Your Questions
Your Questions
Q: Dr. Eppley, Do you know anything about Ultherapy? I had it ten months ago and had my ass handed to me. I developed not just volume loss (a ton) but it shrunk my eyes. I’m not sure if it was just the muscles or the vitreous humor as well. I’ve seen this with quite a few women. Not sure if you know medically/technically what is going on, but even if it is impossible to fix, I’d love to have a scientific explanation.
A: Like many facial skin tightening devices, they work by driving various forms of energy into the skin. This almost always results in the creation of heat whose effects will pass some distance below the skin. Thus the scientific explanation is simple….the energy driven below the tissues causes fat loss/atrophy. It is a simple function of heat and its effects on the fat cells. Fat cells are very sensitive to heat that exceeds 40 to 45 degrees Centigrade and such temperatures have well known fat atrophy/loss effects and is even the basis for devices who are for treating excess fat. Why Ultherapy would cause periorbital fat loss when that area was not directly treated I can not say.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buttock augmentation. I(Brazilian Butt Lift) What is the cost, how long would I have to be off work. what does it mean by not all of the fat would survive?
A: The cost of Brazilian Butt Lift surgery is variable based on the ‘size’ of the assignment. The more fat that needs to be harvested is going to take more surgical time and costs. But on average the total cost of BBL surgery is in the range of $7500 to $8500. Recovery from BBL surgery is essentially like recovering from a major liposuction surgery. While I suspect you could get back to work in about 2 weeks after the procedure that does not mean you would be fully recovered. That probably takes about a full size weeks. The success of BBL surgery depends on how much fat actually survives the harvest and transfer process. What the amount of fat survival will vary amongst patients, it is far to say that not all of the fat will survive, usually only about 60% to 70% will be retained at the most optimistic estimate. This is why in most Brazilian Butt Lift surgeries it is important to harvest as much fat as possible and place as much as the buttock tissues can tolerate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, For my otoplasty reversal another material you had mentioned in the office consultation that I am now interested in but I did not talk much about then is the use of irradiated rib cartilage. This material interests me in that it would be the closest in material to my own (rib) cartilage.From what I’ve read, when sourced well it can be as effective as autogenous rib cartilage, however on the longterm resorption is more common. What would your thoughts be on this irradiated homologous rib cartilage? Risks? Concerns? This seems like a material that would do well at holding the cartilage apart during the healing process and provide the needed projection for the middle support as it can be shaped to any size. It may be a more expensive material to source but that cost wouldn’t be a big concern for me as would finding the best material long term. I’m very interested to hear your thoughts and thank you for your time.
A: While resorption of irradiated cartilage is always a potential issue, this would be less relevant in an otoplasty reversal where the need for an outward pushing force probably does not need to be permanent. And although resorption can occur with irradiated cartilage it does not always occur and is usually partial and not complete. It does come in a nice wedge form of 1 cm width which is really perfect for otoplasty reversal. The only real drawback to using irradiated cartilage is its cost. At $1000 per piece the cost of irradiated cartilage in otoplasty reversal is over $2000 just for the material.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I have very large brow ridges, and a sloping forehead with a prominent central bump in front of the coronal suture. I suffered a blow to the sagittal region as a younger boy and I have always believed that I suffer from premature suture closure. The sagittal skull region is pointed and my skull height is reduced. I read your procedure articles about plastic implants in the forehead region to round the forehead and perhaps make it appear higher and more vertical, as well as similar implants to widen and heighten the overall head shape. I am 69 years old and have combed my hair over my forehead since I was a young man because I am embarrassed about my appearance. At my current age, and with thinner, receding hairline, this is becoming impossible. Can you help me?
A: One is really never too old to address a physical problem that has bothered them all of their lifetime. From your pictures you have a very backward sloped forehead. This make your brow bones look bigger than they really are and also create the illusion that your forehead is too high. Forehead augmentation, using either a custom made implant or using bone cement, can provide a very effective solution to changing the slope of the forehead. In forehead augmentation the goal is to make the forehead inclination closer to 75 to 85 degrees if possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting some initial information about a tummy tuck and breast lifts. I also sustained an injury to one buttock, leaving a large dent of scar tissue that I would like to have repaired if possible.
