Your Questions

Q: Dr. Eppley, I have a fractured cheekbone. In terms of cheek reconstruction will a fat injection be more beneficial than a cosmetic implant? Please email me your answer.

A: Assuming that you are not going to have the cheekbone fracture repaired acutely or that this is an old healed fracture, you are seeking cosmetic camouflage of the external deformity caused by displacement of the underlying bone. (cheek reconstruction) Both fat injections and an onlay bone implant are viable treatment options. But which one would be better depends on the location and extent of the external facial deformity. Each approach has its advantages and disadvantages. Fat injections are simpler to do with a very quick recovery but their survival is far from assured and, in most cases, requires more than single treatment session. A facial implant offers an assured augmentation result but is more invasive with a longer recovery. (swelling period) In some cases of secondary zygomatico-orbital reconstruction I have combined implants with fat grafting to get the best result.

It would be very helpful to see pictures of your face to determine the nature of your cheekbone fracture deformity. From that I could give you a better idea as to which approach may be best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Interested in advice on upside and the downside of temporal artery ligation. I am a healthy 39 year old male and have these arteries near both temples that constantly bulge and have a pulse in the heat, under stress or when exercising. They look like squiggly worms on the side of my head!

A: Prominent temporal arteries are not rare and their presence becomes more noticeable when the need for increased blood flow occurs. (exercising, heat or just bending over) Temporal artery ligation for cosmetic purposes is done through very small incisions in the temporal hairline and usually one at the end of the visible arteries location. (which is usually somewhere close to the forehead) Always two separate points of ligation are done and occasionally three ligation points are required. These small incisions heal imperceptibly and are not a cosmetic problem. The procedure is done in the office under local anesthesia and there is no real recovery at all. One can resume all activities right after the surgery. the only potential downside to temporal artery ligation is in how well it works. The appearance of the temporal artery can definitely be reduced but not always completely eliminated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m looking to obtain some information about posterior jaw or jaw angle implants. I had three surgeries approximately 20 years ago on my upper and lower jaw to correct the alignment and preserve my teeth.  After I healed from my last surgery I was to have jaw inlays placed however I did not opt for it at that time due to the need for external incisions. Attached you will find several photos from today and one from (many years ago) just prior to my maxillofacial surgery to give you an idea of how my face once looked. What is the approximate cost for the entire procedure?  I’m looking for an approximate amount for the entire process, from beginning to end.  Does having previous maxillofacial surgery have an impact on this procedure?

A: Undoubtably you have as one of your orthognathic surgery procedures sagittal split of the mandibular ramus (SSRO) osteotomies. In some cases this can cause some partial resorption of the jaw angle particularly if it was done more than once. You can clearly see in your before and after pictures that have lost the shape in the back part of the lower jaw. (loss of angles) While jaw angle implants is the correct procedure for jaw angle restoration, your prior surgeries have undoubtably caused some uncommon and uneven posterior jaw anatomy. To get the best result in terms of shape and symmetry you would be best served by custom jaw angle implants made from a 3D CT scan. That would not only show the shapes of your two jaw angles before surgery but would allow the computer design to make right and left angles that would match. While standard jaw angle implants would be better than nothing there at all, there undoubtably would be some persistent asymmetry. What is unique about restoring lost jaw angles is that a significant portion of the implants has to lie off of the bone. So custom making and fitting of the implants to the altered anatomy (with the use of microscrew fixation) would be invaluable in terms of implant stability.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am just finishing nursing our fourth baby and am looking into getting breast augmentation done. How long do I need to wait after finishing nursing? Also, we are military stationed overseas so would be flying in. How soon is the follow-up appointment? About how many nights should we plan to stay in a nearby hotel? Thank you! 

A: The first question after having nursed four babies is whether you just need implants alone? Do you have any sagging and is the nipple above the lower breast crease/fold. if sagging is present, as defined by the nipple being at or below the lower breast fold, then a lift will be needed with the implants. As a general rule it is good to wait three moths after nursing to have the breasts shrink back down to reveal the amount of true sagging, if any, and to have a good appreciation of the desired implant size needed for the desired breast size result.

