Your Questions

Q:  Dr. Eppley, I have a very prominent fat pad (?) on the left side of my face.  I am 62 years of age and had a facelift eight years ago. I have a rather thin face which has lost with age some fat which I guess is expected. This lump has created a chipmunk effect like I have a big piece of bubblegum in my mouth all the time. What is the cause of this problem? Is it fat? What can be done about it? I have attached some pictures.

A: Thank you for sending your pictures. By your description and pictures, you have the classic findings of a ‘ptotic buccal fat pad’.  Underneath the cheek bone sits the large cheek or buccal fat pad. With age, and sometimes after a facelift, this large pad can fall downward as the space in which it normally lives becomes loose and it leaves where it normally sits. This buccal fat prolapses or herniates outward, falling down to the level of the perioral (corner of the mouth) region. Patients will describe it as a wad of tissue that is inside the lower end of their cheek.

That being said, the question is what to do with it. There are two approaches, removal or resuspension of the buccal fat pad. While in some cases I would recommend resuspension, that may lead to some facial asymmetry as where it needs to go above is already symmetric to the other side. (usually done only when the problem exists on both sides) Therefore, removal would seem most judicious in your case. That could be done by small cannula liposuction from a small incision inside the corner of the mouth.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, Over the last two and a half years, I have lost 225lbs naturally through better eating and exercising. I am now stable at this weight and in need of surgery to remove a lot of thet excess skin, specifically around my midsection and groin. I couldn’t be happier with where am I today, but know that I am still not myself with all this excess. While there is a lot of extra skin now, where do you recommend surgically to start the process of remaking this thinner but saggy body?

A: Thank you for your inquiry and congratulations on your weight, loss all on your own efforts. Not many people could have made that much progress and sustained it on their own. With that amount of weight loss comes the expected skin excess throughout the trunk region. This is a very common issue that I see, in both men and women, after bariatic surgery where this amount of weight loss is more typical. Your pictures shows that a circumferential lower body lift is a good place to start to remove a lot of this excess skin. Tightening the waistline and getting rid of most of the redundant skin and overhang is always a good starting point on the body makeover process. This is the largest surface area of skin to be removed and needs to be done first before any procedures are considered above or below this area.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am considering a chin implant and I also like to grow facial hair… My question is can or will a person lose hair follicles on the chin due to the incision/scar of to a chin implant? I am seriously considering a chin implant, but I do not want to have a spot on my chin where hair cannot grow any longer.

A: You are expressing an understandable concern that is fortunately not usually an issue. One of the unique aspects of chin implants in men is that the submental approach goes through skin with beard hair. If not properly handled, it is possible that one could be left with a more visible scar due to surrounding hair loss. Avoiding that submental male scar problem is done by the technique used. The initial incision in the skin is made with a scalpel and not cautery to avoid burning the skin and any hair follicle bulbs. The incision is made parallel to the direction of the hair growth as they emerge from the skin. This is why I wear loupe magnification to see this hair direction very carefully. Once through the skin a scalpel, not cautery, is used cut through the tissue all the way down to just above the chin bone. This is because the hair bulbs, which can clearly be seen, are on the very underside of the skin and are still subject to injury During skin closure, small bites are taken through the skin to avoid entrapment and any strangulation of the hair bulb in the loop of the suture being tied down.  With these techniques, my experience has been that submental scars from chin implants in males do not develop beard skin hair loss.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I would like to know if anything can be done to improve my arms scars. I have a history of being a ‘cutter’ but am now over that self-mutilating problem. I would like to put the reminders of this phase of my life behind me. I have sent you some pictures of the arm scars. The first picture is the left arm and the second is the right. I’ll look forward to hearing if there is anything that can be done to make these less noticeable. Thanks for your time.

A: Thank you for sending your pictures. Due to the large number of transverse scars on each arm, I see no significant improvement that could be obtained by any type of individual scar revision or laser resurfacing methods. Those approaches would be hopeless in your arm scar problem. In a few of these type extensive arm scar cases, I have done complete removal of the scarred forrearm segments and replacement it with a skin graft. This is a more radical approach, and replaces one scar problem for another, but at least the social stigmata of the visible scarred forearms is gone and may offer one a better social opportunity for explanation.That may be a satisfactory approach for the right patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have a facial asymmetry problem. Even though I know that everyone has a little asymmetry to their face, mine is not that little. It is quite visible. My cheek bone on the right is a little higher than that of the left. So is the eyeball area above it. I also don’t like my very bushy eyebrows and my left eyebrfow is lower than my right side. My left ear is lower than my right one and that makes it difficult to wear glasses or sunglasses comfortably. I am attaching a frontal picture for your assessment and recommendations. I am leaving this up to you as there seem to be few doctors that know how to treat facial asymmetry and because of your good reviews plus you can help me in all my problems.

A: Thank you for sending your picture and expressing your specific concerns. Your overall issue is one of facial asymmetry with the left orbito-maxillary region as a unit being lower on the left side. The lower positioned left ear would be part of that overall problem. As a general concept to gain better facial symmetry, the lower facial side has to be raised rather than trying to lower the higher side as that is surgically more possible.