A: There are numerous types of tummy tuck surgery (eight to be exact) and breast lifts (four to be exact) so it is impossible for me to say which type of tummy tuck and breast lifts would be best for you. I am also unsure what your buttock deformity looks like although I could imagine. The good thing is that that tissue from the tummy tuck (dermal-fat graft) or fat injections from any liposuction can be used for reconstruction of the buttock indentation. I could provide you with more specifics about these procedures if I knew what you looked like. You could do that by sending in some pictures of your abdomen and breasts. Otherwise I would have to see you in the office to know exactly what you need.
A tummy tuck, breast lifts and buttock fat grafting could all be done in a single operation which would allow for just one recovery. The tummy tuck is usually what requires the most recovery. The recovery from other procedures falls well within that of the tummy tuck recovery period.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had two prior facial asymmetry correction procedures on my jaw. I had an implant placed on my right jaw only which is the side that is imbalanced. It is imbalanced both in width and in depth/length if that makes sense and the surgeon only corrected the width – which he did in excess. Hence I still have the depth discrepancy and it really is simply imbalanced now to the opposite direction it was initially.
The revision was to shave down the initial implant as it was far too large. The revision did not do much and was done poorly – the end of the implant now has a lump that is obvious. I’ve attached pictures for you to review. Please let me know if you need additional or different angles. One of the things that really bothers me is that the fullness is such that my left side often has shadowing that my right does not which almost emphasizes the asymmetry the doctor created.
A: What your case illustrates is how hard is to do facial asymmetry correction surgery by the doctor ‘winging it’. (that is not a criticism of him per se) It is very hard to just eyeball the facial asymmetry and place an implant and have it be right. That rarely is a successful strategy. It often leads to revisional surgery which still doesn’t solve the problem. Also you can see how just a few millimeters one way or the other can make a big difference on the outside of the face. When one has had a failed attempts at facial asymmetry correction along the jawline, it is best to get a better view of the problem. A 3D CT scan is the best way to really see the bony asymmetry, see where the implant is situated and what it looks like and then design a better implant that is matched to the bone on the other side and fits the jawline intimately.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a brow bone reduction procedure before. It was a frontal sinus reduction. This procedure didn’t really solve my issue. I am unhappy with my forehead prominence and how especially at 45 degree angles it looks really abnormal. Is there a procedure to smooth this feature to get rid of the sticking out effect, but also not feminize my face. Obviously I am a male and not wanting a feminization look, i just want to smooth out my forehead protrusion.
A: In looking at your pictures it is unclear as to what type of brow bone reduction procedure you had. By your description of ‘frontal sinus reduction’ that would imply that you had a setback of the anterior wall of the frontal sinus. But with your current brow bone protrusion that is hard to believe. May be it was just burring a few millimeters of the anterior sinus wall. But the degree of brow bone protrusion aside, your forehead appears to be at a 45 degree angle. (although that is hard to tell based on your hairstyle) Such forehead inclinations can make the brow bones appear to stick out further than they really do. (pseudo brow prominence) This may have partially contributed to the ineffectiveness of your prior brow bone reduction surgery. It may be that forehead augmentation to change the slope of the forehead may be more beneficial. By so doing this will also maintain a masculine appearance. To make that determination I need to do some computer imaging from the side view and will need a picture that shows your forehead without hair hanging over it.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I was looking into this procedure to create a more masculine jawline and prominent chin as I feel currently my face has the more oval shape as opposed to a squarer shape that I would prefer due to high jaw insertions and a slightly recessive chin. As you can see in the photos there is some degree of jawline asymmetry present as the left side is significantly more developed than the right, would this asymmetry necessitate the use of a custom implant as opposed to the off the shelf chin and jaw implants. Thanks very much.
A: You would need a custom jawline implant (one piece wrap around type) for the following two reasons. First, the lower facial augmentation effect you are trying to create requires a smooth augmentation from one jaw angle to the angle across the chin. A separate three piece approach (chin and two jaw angle implants) would not have this smooth widening jawline effect. Secondly with the degree of jawline asymmetry that you have, only a custom jawline implant made from your 3D CT scan can be designed to take that into account to get the best jaw symmetry as possible.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift bit can’t decide if doing it under local or a general anesthetic is best. The use of local anesthesia is appealing as it lowers cost and avoids the risks of a general anesthetic. But I want to be comfortable and have a good experience. What do you recommend?
A: The debate of local vs. general anesthesia for facelift surgery is an historic one and continues to this very day. I have heard it many times and like many chronic debates the issues are not black and white and sometimes the main point of the discussion is overlooked. Let me provide some clarification for you.