Since the real time to judge the results of breast augmentation is that of months and no sutures are placed that would need to be removed. One could leave for home fairly quickly after the breast augmentation procedure when one feels comfortable traveling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in having a number of surgeries at the same time including hairline lowering, brow lift, lip lift, cheek augmentation, V line jaw surgery, browbone/forehead implant, lip v/y plasty, corner lip lift, cupids bow augmentation, chin osteotomy, under eye fat grafting, marionette line fat grafting, love band surgery, and tongue tie surgery for the face. As far as the body I would like calf/knee/thigh liposuction with transfer to to buttocks and breast, and hip implants. I was wondering if all of these would be possible to do at the same time?

A: In the world of ‘extreme plastic surgery’, such a collection of procedures would bypass this term and really be excessive. It would not be possible nor advised to do all of these face and body surgeries at one surgical session. Besides taking as long as 12 hours to perform, the physical recovery from this prolonged surgery would be extremely difficult and exposes you to a lot of medical risks. This is a large amount of induced trauma to the human body. The face and body surgeries should be done separately and spaced about three months apart. Even when done separately the face and body surgeries would be considered extensive in and of themselves.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. I would like to make a great change on my odd facial appearance. I would like to have a facial reshaping on my interpupillary distance (IPD) and innerouterintercanthal distance (IOICD) because I think I got hypertelorism. I have 4.5cm telecanthus, 3.6cm intercanthal distance, 3cm orbit, 7.5cm interpupillary distance (IPD), around 14.5-15 cm facial width and around 19.5 cm facial length. What surgery should I do at this stage? Decrease interpupillary distance (IPD) by Facial bipartition or increase bitemporal distance and by custom implants? Thanks for your time. I am looking forward to your reply!

A: Thank you for inquiry and sending your pictures. For your facial concerns no major craniofacial surgery such as a hypertelorism or facial bipartition repairs would be appropriate. These are major intracranial surgeries with some significant risks that would not be justified for a cosmetic issue such as type 1 hypertelorism or mild increased intercanthal distances. Instead you want to think of other smaller facial reshaping procedures that can help improve that appearance. You have a low nasal bridge and epicanthal folds. Reducing the epicanthal fold appearance and augmenting the height of the nasal bridge (augmentation rhinoplasty) are well known manuevers that will help make the eyes looks somewhat closer. Making the adjoining areas wider (temporal augmentation) is another option to consider also. When you put all three of these facial procedures together they will do a lot to decrease your perception of the eyes being too far apart.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a facial scar revision. I have a long grooved scar on my left cheek from a two layer Moh’s operation performed three years ago. I have had several consultations from Plastic Surgeons and now am confused. The plastic surgeons said the original doctor did not evert the edges during closure therefore this is why it looks like it does now. The last plastic surgeon I consulted stated he would place deep sutures and not evert and do zero top stitching, placing just a fine stitch running over and over and than taken out in a week to prevent stitch marks. When I asked if he would evert the skin edges he stated no. Is not eversion the only way to give the best possible outcome with a atrophic scar apart from tension on the inner layers? How do you do it .. The first, Vertical mattress no dissolvable sutures and evert….the next zero eversion and deep sutures. I though eversion was the way to go? Thank you for your time and consideration.

A: When it comes to facial scar revision the various techniques can be confusing. One has to look at the original problem, understand it and then devise a strategy which will improve the outcome. You have classic inverted scar, not because the right wound closure technique was not done, but because this was a wound closed over an area of tissue excision under some degree of tension. That combination is doomed to result in a wider inverted scar no matter how it was closed. Skin under tension closed over an area of deeper tissue deficiency is bound to sink in as it heals over time.

Your scar revision now is different. The wound edges will not be under such tension and there be no deeper area of tissue deficiency since nothing is being removed. Therefore, release of the skin edges and the deeper tissues with reapproximation of tissue layers will solve the inversion issues. There really is not need to do specific skin edge eversion. Providing deeper tissue support or buildup is the key. How the skin is closed is really irrelevant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am hoping you can give me your professional opinion about my problem. I have been bothered by a fairly flat back of my head for decades now and I am at that point that I really want something done about it. Some stories sounds promising which make me hopeful but I am not even sure I am a ‘suitable’ client. What do you think as far as you can tell from a picture? How long will the procedure take (from intake to recovery) as I need to travel to the States. Thanks for your time.