With the objective of raising the left sided facial issue, I would make the following recommendations/thoughts. The left ear could be raised somewhat through suspension sutures from the cartilage to the fascia. A slight setback of its protrusion (sticking out) may be considered. This would be done through an incision on the back of the ear. A left eyebrow lift could be through an upper eyelid approach (transpalpebral browlift) which is the most common approach in men. I would remove a slight amount of left upper eyelid skin (blepharoplasty) which also serves as the access for the browlift. The lower eyelid marginj could be raised slightly on the outside with a lateral canthopexy/lid wedge excision. Raising the eyeball, even a few millimeters, can be difficult but a small orbital floor implant could be placed for a slight lifting effect. A small cheek implant would be used to provide some upper cheek fullness. Eyebrow waxing can be done to reduce fullness and are a good start to determine if their thinning is aesthetically advantageous. If so, you can then consider laser hair removal which is best done locally due to the need for a series of regularly spaced treatments to get some permanent reduction.

Although all of the individual surgeries are small in nature, they can collectively make a noticeable difference. All os this is said with the understanding that your facial asymmetry can be improved but a perfect match to the right side is not possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have 350 cc breast implants placed over the muscle. I have had implants for 25 years, with replacement from silicone to saline fifteen years ago due to rupture. This time the left side has deflated. I was desiring either the option of total explantation or downsizing. I had a consultation with a breast implant specialist that stated he would not downsize me but wanted to go to 425cc and would not downsize due to the compromise in results. He will either increase the size or perform a total explant. I am personally not interested in increasing my size at age 50 whatsoever but am wanting to go towards my baseline look as much as possible because this will be the last time I have implants when they need to be replaced in the future. Is there a way a compromise can be reached for a slightly smaller look? I have read cases where many people have downsized. I realize 350 cc is not large. I could accept the same size if there is no compromise. I don’t expect perfection and I realize that the result would be less than perfect and I can live with that. What is difficult about the idea of total explantation is the bagginess.

A: I would agree that total explantation would be an aesthetically difficult choice due to the resultant loose skin and breast sagging, not to mention the volume loss. While it is always better from an aesthetic outcome (pickup of loose skin) to go bigger in a breast implant exchange in older patients due to the skin expansion of loose skin, if that is not what the patient wants then it is not better. What the plastic surgeon was saying about downsizing was that there will be more skin sag (ptosis) afterwards if one goes smaller. While this is intuitively true, the real question is how significant it would really be at, let’s say, a 300cc implant which is roughly a 15% volume difference. I suspect that it would not cause a significant sagging change. Therefore, I see no reason why you could not go to 300cc or 325cc with a new implant. And you have already stated that you can live with a less than perfect result.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have facial asymmetry of which my left eye area is a big part of why it looks the way it does. I am interested in brow shaving and a canthopexy to improve the eye area. My biggest concern with orbital rim shaving would be losing frontal bossing over that orbital rim. Let me ask you if you have ever performed shaving of the orbital rims for the purpose of better balancing facial asymmetry?

Regarding chin implants. Given your extensive experience with these, especially in ideal jaw surgery candidates who refuse surgery (retrognathic lower jaw), I’d like to ask you if it’s a realistic possibility to recreate the appearance of a jaw when it is in a prognathic position, using a chin implant with wings? What I mean is when I slide my jaw as far forward as I can, creating what is dentally considered mandibular prognathism, I reallylike the aesthetic appearance it has on my jawline, probably because my jawline is retruded by default so when I manipulate my jaw into a prognathic position it actually just ends up looking relatively normal (with the exception of my lower teeth pushing my lower lip forward which is the only giveaway). Basically I’m asking if a chin implant with wings can provide anterior projection to the entire jawline, not only the forward most point of chin but also along the mandibular body of the jaw, bringing most of the jaw (except the mandibular angles) more forward relative to other parts of the face, like what happens when you push your jaw forward in your face.

Also another big question Ive always had about chin implants is how does the placement of a chin implant effects the lower lip? Do chin implants push the lower lip forward at all? And what about augmentation of the chin groove, can this be moved “forward” or augmented at all to avoid the formation of a huge indentation in the chin groove between the bottom lip and chin implant? As it would seem the larger the chin implant you use, the deeper this groove would become.

A:  In regards to orbital rim shaving is done through an upper eyelid incision, it removes the bottom portion of the orbital rim not its anterior projection. So there would be no risk of losing frontal bossing which is a horizontal brow feature. Inferior orbital rim shaving is done almost exclusively in cases of facial/brow asymmetry. There would be no other reason to do it. The result is subtle, not dramatic, and is in the range of 3 to 5mms depending upon the degree of superior orbital rim asymmetry.

If you are jutting your jaw forward and getting the desired look, then a chin implant with match that horizontal result. It may be a little thinner at the sides. The most ideal thing to do is to make a custom chin implant which would overcome that issue.