The discussion of local vs general anesthesia for a facelift makes the assumption that the facelift part is the same and the only difference is in the level of anesthesia. This is a mistaken assumption and is actually the incorrect question on this issue. The real question is what type of facelift can be done under local vs general anesthesia? As I can assure you the type of facelift obtainable does differ with patient comfort. So the question is what type of facelift does the patient need and does it require general anesthesia to be done in the most through manner possible and with the greatest patient comfort. More complete facelifts that include a lot of neck work usually need to be done under general anesthesia. Smaller or more limited facelifts may be able to be done under local anesthesia with IV sedation. (aka conscious sedation)
One erroneous assumption about anesthesia that is not a general anesthetic is that it costs less. While on the surface that is true. (you do not pay for anesthesiologist’s time) But those cost savings are wiped out as it will take the surgeon more time to do the procedure. For example if it is takes the surgeon 50% more time to do the same procedure under local or IV sedation that could be in less time under a general anesthetic, the surgeon’s charge for doing the surgery can not be the same. One important but often overlooked element in calculating the cost of the surgery is the surgeon’s time. To some degree the surgeon’s charge for doing any surgery is highly influenced by the time it takes to do it. The point being is that it rarely makes good sense to choose a local/IV sedation option vs general anesthetic for many elective cosmetic procedures because you are trying to save money.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had upper and lower jaw surgery in 2011 where I was referred by my orthodontist and convinced that I needed it. However, they ruined my face and my bite has subsequently shifted. I would like a sharp jawline. Is it possible to get jaw angle implants? Now, I cannot close my mouth properly and I have a weak chin.
A: While I do not know what you looked like previously, I can see now that you have a very steep mandibular plane (high jaw angles) and a recessed chin. From a jaw angle standpoint, vertical lengthening jaw angle implants are needed to drop the angle down and provide a more square angle shape. (not really square but closer to 110 degrees) Given that you have had prior jaw surgery (and I assume a sagittal split mandibular osteotomy, SSRO), your jaw angles are likely asymmetric and scarred. Custom jaw angle implants would be the ideal method for these unique jaw angle shapes.
For the chin the options would be either a sliding genioplasty or an implant as part of a total jawline implant which includes the jaw angles. Initially I would favor a sliding genioplasty because the vertical height of your chin needs to be reduced. But a custom implant may be designed this way also.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I want a Brazilian butt lift and tummy tuck. Can I get a combined surgery package and price for these two procedures.
A: The combination of a Brazilian Butt Lift and a tummy tuck can be done together. But that is a tough combination in terms of recovery and discomfort. I have done it and patients do get through it but it will be a lot tougher than you envision. Ideally it is better to harvest all the fat that one can from the abdomen and flanks for the Brazilian Butt Lift and deal with the loose skin in a second surgery. (tummy tuck) Whether the combination or staged approach would be better for you depends on what your abdomen looks like now.
While patients understandably would like to combine these procedures to lower costs and have just one big recovery, that approach can be short sighted. In women that have very large abdomens and a lot of excess abdominal skin, it may be more prudent to stage the two procedures. That way the best result may be obtained for both the Brazilian Butt Lift and the tummy tuck with a lower chance of complications.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Is there amount of weight you have to lose to get a tummy tuck… what is the recovery time after tummy tuck surgery?
A: It is always best to lose whatever amount of weight one wants to, if possible, before having a tummy tuck. Once one is within 10 to 15 lbs of their weight goal, then one can have the tummy tuck. Doing a tummy tuck and then losing 20, 30 or 40 lbs after will adversely affect the tummy tuck results creating some additional loose skin. Or at the least making the once taut abdominal skin feel more loose.
Recovery after a tummy tuck depends on how you choose to define recovery. A complete recovery, feeling like you do now, will take 6 to 8 weeks. This is the time when you will feel like you can do anything that you do now and feel comfortable doing it. Some people do return to work, for example, two to three weeks after a tummy tuck. But they are usually struggling to do and only do it because they have to. So recovery could be defined as two or three weeks but I would call it a minimal recovery and an incomplete one at that.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a combination of procedures including:
1. Brow bone implant augmentation using a custom made brow bone implant and possibly forehead augmentation as well. As you can see from the attached pictures this area of my face lacks definition. i would like a more masculine look. I had upper eyelid surgery done some six years ago. Unfortunately that was a botched operation, the surgeon operating on me sliced off too much of my left eyelid which has left the eye about half way to a third open when I close my eyes. The left eye is wider than the right when open. I was wondering, since the brow augmentation is performed around this area, would this type of surgery cause my eyes,particularly the left one to open further, thereby leaving the eye completely open when shut or when i am asleep? I guess implanting around this area is bound to pull the upper eyelid area upwards and pressure on the tissue surrounding that area.. I would not consider going ahead with brow bone implant augmentation if this is the case. Your opinion on this is greatly appreciated
2. Lip reduction to lower and upper lips. Just minor reduction to counter drooping which I notice and is probably due to me getting on in age. When at rest I can see the pink of my inner lips showing.