A: When it comes to determining a good candidate for back of the head augmentation (occipital augmentation), pictures can go a long way in answering that question. Please send some to me at your convenience. The issue is not likely going to be whether you can have the procedure done but whether it is a one-stage vs a two-stage procedure based on your back of head shape goals and your natural scalp laxity to accommodate that change.

Back of the head or occipital augmentation is usually best done by a custom implant made from a 3D CT scan. Although I have done enough of these surgeries to have a ‘stock’ set of implanted designs from prior patients that can be used which does not require a preoperative 3D CT scan. Either way it takes about 3 weeks to have the implant made and ready for surgery.

Patients from other states or countries usually return home within 48 to 72 hours after occipital augmentation surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a v-line jaw surgery in Seoul, Korea and feel that it doesn’t suit my face. Is there a way to reverse it? I fear that it will cause me to prematurely age…it has already given me jowls.

A: While V-line jaw surgery can be very effective at making the jawline/chin smaller, it does create the potential for loss of skeletal support to the overlying tissues. Usually in young people this is not a major concern because the have very good elastic properties of the soft tissue which can adequately shrink down to the reduced jawline bone structure. But if overdone or in some older patients a jawline reduction can result in a soft tissue sag most commonly seen in the jowl area. A V-line jawline reduction can be reversed and requires a custom jawline implant to do so. I have done several of these procedures and the implant is designed based on a 3D CT scan. In some patients I have been fortunate enough that the patient had an original 3D CT scan prior to their jawline reduction surgery so the new and old 3D CT scans could be overlaid and an exact replica of their original jawline structure recreated. In other cases no such prior 3D CT scan existed so the custom jawline implant design had to be based on what was believed to be the original jawline bone structure. In one case, a male patent even went as far as augmenting his jawline far further that what his original jawline structure was like before the jawline reduction.

In short, a V-line jawline surgery can be reversed by a custom jawline implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Can you do lip reduction surgery for me?? I suffer from neurofibromatosis which makes me produce a significant amount of tumors and makes my face look abnormal. I had a botched surgery when I was 9 to remove a tumor on my top lip. When I became of age i tried (with no luck) to find the surgeon responsible for leaving me with the lips I have now. He removed a tumor from my top lip but never restored a natural shape to them. They are huge uneven and unsightly. They make it hard to form words and I have no ability to form a proper smile. I am at a lost. I’m sorry if this is a long explanation, but no one has been able to help me. I just want to know is it possible to reshape and make my lips fit my face.My surgeon didn’t do a very good job of removing the whole tumor because it slightly grew back. You can see where it tried to come back thus giving me a protruding top lip and explanation of how it affects everything else. The surgery I seek isn’t listed but from what I mentioned its yet another tumor removal with hopes of restoration of lip shape.

A: Neurofibromatosis of the face is a very difficult problem for which there is no real cure. Surgical efforts attempts to remove any neurofibroma tumors and restore as much shape to facial structures as possible. But it is not easy and certainly restoring any type of shape or function to a delicate facial structure like the lips is challenging. For whatever result your lips now have I would not fault the original surgeon. He took on a difficult challenge for which there is really no ideal result. Having operated on many neurofibromatosis patients I can testify to the challenge. Neurofibroma tumors recur or grow new ones and surgery causes considerable scar tissue. This combination leaves the delicate and sensitive lip structure as bound to have some degree of residual deformity.

Hopefully further improvement is possible for lip reduction surgery. I would need to see pictures of your lips to see what possibly may be done now.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in getting hip implants. When coming in for hip implants, can you determine how big you want your hip implant of is there just one size?