The lower lip never changes position no matter whagt is done to the chin. That can only change with an entire jaw advancement procedure. You are correct in that the labiomental groove will be come deeper as the chin position changes below it but the labiomental groove is not changes by an isolated chin procedure, implant or osteotomy. That can be overcome with a custom chin implant which builts up that area whereas a conventional chin implant does not.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I had a facelift several years ago that I am ok with the results in the jowls. However, it has resulted in my earlobes being pulled down which I believe is called a pixie ear deformity. My surgeon who did the facelift has died and a different doctor has attempted to fix the ears two years ago by putting a suture behind the ear and pulling them up. After a week when it healed the ears came right back down. Is there another way to fix the ears that is not too extreme? I have read your web site and I really hope that you can help me. Thank you.

A:  A pixie earlobe deformity results after a facelift because the tension on the lifted facial skin has not been properly anchored or supported. This results in elastic recoil of the skin, pulling downward over time on the non-cartilage supported earlobe. This results in it being stretched end elongated. When thinking about what the cause is, it should be no surprise that simple earlobe tuck or suture is destined to fail. The only real way to effectively treat the pixie earlobe is to re-raise the anterior skin flap or perform a more limited form of the original facelift, known as a tuck-up facelift. While it may sound extreme it is nothing like your original procedure and could be performed under local anesthesia. The skin flap needs to be lifted up in front of the ear again and raised up to cradle the earlobe. This will both shorten the earlobe and redistribute the skin forces better so that it does not recur.

Dr. Barry Eppley

Indianapolis, Indiana

Aging is inevitable and it begins to appear first around the eyes. While eyelid and brow lifts provide immediate and significant improvements, many would prefer to lessen these eye flaws without the costs and recovery of an operation.

There are a variety of non-surgical eye treatments combining neurotoxins, fillers, lasers devices and topical products. Which ones are used often follows the age of the person. Those in their 30s and 40s usually just need Botox to control their frowning and squinting wrinkles. Fillers and light and laser treatments are added for those in their 40s and 50s. At age 50 and beyond, surgery is needed to remove extra upper eyelid skin and lower eyelid bags. But these non-surgical treatments are still needed to preserve one’s surgical investment.

Botox is the most known name when it comes to facial wrinkle reduction by injection. But it is not alone as two other injection drugs, Dysport and Xeomin, are also available. While there are some that believe one is better than the other, they all are really comparable. They all take a few days to a week to start working and their effects will last from three to four months. One is not more powerful than the other nor does one cost less. These injections are given by the unit and the cost per unit varies for each one but so does how they are prepared. As such their treatment costs are all about the same.

While Botox is the most common non-surgical eye treatments, injectable fillers can also play a role. Many people will develop shadowing and tear troughs under the lower eyelid, sometimes as early as the late 30s. This can be treated with fillers to plump the area out. While they are over a dozen types of injectable fillers, the hyaluronic acid-based fillers (e.g., Restylane and Juvederm) are preferred. They can be delivered under the thin tissues of the lower eyelids with a low risk of lumps and irregularities.

While eye wrinkles can be held in check with Botox and fillers, they can not reverse certain skin problems. Blood vessels and brown spots can be removed with pulsed light treatments. These are often confused with lasers which they are not. When it comes to improving skin texture  and reducing fine lines and wrinkles, laser resurfacing can provide improvements beyond what an eyelid lift can do.

Topical skin care products complement eye the benefits of injectable and energy treatments. The skin around the eyes is so thin that it responds well to many Vitamin C, retinoid and antioxidant-containing products. A new topical product, Latisse, is great for thinning eyelashes and eyebrows and it works like nothing else. Eyelashes and eyebrows can become one-third longer and thicker in a few months.

While surgery may be needed or inevitable for some, younger and less tired looking eyes may be just a few injections or the wave of a laser wand away.

Dr. Barry Eppley

Indianapolis, Indiana

Without explanation, everyone seems to know what a neck wattle is. While not seen as an endearing neck ornament as one gets older,  this sagging piece of skin and fat is often a source of considerable anguish of one’s appearance.

The good news is that neck wattles can be successfully eliminated and usually much easier than one thinks. The trick is matching the proper solution for the size of the neck wattle. Some wattles are small, others are quite large. Different wattles need different approaches.

The two things that we know about neck contouring is what doesn’t work. There has yet to be a cream that has a real ‘neck rejuvenation’ effect. The winner in that transaction is always the seller of the magical potion. If there was a cream that could really change your neck, we would all know about it and it would cost thousands of dollars per jar. The other scam is that of neck exercises. If a neck wattle was really due to loose muscles, this approach might have some benefit. But it is loose skin and fat for which the ‘neck gym’ remains no better than those creams in a jar.

Getting rid of that neck wattle requires a necklift, also known as a facelift. There are different varieties of  these lower facial lifting procedures depending upon how the size of the wattle. Smaller or more limited versions are popularly known as Lifestyle Lifts. They are great for jowling but not for the bigger neck wattle. For a neck that hangs more, a full facelift is what is needed. It has a powerful change effect on making that neck more shapely and tucked up again.The difference between the two is the location and extent of the incisions around the ears and the time of recovery.

 To really change the neck in more significant wattles and sagging, the facelift must have an incision that goes up behind the ear and back into the scalp. It is the pull from behind the ear that draws up and tightens the loose skin in the middle of the neck. When needed, the extra recovery is worth the investment.