3. Alar base reduction in combination with Weir incisions to reduce nasal side walls and inner nostrils as well. When I smile my nostril flare excessively which bothers me, so I refrain from smiling as much as I can.
4. Finally I would like to raise/heighten my dorsal bridge as well as trim the bony area along the bridge to give definition. In addition I would like the bulbous nasal tip defatted if this is something you can do. Again, I just a subtle change as I do not want it looking to pointy.
5. I have had previous rhinoplasty with a premaxillary implant inserted below nasal base and I want to remove this.
Are these procedures you can do? Can you perform these procedures at the same time? Have you any experience performing all the procedures i have mentioned above on ethnic people like me?
A: Thank you for your inquiry and sending all of your pictures. In answer to your procedural questions:
- When it comes to a brow bone implant it is critically important that the decision for total forehead augmentation be considered using computer imaging. That has to be factored into the implant design. With the slope of your forehead I suspect brow bone augmentation only may only make the forehead look more inclined backward. As for the effect on the eyes, I have not really seen much effect on the eyelid position. If anyway I would think it would push the eyelids down lower and not pulled upward.
- Lip reduction almost produces less of a lip reduction effect than most patients want. So a more subtle lip reduction effect is the more likely one to be achieved as opposed to too much of a reduction.
- Reduction of nostril width changes the outer location of the nostril but has no effect on the inner nostril along the midline columella.
- The height of the nasal bridge can be raised and this can be done by either an implant or a rib graft. Since you may already being having a brow bone-forehead implant, I suspect the implant option would be more appealing. Reducing a bulbous tip in thick-skinned men always produces more of a subtle change and never a dramatic or a pointy one.
- The premaxillary implant can be easily removed.
All of these procedures can be done at the same time (custom forehead implant, rhinoplasty, lip reduction and premaxillary implant removal) The only thing ‘ethnic’ about your procedures is that of the nose and I have done many such ethnic rhinoplasties.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, On your website you seem to do plastic surgery related to skull reshaping. Has there ever been a case where someone had macrocephaly or a head circumference of 24.5 inches where you reduced this to 22 inches? I don’t think burring would accomplish that much. Would a craniectomy (or removing part of the skull) accomplish this or is that too dangerous. I have been able to reduce the size some myself by constricting and applying pressure to the scalp from different angles in a similar way a baby is fitted with a cranial mold.
A: The simple answer to your skull reshaping question is that burring is all you can do. You are not going to a craniectomy for an aesthetic skull size concern for a number of reasons including surgical risks, bony irregulatiies and, if nothing more, sheer cost. That is an operation that will cost $50,000+ to do with a neurosurgeon.
No one is able to have their skull reduced by 2 inches or more in circumference even with a craniectomy. (you have forgotten to take into account the space the brain needs which will tolerate no inward push)
Whatever reduction you have obtained by ‘compressive wrapping’ of the scalp, burring reduction will at least do that if not more. But burring reduction is the only aesthetic skull reshaping option you have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in buttock and calf augmentation. I prefer the fat from my body to be used. But I have one question… how long will the fat persist in my calfs and buttocks?
A: Thank you for sending your pictures. Fat injection calf augmentation can be done as long as one has enough fat to harvest to do the procedure. It would be very unlikely, however, that one would have enough fat to do both their buttocks and calfs. You would likely have to choose to place fat either in the calfs or the buttocks and choose an implant for the other location. Given that fat takes and persists better in the buttocks, it would make the most sense to use all of the available fat for the buttocks. Fat injections do not persist very well in the calfs and calf implants offer a simple, assured and permanent augmentation procedure.
When it comes to body contouring by fat injections it is important to understand that they work best in areas that already have some fat. Thus it is no surprise that fat injections work better for buttock augmentation than they do for calf augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have some questions about facial asymmetry correction. After finally doing my research I have seen amazing reviews on you and before I make some big decisions, I am asking some help from the surgeon point of view. I have two questions I would like to ask.
1) Every time I take a photo and my phone flips it my face looks very asymmetrical and weird looking. What procedures from the photos I sent do you need to perform to look even?