A: The size of hip implants one can have is dependent on multiple factors including hip location implantation site, how thick/thin the overlying tissue are and what type of hip augmentation results one expect. There is no such thing as a preformed hip implant as the patient demand is too low for any manufacturer to make true hip implants in standard sizes. Hip implants are done using either standard buttock implants or buttock implants that have been custom carved at the time of surgery to fit the patient. Before surgery the location of the desired hip augmentation is measured and those dimensions are used in picking or making the hip implants to be used.

I would need to see some pictures of your hips and your location of your desired hip augmentation site to determine if this is a procedure that might be beneficial for you. One key factor in qualifying the patient for hip implants is whether they can tolerate the location and length of the incision needed to place them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Just wanted to follow-up with you regarding my Mentalis Muscle Resuspension Surgery. I wanted to makes sure I understood what you told me during our consultation. You made the following points:

1) That my chin and lower lip sag are “fixable”.
2) Based on my chin x-ray, you said that the screws were placed
way too low to fix my issue. You would place screws much higher
between tooth roots
3) Also you would dissect a much larger area (under and around
the chin) to get enough lose skin to pull up and overcorrect issue as
there will be some sagging after surgery
4) And during the operation you would be able to place my head in
an upright position so you can confirm that my lower lips are way
above my bottom teeth before you attach the anchor then after
attachment confirm it has been raised high enough.
5) Lastly you recommended a V-Y lower lip mucosal
advancement.

What kind of results have you had with similar situation as mine?  Do you usually have good luck?

A: Correction of a sagging chin and lower lip is challenging and the best results come when every available technique is done for it. The entire chin tissues must be mobilized and the anchorage point for the muscle must be high with a screw(s) placed between the tooth roots. While this can lift sagging chin tissues, it does not always guarantee that the lower lip will end up elevated. Raising the lower lip is very difficult to sustain and that is why I usually perform a soft tissue elevation/roll out of the lower lip as well. Reattaching the mentalis muscle higher is no guarantee that it will push up the lower lip. It may seem that way when one pushes the chin tissue up on the outside with their fingers but it does not work that way in surgery.

My experience has been with these techniques that everyone gets improvement but it is the lower lip position that can remain the most incomplete part of the repair.

Dr. Barr Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had liposuction of my stomach, love handles, pubic mound and back rolls one week ago. The doctor said he removed almost 3.5 liters of fat. I am very concerned because I have such massive swelling in my pelvic area that feels so hard that I know there’s blockage of my lymphatic  system. I feel nauseated, toxic and the hardness in pelvic feels like rigor mortis. Not sure of spelling. The rock hard mass that I feel in my crotch can’t be normal for liposuction. It feels like deadening of my torso and tissues inside. I am very scared. Yes, I rejected most of the pain medication becasue I’d rather gauge how I feel instead of covering it up. Outside of my 8 hours sitting at my desk, all I do is bed rest.  All week I have been like a hospital patient. 

My job is stressful and may have caused the collection of cortisol in my midsection in the first place, but I think I can’t eliminate because of medication, stress, constipation and a very compromised lymphatic system. Not sure if I have lymphedema, but I am very sick. I drink plenty of water, but told nurse that I stay moving 3 times a week to keep my blood flowing (typically walking on treadmill 20 minutes regular pace). I eliminated my arm/muscle training and refrained from squats. 

Please help me with the rock hard blockage in my pelvic area, primarily. Massage doesn’t work. What’s good?

A: Everything you are experiencing is perfectly normal and expected with the liposuction you have had. Every patient who has aggressive liposuction of the torso gets every symptom that you have. It is, in fact, a lot of temporary lymphedema as liposuction of any type disrupts normal lymphatic outflow initially.

There is nothing to be scared about with how the tissues feel. All patients do not realize, and now you do, that liposuction is a very traumatic operation and creates a lot of subcutaneous tissue injury. This creates lots of swelling, fluid and overall lymphatic congestion. The solution is simply time. It will takes months for the tissues to fully recover  and feel normal again. Unfortunately there is no magic solution or method to hurry this process…and that is certainly true at just one week after surgery.

With abdominal liposuction women and men will develop substantial swelling at the ‘bottom of the well’ over the pubic and down into the genital area. This effect is magnified when pubic mound liposuction is concurrently done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am having abdominal etching liposuction next week. How defined do you think you can get for me as well as removing my love handles? I know this guy is 28 and I’m 52 but I really want to get some definition with the abdominal etching. 