The other neck wattle surgery that few people have ever heard of is the direct necklift. It is the real wattle reducer and is the simplest of procedures to go through with but a few days of recovery. By cutting out the wattle directly, it is gone forever and creates a neck shape that will last for decades. The tradeoff for this simple wattle eliminator men is a fine line scar down the center of the neck. For men who have beard skin, this scar heals beautifully and may be the procedure of choice in the older male. For women, this potential scar must be considered very carefully.

Q:  Dr. Eppley, I am a 51 year-old female that is unhappy with my upper lip. It has become flaccid with age and my philtrum is elongated and flat. My lip droops over my teeth and subsequently you do not see my upper teeth when I smile. I want to shorten my philtrum and open up my smile to see more of my teeth and try to look more youthful. I am open to all suggestions.

A:  Thank you for your inquiry. You are describing perfectly the need and benefits of an upper lip or vermilion advancement. This is an excisional procedure where a predetermined amount of skin in a very specific shape is removed and the vermilion of the upper lip advanced or moved upwards. This will not only shorten the upper lip, between the base of the nose and down to the top of the cupid’s bow of the upper lip, but it will also cause more upper tooth show. To get the philtral columns more pronounced like ridges and not completely flat, dermal graft inserts can be placed vertically along their length at the same time as the upper lip advancement. This can be a procedure done under local anesthesia in an office setting.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, can we practice an onlay cranioplasty with tkryptonite in the front of the skull and end up having a smooth forehead shape? Are the most common complications of kryptonite cranioplasty surface irregular and a palpable demarcation between the bone of the skull and the kryptonite in certain areas? What is the likelihood that a second would be needed to smooth the surface of the kryptonite? If the demarcation between the bone of the skull and the kryptonite is especially annoying on the forehead after surgery, what is the solution?

A:  In answer to our specific questions:

1) It will not likely create a smooth contour.  

2) What you have mentioned are the two aesthetic complications with an injectable or minimal incision kryptonite cranioplasty.

3) It can be done endoscopically (small scalp incisions) with a long handled rasp.

4) It will be and it is corrected secondarily as mentioned in #3.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I desire a more womanly face. My face is very big and square and is way too masculine looking. I am not sure if my jaw angle needs reducing or if Botox injections will suffice. Can you please advise? I have attached some pictures for you to see my big square face.

A:  A square face, by definition, is when the lower jaw width is just as wide as that of the cheekbones. The width of the jaw angle area plays a major role in creating the horizontal dimension of the lower face in the frontal view. The width of the back part of the jaw (jaw angles) is created by three anatomic components; the thickness or flare of the jaw angle bone, the thickness and volume of the masseter muscle and the flare of the jaw from the front (chin) to the back. (posterior border of the ramus) Only the thickness of the masseter muscle by Botox injections and the flare of the jaw angle (ostectomy or jaw angle reduction) can be reduced. The key question is which one of these two is making the greatest contribution to the width of your lower face. While I suspect it is more bony than muscle by your pictures, it is important to make the right diagnosis. I would recommend getting some simple x-rays (frontal, side and submental plain x-rays) where the bony anatomy will be very apparent. A frontal and lateral cephalometric film (orthodontic type x-rays) with a panorex will also suffice for making this diagnosis.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, The problem with my face is it’s very skinny when I don’t smile. When I smile I have the biggest fattest face ever! I have these fat pockets around my nose. And instead of a smile I look like I’m sneering. I was in an auto accident and it caused nerve damage to my left lip. I want to fix my smile so its even again and you can see more of my teeth. I also have a brow that I hate and would like to get rid of. I also would like some work done on my chin because I hate the way that looks. And also when I smile I have “jowls” and I’d like to get rid of those and my double chin. My double chin is hereditary and being tall and skinny this looks very strange. I would also like to get a nose job because I have my fathers nose and I think it looks very masculine. Overall what I am trying to achieve is a slimmer face, with more feminine features and a better more applying smile. I don’t feel like my face goes with my personality, and how I feel. Also anything else you see that needs to be done please let me know.

A:  Thank you for sending your pictures. In looking at your face and reading your objectives I would consider the following procedures. A rhinoplasty is needed to make your nose thinner and less wide, particularly in the tip. I would also recommend buccal (cheek) fat pad removal (subtotal) and small cannula liposuction of the fullness above the nasolabial (lip-cheek) grooves. A lip lift (vermilion advancement) done with differential skin removal (left greater than the right) will help with better lip symmetry and overall fullness. A submental chin reduction is needed to decrease the amount of chin prominence and protrusion. Liposuction can be done in the neck and jowls to remove fat in these areas.

Unfortunately, I can only do limited computer imaging because your pictures are inadequate.  Smiling photos make a lot of facial feature distortion.