2) How come when I ask my friends they don’t notice it with my eyes and eyebrows unevenly but in the photos I can notice it extremely.
Also I forgot to mention under my eyes too. Thank you.
A: Thank you for sending your pictures. When it comes to facial asymmetry correction it is first important to identify which facial features are the asymmetric ones. What I can gather from the one front view pictures is that you have significant eyebrow asymmetry. The right eyebrow sits lower than the left. Because a picture freezes the face for a continued assessment most facial asymmetries are easily seen. In real life the position of one’s face is constantly moving and rarely does one talk to someone dead on with a ‘frozen face’ so one can get a good assessment of facial symmetry or asymmetries. The treatment for eyebrow asymmetry would be a unilateral endoscopic browlift. This could be effective provided one has some eyebrow tissue laxity which can be assessed by whether you can manually raise up the eyebrow with your fingers.
Your undereye hollows are the result of deficient inferior orbital rim bone. While this can be treated by fat injections, it is probably best treated by infraorbital rim implants with an overlay of fat injections if needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Hi, I’m interested in improving vertical chin lengthening. Below are attached pictures of before and after application of 1 and then 2 syringes of Juvederm Volume below my chin to increase vertical projection. I like the result but considering a more permanent option. In my research it seems that most chin implants address mostly horizontal projection. My horizontal projection is fine but I would like to increase vertical projection to get more sharper look in profile. I’m in great shape and don’t think dieting and more exercise would greatly improve my facial profile or remove the appearance of double chin. Would like to get your opinion on options. Thanks.
A: When looking for vertical chin lengthening, there are two options. An opening wedge siding genioplasty would be the autologous option. The chin bone is cut and open vertically downward and then plated in its new vertical fashion. The other option is to make a custom chin implant that mainly adds a vertical dimension increase. The decision between the two would be based on how much vertical increase one seeks. Large amounts of vertical increase are best done with a vertical bony genioplasty since it carries the soft tissue downward with it as it remains attached to the bone. With a custom chin implant it is important that enough chin soft tissue is available to be mobilized over the implant.
Lastly, vertical chin lengthening is not going to be enough to completely eliminate the double chin. Liposuction of the submental region would need to be done as part of the chin procedure.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a rhinoplasty and chin implant two years ago. But I am still not happy with shape of my nose, chin and face overall. I wish I can start over. I feel my nose is still too long and pinched and wish it was straighter and more refined. I also want a more angular facial shape with a masculine defined jawline and cheekbones. I think my chin implant has done only so much to help my desires. See my before and after pictures. Are my expectations and desires unrealistic? Can you help? Thanks so much.
A: Thank you for sending your before and after pictures. I think on both counts (rhinoplasty and chin augmentation) you have had good improvement and I would not agree that there would be any benefit to ‘starting over’…even if you could. You have reasonable results from both your rhinoplasty and chin augmentation. Your nose may be just a tad too long but that is a pretty good result. You are not going to be able to make any drastic changes to it other than perhaps some tip shortening. I do not know what you mean by being ‘pinched’. The refinement of any rhinoplasty is controlled by the thickness of the nasal skin. Having thicker skin there is a limit as to how much refinement can be obtained. You are likely as good as it can be. In that regard you probably do have some unrealistic expectations. Your chin implant has provided a substantial improvement and you would not want any further horizontal augmentation. What you are ‘missing’ from a facial skeletal standpoint is a lack of jaw angles and cheek prominence. The nose and chin have helped but they were not the sole solution to a more masculine face.
In short I would recommend some nasal tip shortening and cheek and jaw angle implants. This will then provide a more comprehensive approach to facial masculinization.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, How much do you charge for Selphyl? And how many cc’s are included in the Vampire Facelift? I did this procedure over 4 years ago and am interested in getting it done again.
A: You have asked about two similar but slightly different injectable facial rejuvenation procedures.
Selphyl is a kit or system where PRP (platelet-rich plasma) is added to PRFM to create a gel-like matrix for injection. By adding a calcium chloride solution, the Selphyl system converts PRP into an injectable gel. This fibrin matrix serves as a three dimensional scaffold to maintain the platelets at the site of injection. This PRP gel adds both volume to the injected facial areas and serves as a tissue stimulant onto which fibrous tissue can be created. The cost of a single Selphyl treatment is $1500.
The Vampire Facelift takes PRP and traditional hyaluronic-based injectable fillers and injects them separately into the facial areas. The injectable filler serves as the three-dimensional matrix in which PRP is secondarily injected. It is not a kit or system per se and is more of a technique that has been given a branding name. A single Vampire facelift may cost up to $2500 depending upon how much injectable filler is used.