A: I believe your answer comes from what you have stated after your initial question. Your observation that the model is 28 while you are age 52 speaks volumes in terms of result expectations….that is not an achievable goal. Three factors come into play in any type of body contouring that will define the result…1) How toned and defined are the underlying muscles, 2) how thick is the fat layer between the muscle and the outer skin and, of equal if not greater importance, 3) how much elasticity of the skin exists to shrink down around the reduced fat areas. The older one gets the loss of skin elasticity plays a major limiting factor. I have seen goal pictures like the one you have provided many times and I have yet to see any patient get that type of abdominal etching result no matter how much fat is removed.

In short I think we should temper our expectations to an abdominal result that has some definition but never as defined as we would like.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting jaw angle implants that are of a standard vertical lengthening size that you have designed. The look that I am trying to achieve is a jaw that isn’t “high up”. One that is not quite lined up with my chin but low enough. So I’m just concerned that this will leave me with just a “slight” change and still leaving me with a high jaw line. From your experience and knowledge what is your expectation? I just payed for everything and set for our consultation, I apologize for the questions and concerns, but this is so important to me and Im spending my savings. So all I want to know is, what to expect. Can you not give me some assurances as to the results? 

A: The reason I am being nebulous with the answer to your question is two-fold. First it is an accurate statement that no one can predict what the final results will truly look like. Will it be better than what you have now…absolutely yes. Will it meet your expectations….unknown. This is no different that a woman getting 350cc breast implants and asking will it meet her expectations. It is certainly going to be better but whether they are big enough or have the right shape can be hard to answer with absolute certainly. Secondly, the very question you keep repeatedly posing is exactly the reason why your surgery, and any young male who is getting facial bone augmentation, makes me nervous. As I have said before, you are aiming and probably expecting a result that is only going to be achieved by custom made jaw angle implants. But because that it not a viable financial option for you, you are hoping that any non-custom approach will produce satisfactory and fairly assured results. The importance of that to you is further emphasized by your statement that you are spending your savings for the surgery. Patients who put themselves in this financial position, particularly young male patients, often end up with unsatisfactory outcomes.

I would like to emphasize that this is not the type of assurance I can give you. As I have said previously the only way you should have this type of jaw angle implant surgery is by the following guidelines:

1) You view an acceptable result as one that provides any improvement at all to your existing high jaw angles. I can provide no assurance that an 11mm vertical length will be ‘low enough’.

2) If you are seeking a specific target length or certain jaw look, as shown by model or other celerity pictures, and that is the only result that will make you happy…then you should not have the surgery. This is what custom jaw implants are used to create.

3) An understanding that there is a relatively high incidence of jaw angle implant asymmetry when using non-custom jaw angle implants that provide vertical lengthening. When half the implant needs to be positioned off the bone the difficulty in getting symmetry between the two facial sides escalates considerably over any other type of facial implant which is positioned entirely on the bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am getting a nasal implant for my rhinoplasty but I am very leary of necrosis and the aesthetic results and safety of a Shirakabe vs. Dorsal nasal implant. I would like to ask you whether the Shirakabe or Dorsal nasal is best for avoiding necrosis. Which one? or does it not matter? Would a dorsal nasal implant have good results since I have a bulbous tip? Aren’t Shirakabe’s better for Black/Afro American? Could you define my nasal tip more (having a dorsal nasal implant in comparison to a Shirakabe) without necrosis developing? Thanks.