You mentioned a dislike for your brows but I am uncertain what specifically you do not like about them. Until I know more, I can not make any recommendations on whether they can or cannot be favorably changed.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I recently had Botox injected into my lips to help treat my lip lines. I was not pleased with the results at all. Besides not getting rid of any of the wrinkles it also gave me the unhappy effect of making my upper lip look funny (not in a good way) when I smile. I happened to have heard on my way out when paying my bill that this was the first time the doctor had ever injected Botox into a lip. I am upset that I paid for not only no result but that it may me look worse. On my own investigation I read on the internet that Botox is only approved for use in the forehead. I think I should get my money back and maybe even sue the doctor. What do you think?

A:  Botox is used for a wide variety of aesthetic facial applications. It was initiallystudied and subsequently cleared by the FDA for glabellar (between the eyebrows) wrinkles and is known as an ‘on-label’ use. Despite this one approved cosmetic use in the face, it is a perfectly acceptable medical practice to use Botox for numerous other expression-reducing/wrinkle reduction indications. This is known as ‘off-label’ use and is commonly done with many drugs. It is neither wrong nor malpractice to do so. The use of Botox in the upper lip can be effective at wrinkle reduction but is technique and dose sensitive. Unfortunately for you, this effort did not turn out to produce the desired effect. The good news is that your Botox will wear off in a few months and you will return completely to normal. I would discuss your dissatisfaction with the treating doctor and see what accommodations they may be willing to do.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I have heard alot about you and even read alot about the scar revisions you do on the internet. I found your website very helpful. I had a car accident in January, 2010. I had an injury under my chin. I was taken to the hospital and the doctor just cleaned the wound and put a band-aid on it. After a month when i shaved i had two scars under my chin. one in oval shape and one in small line red-pinkish in color. I showed it to a plastic surgeon and he told me to use Kelo-cote gel for two months. i used it for 2 months and the scar was a little bit soft but not much result was seen. Then n November, 2010 i had a revision surgery on both the scars. One remained the same and the other was reduced to 60% of the original since doctor had told me she will reduce the whole scar in two surgeries. I am not satisfied with the results from the first surgery. The scar is very visible and is pinkish in color and is even more visible now. I am attaching a picture of my scar before surgery and after revision. I would welcome your recommendations.

A: In looking at your submental or neck scars, I can see that both scars are fairly wide and in need of further scar revision. The biggest scar from the beginning was a tough assigment given its very large width. I have no idea as to the type of scar revision that was performed but I suspect it was a simple linear excision. Both scars would fare better with geometric approach to scar revision to distribute the tension on the closure better to decrease the amount of postoperatve widening. This is particularly needed when the excisions are wide and in an area prone to scar stretching influences.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, what is the difference between the silicone used in breast implants as opposed to that used as as ‘black market’ soft tissue filler? if it is so dangerous to inject silicone into other parts of one’s body like the buttocks and the breasts, why then are silicone breast implants considered safe? Since silcione breast implants could rupture and leak out, how is that silicone in your body any different than injecting it elsewhere? This doesn’t make any sense to me.

A: This is a good question and it doesn’t make sense to you because, although the name silicone implies that all is the same, they are somewhat different chemically and how they are packaged. This turns out to make a big difference when introduced into the body.

Injectable silicone used for illegal soft tissue augmentation is an oil that is less polymerized and less stable. It is also dispersed in the soft tissues in small droplet form. This leaves a lot of surface area of the oil onto which inflammation and scar tissue can form. Silicone in breast implants is in a more highly-polymerized (stable) form that is encased in its own protective bag or barrier. This results in no actual silicone being exposed to the body so no reaction to it occurs. The only reaction the body as is to the bag that contains it. If ruptured, the released silicone is further protected by the body by the natural scar (capsule) that always forms around the implant. (a second bag or barrier if you will) The more polymerized silicone gel causes less inflammation or reaction from the body than oil even if it does become exposed to it. Silicone gel in breast implants has also been highly studied and evaluated by the FDA with rigorous scientific scrutiny as to its bodily effects. Injectable silicone oil has never been exposed to such scientific scrutiny as a soft tissue filler and thus has never been approved for an injectable augmentation approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I banged my forehead when I was 11, I’m now 19 years old. I have been left with a noticeable dent in the middle of my forehead and would like it to be less noticeable. A cut type of scar would be much more acceptable than the dent that I have now. I would much prefer a cut scar from surgery that I can cover with make up, rather than a dent that A LOT of people notice and feel they need to point it out to me. Thank you!

A: If this forehead indentation is bone based or from soft tissue atrophy, it may be best treated by building up the bone underneath it. (frontal cranioplasty) This would be a ‘scarless’ way to do it and it could be done from a small incision  back in the scalp where it would not be noticeable. While the indented forehead area could be excised if it was small enough, I woudl question whether a scar would be a good trade-off for the indentation. The size of the indentatio  could also preclude the excisional option. I would have to see pictures of the indentation to see what would be the best surgical treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, Ive come to highly respect your opinion, especially regarding the lower face as you’ve done some beautiful work.  I have an asymmetric face. In seeing an orthodontist,  he said I am not a candidate for jaw surgery. I think he is wrong. I think jaw surgery is probably the only real solution that will properly address my lower face. My jaw is clearly longer on one side than the other in both the ramus and the condyle, its visible in X-rays. The cheekbone is also visibly lower on one side both externally an by Xray.