The facial rejuvenative concepts between Selphyl and the Vampire facelift are similar even though their methods and materials are slightly different.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am contacting to find out more info about chin ptosis correction. I am 26 years old and had a chin implant that I strongly regretted. It was removed about six months ago. I notice that my chin has not returned to its original shape and size as I had been told that it would. There seems to be excess tissue underneath my chin and I miss the taut appearance that I used to have naturally. Just curious about what is involved to correct this issue and the potential cost. My incision was made underneath the chin, not intraorally. Thanks a lot for any info.
A: Unless the chin implant was fairly small and removed shortly after insertion, rarely do the chin soft tissues return to their exact shape as before surgery. All face and body implants are, to some degree, tissue expanders and they can create some overlying soft tissue changes no matter how small they may be. The approaches to chin ptosis repair are of two fundamental types, resuspension and excision. Sagging chin tissues can be resuspended, excess chin soft tissues can be removed. Which approach is best depends on the nature of the chin problem. I would need to see some pictures of your chin to make that chin ptosis repair determination. My suspicion is that you have a very small amount of soft tissue sag at the bottom of the chin that can be easily solved with a submental tuckup procedure. As long as the lower lip position is good any soft tissue sag off the chin bone is usually best treated by a chin ptosis repair using excision.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had so much filler, including volume (five vials of Sculptra and Juvederm within the past year) and I still feel that my cheeks are not full enough. I had very high cheek bones when younger and I am now 52 years old. I used to do the IPL laser years ago and this thinned my face very much due to fat loss. I would like to have a consistently full face rather than be dependent on these costly fillers. When I do the filler the swelling makes me look fantastic, but once the swelling is over it is deflation all the way. I thought that cheek implants, even the smallest, would give me a foundation that I could be happy with.
A: injectable fillers play a major role in facial voluminization, particularly in the cheek area. But the reality is that it is not a long-term solution to one’s desire for fuller cheeks. Fillers are great long enough until one’s decides that they either want to ‘graduate’ to more permanent solutions or to stop their cheek augmentation efforts. While fat injections are one of the two more permanent options, cheek implants provide an assured method of permanent cheek augmentation. With the wide variety of cheek implants style and sizes, patients and plastic surgeons have a lot of good options to choose from for permanent cheek augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a custom jawline implant. But before making this expensive decision I just want to make sure a sliding genioplasty is not something I should consider and living with a custom chin implant for life is 100% the best for me. I really think vertical length is one of the key factors with my chin being weak. I would appreciate your thoughts before I make this choice. Thanks so much.
A: In looking at your goals by your own imaging, you need chin and jaw angle changes. When it comes to vertical chin lengthening that can be done by either a sliding genioplasty or a custom implant. If you were just doing the chin alone and did not care about the rest of your jawline then the debate of a sliding genioplasty vs. implant has merit. But when you factor in the rest of the jawline for aesthetic improvement, where jaw angle implants would be needed and the only way to get that improvement, then a custom jawline implant makes the most sense. While a sliding genioplasty can be done with jaw angle implants, those areas will remain unconnected and not have a smooth line between them. A custom jawline implant creates all the chin and jaw angle changes one needs and connects them in a smooth wraparound fashion. In my experience this produces a far better result for almost all male jawline enhancements with lower risks of nerve injury/numbness. An even though the implant is more expensive to manufacture up front, it is done in less surgery time (so the costs differences are closed to a wash) with lower risks of revisional surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in forehead augmentation. I have very large brow ridges, and a sloping forehead with a prominent central bump in front of the coronal suture. I suffered a blow to the saggital region as a younger boy, and I have always believed that I suffer from premature suture closure. The saggital region is pointed, and my skull height is reduced. I read your procedure articles about plastic inserts in the forehead region to round the forehead and perhaps make it appear higher and more vertical, as well as similar inserts to widen and heighten the overall head shape. I am 68 years old, and have combed my hair over my forehead since I was a young man because I am embarrassed about my appearance. At my current age, and with thinner, receding hairline, this is becoming impossible. Can you help me?