A: I think in general one has to be very leery of having any type of synthetic material under the skin across the nasal tip. A nasal implant that puts any pressure on the nasal tip skin is destined for long-term problems. The issue is not immediate skin necrosis but long-term skin thinning, implant visibility and/or infection. Synthetic implants that cross the nasal tip area have a significant long-term risk of these issues. While implants work well for the nasal dorsum and have a much lower incidence of problems, the same can not be said for the nasal tip. The best ‘implant’ for the nasal tip is your own cartilage, particularly that of rib cartilage. If you were asking me what is the best to use both in terms of results and the lowest risk of potential complications, I would choose cartilage over an implant every time in rhinoplasty surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a scalp scar revision. I had a hair transplant done five years ago which was supposed to leave me with a “pencil thin” scalp scar. What I ended up with is a far cry from such an optimistic prediction. So now I’m looking for best scar revision option, maybe combined with tissue expansion and w-plasty/ geometric broken line closure. I just want to laser my hairs out and be bald. I know scar will not disappear but i want just to improve it as much as possible. Do you think based on my attached picture that the scar can be reduced to an acceptable level on my scalp? Thanks.

A: In looking at your pictures, you have a modestly wide occipital scalp scar harvest site. Your assumption is correct in that only a scalp scar revision has any chance of making a lessening in its appearance. Only by cutting out the scar and getting back to unscarred scalp that contains hair follicles can make that improvement. Given the pattern of the scar a running w-plasty/modified geometric closure would be the preferred type of skin closure. The key to a scalp scar revision’s success is how much tension is on the closure. It doesn’t matter if the best interdigitating skin closure is done, if the tissues are tight some recurrent scar widening will occur. While there is no question that a scalp tissue expander is always going to be of great benefit, you obviously would not like to take it that far if it can be avoided. Since it has been five years and I assume that you had only one harvest procedure, there is a good chance enough scalp laxity is present to avoid tissue expansion. If you have had two strip harvests and the back of your head feels very tight then scalp expansion may be needed for more assured success.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley ,How many rhinoplasties have you performed? What is the percent of having to redo a rhinoplasty that did not come out as desired.

A: I have performed over 500 rhinoplasties in my career. The number of medical complications, such as infection, in rhinoplasty surgery is very low as I have seen only two. (both that involved the use of synthetic implants) Revisional surgery in rhinoplasty surgery, however, is not rare and in fact is actually common. These revisions are for aesthetic reasons and the  national average is around 15% if not higher. That number is my rhinoplasty surgery experience is about right although it may be a bit lower. There are a large number of reasons for rhinoplasty revisions and some of that is driven by the patient themselves. Some patients can tolerate minor imperfections in their nose while other patients continue to seek absolute perfection and may go on to have multiple revisions. I have seen patients who are quite content with their result even if I has wished I could make some further improvements of it. Conversely there are other patients that desire a rhinoplasty revision when I would have preferred and thought more medically appropriate that they leave it alone. The point is that the risk of revisal surgery in rhinoplasty is real and not rare and one that every patient who undergoes the challenging operation of rhinoplasty must accept.

It is also important to differentiate the risk of revisional surgery based on the type of nose that is being treated. There is an enormous difference in the likelihood of needing a revision in a cleft rhinoplasty procedure that someone who only wants a small bump on their nose to be reduced.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had Permalip lip implants placed in the top and bottom lip. My smile is horrid. And can’t even open my mouth wide enough for the dentist. My lips are extremely tight. I still want larger lips but not tight distorted lips.

A: The most common complications from Permalip lip implants is that of implant asymmetry or an inability to achieve the lip size increase that one wants. I have not had the experience of these lip implants causing extreme lip tightness or significant interference with one’s smile. But based on your lip symptoms it is clear that these implants needs to be removed and should bone replaced by fat injections. You need to get rid of what is causing the tightness (the implants) and replace them with a material that can help relieve some of the tightness and still provide significant augmentation. While it is true that fat injections into the lips have variable amounts of take and unpredictable volume retention outcomes, they are the best solution for relieving lip scar contractures. The residual capsules from the lip implants do provide a more favorable site for fat placement and graft retention.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, Two years ago I wanted a change and I got a Terino Square Chin implant. While I do think it made my chin look better, I would never wear my face without a full beard now. The implant is huge and I believe it did not address the vertical increase that I needed. The groove under my bottom lip looks way to big to be normal. I have also attached a current photo of myself with the full beard. I believe there were some irregularities under the implant with my chin that have now been pronounced since the implant was not custom.What should I do now? I feel that the sliding genioplasty with an implant) may have been my best option from the start but the recovery time is extremely long. My recovery time from this implant was over 10 days. I do not feel hideous or anything so this is not urgent but I really would like to understand if what I am looking for is even possible. 