My questions aside from obvious rhinoplasty and chin augmentation, can anything at all be done to address this “tilted” look to my face and eye area? It bothers the heck out of me . Your feedback would be highly appreciated. I think surgery is my real need and only true solution.

A: I do not have the advantage of seeing any x-rays so my comments can only relate to your photographs. The most significant component of your facial asymmetry is in the orbits with the one being lower than the other. That is potentially improveable through a brow shaving procedure through the upper eyelid and a lateral canthopexy corner of eye tightening procedure done on the lower orbit. That is relatively low risk and is an operation commensurate with the magnitude of the problem.

Straightening your nose through rhinoplasty is of obvious benefit as well as chin augmentation, via an implant or osteotomy, as you are already aware.

As for jaw surgery in terms of orthognathic repositioning…no. Your orthodontist is correct based on what I see in the photographs. I have no clue as to what your occlusion is but this would involve a major effort and years of orthodontic work. There would have to be a major malocclusion to justify that effort. You are far better off camouflaging the jaw asymmetry with chin augmentation and possibly a lower border shave/ostectomy on the elongated side.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interesting in what you refer to as an extreme chin augmentation (osteotomy and an implant).  I have a short lower jaw, but unfortunately have been told I’m not a candidate for orthognathic surgery due to the position and condition of my teeth.  To help correct this problem, I have had a chin implant placed but the results do not satisfy me as it is not big enough.  I am attaching a copy of my ceph x-ray.  I do not have a profile picture at this time, but it is pretty clear where my chin is from this x-ray.  Can you please comment on having this surgery?  I have seen a lot of your before/after pictures on other sites for chin augmentation and am very impressed with your work and the knowledge you seem to have from the questions you answer on your site.

A: Thank you for your inquiry and sending your ceph x-ray. You do an underlying significant lower jaw deficiency as seen on your film. Your current indwelling chin implant provides only 7mms horizontal projection and is positioned just slightly high on the bone. Your true chin deficiency is more in the range of 16 to 18mms deficient. You therefore already have half of an extreme chin augmentation with the existing implant in place. You now need a chin osteotomy done just above your existing implant to advance the bone (carrying the implant) forward about 10 to 12mms with a vertical opening of 2 to 3mms. This will create the most ideal chin projection for you. So doing the previous chin implant was not a wasted procedure. You would have needed it anyway as the bone can only be brought forward so far. i have done some computer imaging and predictive tracings on the ceph x-ray that you have sent me.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in having a more round forehead appearance. It is too flat and doesn’t seem to fit the rest of my face. I would like to know the best method for forehead augmentation; fillers, implant, or bone grafts. Thank you!

A: Thank you for your inquiry and sending your pictures. I can clearly see that there is a disproportion between the projection and shape of your forehead (and the upper portion of your nose, the frontonasal junction) compared to the rest of your face. Your entire lower forehead and brow needs to be built out, including an upper nasal (bridge-frontonasal junction) augmentation. I have done some imaging to show what that would look like based on the one photo that you have sent. Forehead augmentation can not be done with fillers, bone grafts or preformed synthetic implants. It requires a moldable cranioplasty material that is specifically moldeded in surgery to the desired forehead shape and allowed to harden. The two basic types of cranioplasty materials are hydroxyapatite and acrylic. (PMMA) Each has their own advantages and disadvantages. Because of your recessed forehead/brow area, the nasal junction of the forehead is severely recessed. That would need to be built up with a small bridge implant placed through the inside of the nose. If not done, building up the forehead/brow will make that area look even more recessed inward.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I’m not sure what is the best procedure for me but I want permanent filling of my concave or hollowed temple areas. I have tried injectabvle fillers but none even lasted a year. I loved the look to my face that made it look more symmetrical and younger but they just didn’t last. I also had fat injections done last year but that didn’t take either and I am still concave there. It was only one fat transfer procedure so maybe it takes more than pne?  I’m starting to lose hope that there’s any way to fill in the temples permanently. I feel that this issue makes me look older and definitely doesn’t help my outer droopy eyelid area. I’m unsure what my options are for a permanent fix and appreciate any direction you can provide.

A:The only real permanent fix to most cases of temporal hollowing is to place a non-resorbable temporal implant, either that of a synthetic composition (silicone) or that of a collagen matrix. (dermal graft) These are placed under the temporalis muscle fascia and are tremendously effective…and are permanent.These implants are placed through a small incision in the temporal area, have minimal swelling or discomfort, and have virtually no discomfort. This would be the best solution given that you have tried all of the injectable approaches. I do not believe that repeat fat injections will work if they did not last the first time. While temporal implants can get rid of temporal hollowing, it does not lift up or provide any improvement to a droopy eyellid area. That is outside the influence of temporal augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in buccal fat removal to make my cheek area less full but I have a few questions. If complete removal of the buccal fat pads is what is decided to be the best result after seeing my photos, is there a high risk for nerve damage?  I’ve read that partial, more superficial removal is fairly safe but complete removal poses a risk of possible facial paralysis and/or nerve damage.  From what I’ve heard and read it seems as if plastic surgeons are either for or against buccal fat pad extraction, in regards to the risks and how the patient will look when aging.  I don’t seem to find any middle ground.

