource over the years, so thanks for all the great work that you do!

I have a concern about the jaw angle implants I had placed about seven weeks ago. I wanted and thought I was getting Medpor “Angle of the Mandible Implants” with 5mm lateral projection and 10mm inferior projection but ended up with “RZ Mandibular Angle Implants” due to a major misunderstanding with my surgeon. The implants currently in place have a whopping 11mm of lateral projection and negligible drop-down. As you can see from my “after” photo, these implants extend well past my zygomatic arch, resulting in an “hourglass” shape that I don’t care for. My question is, if I swap out the implants I have for the implants I originally wanted, do you think (based on my “before” picture) that I will experience a similar version of the same problem–just on a smaller scale? In other words, do my high arches and thin skin doom me to that hourglass shape no matter what? My aesthetic goals are to 1) make my jawline flush with my arches and 2) achieve the drop-down effect available only with the “Angle of the Mandible Implants.”
Thank you so much for your time and consideration!

A: The current problem with your indwelling implants, besides the fact that they have too much lateral projection, is that they are malpositioned high up on the bone rather than wrapping around the lower border of the mandible. This then gives you closer to 15mms lateral projection because the implant is actually rotated 15 to 20 degrees of how it was intended to be positioned on the bone.

I think you can reach your goal by one of two implant approaches. A Medpor RZ style jaw angle implant is fine if it was the small 3mm lateral projection size. Or the Angle of the Mandible Implant (aka Ramus with inferior ridge) with 5mms lateral projection would also work. Both would need to be trimmed to fit but you need a surprising small amount of lateral projection to stay within your zygomatic arch width.

However, the use of these new implants will still create the same problem if they are not in proper position on the bone. Placing jaw angle implants that drop the angle vertically downward are technically difficult. All of the soft tissue must be released from the inferior border, including the tendinous attachment to the jaw angle, to allow the implant to sit in its intended position. Also, when jaw angle implants are placed at this level they are inherently unstable because they is never a precise implant to bone fit. (the shape of your jaw angle I can guarantee is different than the skull model from which the implants are made) This is why screw fixation is almost always needed to ensure proper implant positioning as half of the implant is not on bone.

The problem you have is one I see when the surgeon may be used to placing silicone jaw angle implants, none of which have designs to drop the jaw angle down. This is a much more simpler procedure which involves just sliding the implant along the bone surface, dropping it into place if you will. (this is why your implants look the way they do now)Placing vertically lengthening jaw angle implants is much more difficult to do and is further complicated by the frictional resistance of the Medpor material, further adding to the difficulty of the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 33 years old and  my cheeks are coming forward creating deep folds around mouth. I hate fillers as they don’t help, they make the cheeks look worse. I like the look of the cheeks slightly pulled back giving me a more youthful look. Is this something you could do on someone my age and how much would you charge to do this procedure. Thanks!

A: With aging, the soft tissues of the cheek do slide off of the bone and fall downward towards the mouth area. This is the source of the deepening nasolabial fold (lip-cheek groove), the cheeks tissues from above falling downward into the fixed tissues of the upper lip. The amount of falling tissue can be appreciated at the corners of the mouth where a roll of skin ends up hanging over the corner driving it downward creating a frowning effect. Some younger people have full cheek tissue that naturally sits lower but do not have a downturned corner of the mouth because the tissues are not really falling…yet. At the age of 33, I doubt if you have significant tissue falling or sagging and I will assume that this is really part of your natural facial anatomy.

A cheek or midface lift can lift these tissues and there are different versions of it. These include a traditional transcutaneous lower eyelid approach, a temporal endoscopic approach and a purely intraoral approach pinning the tissues up on the bone with a resorbable device. (endotine) The real question is how mobile your cheek tissues are and how much they can be lifted. At your young age, those cheek tissues may not be very mobile. That would be the determining factor in whether any form of a cheek lift would be aesthetically beneficial for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a mentalis muscle resuspension about 10 years ago. This was due to complications from a sliding genioplasty that made my chin huge, and a subsequent reduction a few years later. The suspension worked well but my lower gumline has slowly receded to the point where a few front teeth may be in jeopardy.Would dental implants affect the suspension in any way? It feels as if recently either my one tooth is infected or the suspension site has problems. Is it possible to redo the procedure if necessary? Also, would it be possible at this point to move the chin forward a bit due to some slack skin from the original procedures? Thank you for your time.

A: There are different types of mentalis muscle suspension procedures and I obviously don’t know which one you had done. Whether the suspension is the cause of your anterior mandibular gingival retraction I don’t know. But that issue aside, I see no reason that the teeth in jeopardy could not be removed and replaced by dental implants. The placement and soft tissue coverage around the implants would not negatively affect your prior suspension. It is always possible to redo your suspension at any time in the future. Moving the chin bone further forward (redoing your sliding genioplasty) would only help your soft tissue suspension effects as a whole new tightening of it would be done during that procedure.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley,  why is diced cartilage used in rhinoplasty? What is the risk of cartilage graft resorption in the nose? Does diced cartilage resorb less than regular cartilage? In using diced cartilage wrapped in surgicel, I keep coming upon studies showing that when compared to a patient’s fascia, it is much more often reabsorbed, at a much faster and greater rate. I would not like to use fascia just because I don’t feel it is 100% necessary in my case as well as avoiding another part of my body altered for this rhinoplasty. However, I am quite concerned about resorption of these diced cartilage grafts. What would you say would be your estimated percentage of resorption if it were to occur? Rib rhinoplasty is quite a major operation, I would not like to go through such a procedure with an additional scar on my body for an outcome that wasn’t dramatic or only to be reabsorbed down the line.

A: The concept of ‘dicing’ cartilage for rhinoplasty is to make it more malleable, eliminate warping (and the insertion of metal pins into solid grafts to try and avoid that problem) and to avoid excessive pressure on the overlying skin when solid graft is used. The cartilage graft is cut into small 1mm cubes and then placed into a collagen container. (sausage roll) This creates many tiny pores/channels into the graft that allow it to become very quickly revascularized and filled with collagen fibrous tissue which makes it become firm. Whether diced cartilage grafts or solid cartilage grafts have more or less resorption is a matter of debate and there is no clear science that demonstrates that one is necessarily better than the other when it comes to resorption resistance. In theory, the rapid revascularization and nourishing of the diced cartilage would lead to less resorption long-term. As the what causes a graft, of any source and tissue type, to resorb or not is how quickly it can re-establish nourishment. (blood supply) That being said, I have not seen significant resorption with either type of cartilage grafting in the nose.

There is largely one animal study that has created the spin-off of the negative use of Surgicel in diced cartilage grafts. Whether that translates to humans is speculation and has never been proven or shown. Certainly Surgicel is more convenient for the patient as it avoids a donor scalp scar. But when the patient will permit it and is accepting of a  temporal scalp scar, the use of one’s own fascia is always a more natural choice that will have less inflammatory response than that of an oxidized cellulose material. It would seem logical that less of an inflammatory response would lower the potential risk of some cartilage graft resorption.

Dr. Barry Eppley

Indianapolis, Indiana