A: Given what you had hoped to achieve and looking at where you are now, the only option to consider is a custom chin or custom jawline implant. Compared to many patients who have gotten square chin implants your results would not be considered remotely huge or disproportionate. But that is clearly how you feel and that is all that matters. You desired results show a lower and more square chin but the width of the squareness is fairly normal and not at all what the Terino square chin implant can achieve. Only a custom chin implant can make that type of non-standard chin augmentation change. You have also shown on your ideal result some jaw angle changes as well. How important that is to you will determine whether you should have a custom chin implant or a custom total jawline implant.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had a genioplasty and jaw augmentation a little over a year ago. The jaw augmentation was performed using hydroxyapatite paste along the jawline and the results are pretty asymmetric and too bulky for my face. The surgeon who performed the procedure is in Belgium and if possible I’d rather have it corrected by someone closer to home. I’m hoping my jaw can be shaved down or contoured to better fit my face and correct the asymmetry. I really hope you can help me. Thanks and kind regards.

A: While hydroxyapatite granules are the most biocompatible material for only bone augmentation, they unfortunately do a poor job of establishing a smooth outer facial contour. I have revised numerous patients who have undergone hydroxyapatite facial augmentation by hydroxyapatite (HA) granules/paste and they all have the same lumpy irregular bone contours. The concept of injectable HA bone augmentations is appealing but it is prone to a high incidence of aesthetic contours problems just like you have. The good news is that these augmentation irregularities can be smoothed or modified to a better contour just like any bony outcropping. Interestingly many HA augmentations will have a fair amount of bone ingrowth into and around them which actually makes their modifications easier than if the granules were just on top of the bone by themselves. It would be very helpful to have a preoperative 3D CT scan to a clear idea as to the exact location of the HA augmentations and their size compared to where the excessive bulk/asymmetries are seen on the outside of the face.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I came across one of your publications on the Internet regarding cutis verticis gyrata scalp condition.You recommend fat grafting to treat this condition.
A doctor I have consulted (where I am living) also recommend me to try this procedure. But I am not sure about the efficiency of this procedure. Would you mind to advise if fat grafting technique could be a good option to solve my case ? I have attached pictures of my scalp so you can have look. I am looking forward to hearing from you.

A: Cutis verticis gyrata of the scalp is a very unique, peculiar and fairly rare scalp condition. Why it is occurs is not known and how to really effectively treat it is similarly not known. The vertical grooves or grata are scalp indentations (not bone) that become fibrotic and adhered down to the bone. This adherence is quite dense and unbelievably stiff. There is almost nothing but scar tissue between the skin of the scalp and the bone. The only really viable treatment option is injectable fat grafting. Having done that procedure it is really hard to get into and raise the grata to place the fat grafts. It takes an initial release with ‘picklefork’ instruments to get the tissue separated to create the tissue plane to place the fat. And it will likely take more than one fat grafting session to get the best result. But you would have a good idea after the first treatment session of the value of doing further fat injection treatments.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I had brow augmentation by injectable fat grafting done ten days ago. I had a quick question about after care from the procedure. Should I be avoiding going into a sauna? I figured the heat would increase blood flow to the fat graft, but I just heard about how Vanquish destroys fat cells by warming them to 110 degrees.

A: While high heat is a known detriment to fat cell survival, the actual temperature at which that would occur is around 140 degrees F….not just 110 degrees. Vanquish does help destroy fat cells but that is by causing an internal temperature of the fat in the treatment to reach and be sustained around 45 degrees C. Therefore, I don’t believe the heat from a sauna would make any difference in fat graft survival. While the heat from a sauna may reach 145 degrees, your internal body temperature never rises more than a degree or two. Vanquish specifically creates temperatures at the subcutaneous tissue level of 45 Centigrade plus with the specific purpose of destroying fat cells. External sauna temperatures do not create the same subcutaneous level temperature changes. If they did you would be ‘cooked’ just like the fat cells that were placed by an injectable fat grating technique.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I have a question about mentalis resuspension and v-y inner lip plasty. I had a sliding genioplasty and no plate was used during my sliding genioplasty, just two screws which seem to have been placed quite low. Could this be part of why the mentalis muscle is not as high as it was? Thank you.