A: Having done many buccal fat manipulations over the years, I have no concern with facial nerve damage with buccal fat removal. It is not something that I have ever seen. Whether it is subtotal or closer to a more complete buccal fat removal, that problem is completely avoidable if you know how to do the procedure properly. How aggressive one should be with buccal fat removal is based on what type of face they have and how much the buccal fat pads are contributing to the submalar fullness. The amount removed varies depending upon the patient, their immediate thinning needs, and in consideration of what the future may be as they age with their kind of face shape.

Dr. Barry Eppley

Indianapolis, Indiana

Have you ever looked in the mirror and seen that tired look and wondered why? If you are over  forty, this might be a near daily occurrence. Fullness or extra skin of the upper eyelid is one of the most common causes of tired looking eyes. You may be wondering what’s the best way for me to remove this fullness and restore the youthful, attractive look to my eyes. Is it an eyelid lift (blepharoplasty), a browlift or some combination that is right for me?

Fullness and heaviness of the upper eyelids occurs for two reasons. The most common reason is too much skin and fat. Due to the constant stretching of opening and closing your eyes (the upper eyelid accounts for most of eyelid closing) extra skin is created over time. Eventually this can become so significant that it hangs down onto your eyelashes, known as hooding. The other contributing reason can be the position of the eyebrows. If the eyebrows have dropped down and are too low (gravity does usually win) this can also add fullness to the upper eyelids as it pushes the eyelid skin down.

To really know whether it is the eyelid skin, the eyebrows or a combination of both that is causing those full and tired looking upper eyelids, you must do an eyebrow placement test. By putting your eyebrows in the proper aesthetic position (by pulling up on the forehead skin until you have the desired eyebrow position) and then opening and closing your eyes, one can see the true amount of upper eyelid fullness remaining. By so doing, there are three possibilities for correction which will be revealed.

When the eyebrows are lifted to a better position, all the upper eyelid fullness is gone. This means the fullness is due to low eyebrows and the solution is some form of a Brow Lift. In this situation if only an eyelid lift was done, it would actually cause your eyebrows to become lower.

When the eyebrows are lifted, some but not all of the upper eyelid fullness gone. This means a combined browlift and eyelid lifts are ideally needed.  It would also be perfectly appropriate to just do an eyelid lift and accept the lower eyebrow position. For men this is usually more common than in women as most men have naturally lower eyebrows.

If the eyebrow is already in a good position on the lower end of the forehead and all of the eyelid fullness remains, than only eyelid lifts are needed. This is , by far, the most common tired eye scenario particularly if one is under the age of 55 or so.

Plastic surgery correction of aging of the upper eyelids must consider its upstairs eyebrow neighbor to determine the best solution to a less tired and rejuvenated look.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I would to make my face less fat. It is very round and the fattest area is on the side of my face. It gets a lot better when I suck my cheeks in as this seems to draw in the area where it is the fattest. What is the best procedure to get rid of this facial fat?

A: It is always a little unclear to me when a patient says the ‘ side of their face’, that can mean different things to different people and is of particular significance when one wants a defatting or thinning procedure. Having said that I have a strong suspicion when you mean the equivalent of when you suck your ‘cheeks’ in means the entire side of your face….of which there is no surgical procedure that can accomplish that look completely. There are some areas that make up a portion of the side of the face that can be improved by liposuction. The perioral mound area extends from the corner of the mouth back about halfway between the corner of the mouth and the ear, which is the anterior half of that area. For fullness that goes all the way to the back to the ear, there is no solution.

You would be best off to consider subtotal buccal lipectomies and perioral and lateral facial liposuction. But it will never equate to the contouring or thinning effect of sucking in one’s cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting deltoid and biceps implants. I am not a body builder nor am I trying to bulk myself up. I have a congenital deformity involving my left shoulder and arm. No one knows why but it never developed right and my shoulder has a big indentation in it and is very embarrassing for me. I also can not lift my left arm even up to 90 degrees on that side. I just want to look more normal in appearance. I have attached some pictures for you to see and tell me what you think.

A: I can see that you have an ipsilateral deltoid hypoplasia. It almost seems that there is a general delto-pectoral hypoplasia present on your left side. Deltoid augmentation would definitely help for symmetry. The question is whether this should be done with an implant or fat injections. Each has their own distinct advantages and disdvantages. The advantage of an implant is that the volume would be stable. Its disadvantages are that there is no preformed implant that matches your deformity, it requires an incision for placement, the outline of the implant may be visible, there is a risk of infection and the location of the implant may interfere with raising your arm. The advantages of fat is that it would have none of the aforementioned complications of an implant because it is natural and could be tailored better to the entire shape of the deltoid deformity. Its disadvantage is that its volume retention is not always predictable.

From a biceps standpoint, I see no specific hypoplasia on the same side. They appear symmetric between the two sides. I am assuming that the request for biceps augmentation is to simply augment what you already have, not correct a deformity.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am 54 years old and am interested in getting a facelift, rhinoplasty, and blepharoplasty surgery. I’m trying to achieve a more youthful look, less sagging, and not so tired looking appearance. I have attached some pictures of me so you can show me by imaging what the results may be like.