A: Thank you for sending your pictures. I can clearly see your forehead concerns with a large flat area above your brow bones which slopes backward up into the skull. There is a relatively straightforward solution to our forehead deformity by building up the bone over the area of the depressed forehead region which is fairly well delineated. (forehead augmentation) This could be done using either a custom made silicone forehead implant from a 3D CT scan or using bone cement (PMMA) to do the forehead augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting breast implants. I am in the process of losing weight (40 pounds to date) so would also like to consult with you regarding how much more weight loss would be ideal before having the breast augmentation surgery. Thanks!
A: In the face of future weight loss the standard answer would be to wait until one’s weight loss is maximized before getting breast implants. Like all standard answers, however, the specific response for any patient must be further qualified. If one has no existing breast ptosis or sagging and not much residual breast tissue (volume) then further weight loss will have no impact on current breast implant size selection or whether ones needs a breast lift or would affect what type of breast lift one might need. However if one already has some breast sagging and /or some significant breast volume, further weight loss will affect both. And, as a result, any breast implant/enhancement decisions made now may be adversely affected when further weight loss occurs.
The final variable is this decision is the amount of weight loss one believes they can achieve before getting breast implants. As you have stated you seek a 40lb weight which would be considered substantial in how it could potentially affect your breasts. If it was a 10 or 15lb weight loss that amount would be considered to have a negligible influence on the current state of your breast shape and position on the chest wall.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in cheekbone reduction or recontouring. I’m wondering if there is a possible solution to my low cheekbone contour, by this I mean the ‘hollow’ shadow line that you see in many male models or those with high cheekbones. From looking at my face at the front is the cheekbone insertion too low or are my cheekbones just too large in length size? I ask this because the cheekbone seems to start at a high position i.e. just under my eye but seems to extend a lot length wise down my face. Any possible solutions to this would be appreciated.
A: Interestingly, while many men seek to obtain the cheek look that you have (and can’t) yours appears to be a question as to how to change your high and wide cheekbone prominence. Your cheek look is a function of both the high and wide shape of your cheek bones as well as the lack (or minimal amount) of facial fat. As a result you have a very classic pattern of ‘cut out’ cheek bones whose pattern can be seen very clearly on your face. Since a face like yours is very unlikely to maintain any injected fat, the only possible solution is to recontour your cheek bones. A reduction in your cheekbones (cheekbone reduction) to reduce its width, and possibly adding a small submalar implant (to fill out the submalar hollows), would be the one way I can see to modify your cheekbone shape.
Cheekbone reduction surgery is often about modifying the shape of the cheekbones as opposed to just pure bone removal.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in jaw asymmetry correction. I was referred to you by a friend and I would like to consult you over my concern. I have a slightly asymmetrical face with a swelling on the right side of my face. Based on the scan my right mandible is longer than the left side while it is more bended (curved) than left as well. To me the chin misalignment is not a big issue and doesn’t have that much impact on my look but rather the swelling on my right side of face is very noticeable and unpleasant. So my main concern is just getting rid of the swelling on the prominent side with the least manipulation on my face. Please note that I am not looking for a perfect face. More of a normal face is what I am asking for. I was wondering what options I have here to just get rid of swelling?
A: Thank you for your inquiry and sending your picture. What you refer to as right jawline swelling is not really swelling. This is reflection of your lower jaw asymmetry due to how it developed. As you appear to have had a CT scan it shows that the right jawbone is bigger and longer than that of the left side. This will also include the overlying soft tissues as well. In essence your entire lower jaw is shifted during development of which also consist of chin asymmetry and a left jawline/facial ‘shortness’.
It would be helpful to see the CT scan and hopefully it was a 3D type. But having seen many such jaw asymmetries before, the treatment approach is fairly straightforward. In an ideal world I wish just reducing the larger jaw on the right side would straighten out your face and give it substantial better symmetry. But this is unlikely to happen by itself. The reason is that you can not reduce the larger bone enough to make a big difference. (there are teeth and nerves in the bone so that is a limiting factor as to how much bone can be reduced) In addition it is not possible to reduce any of the thickness of the overlying soft tissues as it contains muscle and branches of the facial nerve.
For these reasons this is why many jaw asymmetry corrections must employ a ‘triple point’ approach. This means all three points of the jaw (chin and two jaw angles) are treated. Reducing the right jawline, straightening the chin and augmenting the left jaw angle provides the best method of jaw asymmetry correction. Even with this approach perfect lower facial symmetry is not usually possible. But it is usually the best approach to mask the lower facial disproportion which now exists.
In short, you have three options:
- Right jawbone reduction with the understanding that it will only produce a modest improvement,
- Right jawbone reduction and left jaw angle augmentation since you have stated that you are not bothered by the chin asymmetry, and
- Right jawbone reduction, left jaw angle augmentation and a leveling chin osteotomy for straightening.