A: Thank you for sending your pictures. Here is some imaging for the following procedures; a facelift (neck-jowl lift) and a rhinoplasty.You could get a really significant improvement in your neck wattle as it is a large amount of loose hanging skin. That would dramatically change your neck-jawline profile. It is interesting as to why you have such a large amount of hanging neck skin even though it appears you are relatively thin. Perhaps you have lost a lot of weight ?? Regardless a full facelift will remove inches of skin from the neck and tighten up the entire jawline.

From a nose standpoint, you tip is wide and thick and turns down slightly. There is also a small bump higher up on the nose. A full rhinoplasty would take down the bump, shorten and narrow the tip with some lifting and narrow the size of the nostrils. This type of nose change at your age changes the structure of the nose and makes it look smoother and more refined, a look that has a more youthful quality.

The combination of these two procedures, as the imaging illiustrates, would make significant rejuvenative changes to your overall facial appearance

As an addendum, I did not do nor is it possible to do realistic blepharoplasty computer changes. It is clear from the pictures that you have some extra eyelid skin that can be removed as well as some herniated fat from the lower eyelid. Your lower eyelid shows no significant skin excess, however, other than a few millimeters. Together, this type of upper and lower blepahroplasties will make you look less tired.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am 22 years old and my breasts are more saggy than I would like. I have not even had kids yet and they sag. I have a good breast size but much of it just hangs low. I have read about the crescent and Benelli types of breast lifts and was wondering if these would work for me. I have attached a front and side view of my breasts so you can see what they look like.

A: The decision to undergo a breast lift is an aesthetic choice between breast sagging and better shaped breasts that have scars. For some patients with very saggy breasts this can be a relatively easy choice. For other patients with more minimal sagging, such as yourself, that choice is a more difficult one. You have asked about the Benelli (donut) and the crescent lifts because they have the least amount of scarring of all the breast lifts. In reality, they are not breast lifts at all but really nipple-areolar repositioning techniques. They do nothing for lifting or reshaping the breast mound. They work best in cases where an implant is needed to restore breast volume and a slightly higher nipple-areolar position is beneficial. In your case they would provide no breast lifting benefit. More substantial breast lifting techniques are needed to really lift your breasts and that would involve vertical and maybe even horizontal breast crease scars as well. Given the amount of sagging that your breasts have and your young age, the trade-offs for a breast lift are very questionable. Iwould not recommend this procedure at your age. Wait until after you have had children when the need will be greater and the scar trade-off will be more convincing.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am 59 years old with a younger looking face and body but an old, wrinkly neck. My neck does not match the rest of my face or body and makes me look old. From what I’ve read, a direct necklift may work to improve the appearance of my neck but would be of interest to me since it may cost less  but I’d like to know what you think. I have attached some pictures which shows my wrinkly saggy neck.

A: Thank you for your inquiry and sending your photos. You have a most unusual amount of neck aging compared to that of your face. And the direction of your neck sagging is mainly horizontal and not vertical. Many men develop so called turkeynecks which are largely a vertical skin sagging problem. This is the typical direction that direct neck lifts treat which is a vertical neck skin removal with some minor horizontal skin removal at both ends of the vertical excision.

Your neck, however, shows a substantial amount of horizontal skin laxity as seen by your many horizontal neck wrinkles. This indicates that a direct necklift for you must have a different excisional pattern. Using your horizontal neck wrinkles, two to three inches of neck skin can be removed across the width of the neck keeping the final scar in a horizontal neck wrinkle line. The only question is whether a vertical component to the skin excision needs to be done as well. I can not tell that from your photos since your face is tilted upwards in the photos you sent which may artificially make any neck wattle look better than it really is.

There is also the option of a more traditional facelift approach which will also work very effectively as well, albeit with more recovery and expense.

Dr. Barry Eppley

Indianapolis, Indiana

Q:  Dr. Eppley, I am interested in getting rid of  my lower abdominal pooch. The skin has some stretch marks which become really apparent when I lean over. The wrinkly skin really sags when I do this and it is very unattractive. I am wondering if I can just exercise this area away (my husband says I can) or whether this needs liposuction to make it better. (which I think it does) What are your thoughts?

A: Many women, who are not overweight, have developed a little pooch in their lower abdomen between their belly button and their pubis. Its relatively small size suggests that it is a non-surgical problem that can be exercised away. Usually I see women who come in after they have proven to themselves that they can not get rid of it on their own. Your wrinkled skin that sags when you bend over is the key in answering the question of whether this is a surgical or non-surgical problem. This tells you that there is too much skin and it will not shrink down on its own. Excess skin most certainly can not be exercised away. The only real solution is that of some form of a tummy tuck, particularly if you are using the criteria of how it looks when you bend over. Stretch marks are a sign that the elasticity of the skin has been destroyed and no recoil or shrinkage of it can occur. Only surgical removal will solve this loose saggy skin condition.

Dr. Barry Eppley

Indianapolis, Indiana