With each treatment option the degree of jaw asymmetry improvement increases.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m trying to find out more about lateral epicanthoplasty, could you help me find more information about this before I take this procedure?
A: Unlike the better known medial epicanthoplasty, a lateral epicanthoplasty procedure also exists.The epicanthoplasty procedures can elongate the length of the eyes, increase the eye size, and improve the aesthetic results of double-eyelid surgery. In addition to focusing on the fold at the inner eye (medial epicanthoplasty), the lateral procedure also addresses the outer portion of the eye. Lateral epicanthoplasty is done to lengthen the eye and correct a slant that makes an eye appear droopy or tired. The most common misconception about lateral epicanthoplasty is that it is like its medial cousin when in fact it is not. The medial epicanthoplasty is about correcting the overhanging skin fold. The lateral epicanthoplasty, more accurately called a lateral canthoplasty, changes the position of the corner of the eye and is not an external skin removal procedure. It does require small skin incision to do but its objective is to elevate the outer corner of the eye by tightening the lateral canthal tendon. In short, a lateral epicanthopasty is not a unique procedure but is the well known lateral cantoplasty procedure which has been around for decades. In many cases it is not even a true lateral canthoplasty but is really a lateral canthopexy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have rather under defined but wide cheeks. I’m interested in undergoing both Cheekbone Reduction and Cheek Implant surgeries. I saw your answers on RealSelf and wanted to know more about your experiences in these surgeries. Also, how much would it cost to perform both surgeries? Thank you a lot in advance.
A: You have the classic wide cheekbones (technically zygomatic arches) that do not have much anterior projection over the body of the zygoma. (malar prominence) Hence your description of ‘underdefined but wide cheeks’. As you already know improving this type of cheekbone anatomy requires cheekbone reduction surgery (technically inward respositioning of the zygomatic arches) and implant augmentation. (anterior cheek augmentation) The most challenging aspect of this surgery is in the cheek implant design. There is no standard cheek implant made that achieves the type of cheek augmentation that you need. Fortunately I have treated enough Asian patients who desire this exact type of cheek change that I have designed specific cheek implants to achieve this anterior projection but which create no lateral projection or width increase.
I will have my assistant pass along the cost of the surgery to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in temporal artery ligation. There are a few pics of how it looks just about everyday when I exercise it gets about 3-4 times worse and throbs rapidly. I went to the doctors and they said that its common and since I’m a big guy at 6’4 and 240 lbs that it’s not uncommon and there really is no treatment. When researching online it suggests prednisone in a large dose along with other things. I’m not sure if I should seek another doctor opinion or if prednisone is something that is going to help with it.The arteries being prominent drive me a bit crazy I know they are super noticeable and I get a comment here and there about them which is frustrating to say the least. How much does surgery cost? And would it be wise to try out the prednisone if I can find a doctor who thinks that would help.
A: Your prominent temporal arteries show a very classic pattern along the squiggly pattern of the anterior branch of the temporal artery. I have not heard of using steroids for reducing the appearance of prominent temporal arteries. That is the type of treatment for temporal arteritis but that is not what you have. The only successful treatment for their reduction in multiple point ligation. That is a procedure done under local anesthesia in the office. I will have my assistant pass along the cost of the surgery to you on Monday.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’ve had a chin implant procedure. The photos are of me about a year after the procedure. I am not fully satisfied with the size. Do you think a sliding genioplasty (perhaps while keeping the implant I have) would help? I don’t think I look bad, but I would like to have a more masculine face.
A: Thank you for your inquiry and sending your pictures. I would agree that your chin projection is still inadequate and could be further improved. The question is whether this is best done by a new custom made implant or whether a sliding genioplasty should be done keeping the existing implant in place. The answer to that can not be completely derived from profile pictures. It would be helpful to know the size of your existing chin implant and where it is positioned on the bone. These pics of information you are not likely to know and are best determined from getting a 3D CT scan. That will provide invaluable treatment planning information. It is clear in your profile view that you need at least another 7mms of chin advancement and come vertical lengthening as well. But your front view pictures would also be helpful so see what your chin width is. A sliding genioplasty in the front view will usually make the chin more narrow and not wider so this is an important assessment to make.
Please send a front view picture for my assessment. We can help you get a 3D CT scan where you live. You simply find a facility where you want it done and we will fax the order to them for you to get it.
Dr. Barry Eppley
Indianapolis, Indiana