A: One of the methods in sliding genioplasty bone fixation is that of lag screws as opposed to a step fixation plate and screws. This is undoubtably the two low placed screws that you see. Placing lag screws does require more muscle and soft tissue stripped off of the chin to place them. But I do not think, based on this description alone, as to why you think the mentalis muscle is not as high as it once was. You are likely referring to the depth of the labiodental fold of which the mentalis muscle makes little contribution to it. The labiodental fold is a fixed structure that is an external indicator as to the depth of the vestibular sulcus intraorally. When the chin bone is advanced the depth of the labiomental fold will often appear deeper since its position did not change but the chin projection became greater. This is not usually a reflection of loss of mentalis muscle attachment, it is the natural deepening of the labiomental fold area which will occur despite having the mentalis muscle attached back into its original position. This deepening of the labiomental fold is a natural occurrence in many sliding genioplasty outcomes.

Dr. Barry Eppley
Indianapolis, Indiana

Q: Dr. Eppley, I am in need of secondary chin surgery. I am a female and am 34 years old. One year ago this month I had a chin implant removed due to a number of reasons including bad positioning and shape. It was in for five years and was not replaced with another. It was inserted and removed orally and it was fixated with a screw. It has left me with soft tissue complications and still gives perception like the implant hasn’t been removed. I found the a link where you go into detail about chin implant complications nearly identical to what I have currently. It describes how you would tackle the problem and seems you have extensive experience in the procedure. It seems I’m finding it very difficult to find someone in my country who can tackle the issue. From my pictures would you class my soft tissue deformity as a mild case of Witch’s Chin?

A: Thank you for sending all of the pictures. You definitely do not have a Witch’s chin deformity. At rest you have a perfectly normal position of the soft tissue chin pad on the bone. Your deformity appears when you animate and the soft tissue contractions (dimpling deformity) appear. This is the result of the soft tissues being stretched out by the implant and then, with the implant being gone, its support is lost and there is now too much soft tissue. This will create an abnormality on contraction which you now have.

Treatment options include:

1) Doing nothing. It is not predictable that any improvement can be gained.

2) Replace the implant and recreate the soft tissue support. (although placed from a submental position and tighten the mentalis muscle from below)

3) Do a submental approach to the mentalis muscle repair with excision and midline reapproximation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial feminization surgery but don’t know exactly what types of procedures I need. What are my options? Can they all be done at once> How much of a change to my face can they make?

A: Facial feminization surgery (FFS) involves a wide variety of bony and soft tissue changing procedures to create more of a feminine facial appearance. In a single surgery as few as one or two of these procedures can be done or as many as dozen or more . I have done as many as 15 procedures in a single patient. As a result FFS can produce subtle or major facial changes. Procedure options going from top to bottom of the craniofacial include: 1) skull augmentation, 2) hairline lowering (scalp advancement, forehead reduction), 3) forehead augmentation, 4) brow bone reduction, 5) lateral brow bone contouring, 6) browlift, 7) lateral canthopexy or corner of eye lift  8) rhinoplasty or nose reshaping, 9) cheek augmentation using either implants or fat injections, 10) lip lift or lip advancement, 11) corner of mouth lift, 12) lip augmentation with fat injections or Permalip implants, 13) chin reduction, 14) jawline/jaw angle reduction, 15) masseter muscle reduction by electrocautery or Botox injections, 16) submentoplasty (reshaping under the chin) and 17) adam’s apple reduction. (tracheal shave)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in need of lip and earlobe reconstruction. A middle piece of my upper lip and my entire left earlobe were bitten off by a dog last year. Both my lip and ear have fully healed but I need reconstruction to get them to look better. I have attached some pictures of my lip and ear for your thoughts on best to reconstruct them.

A: Thank you for sending your excellent pictures. They show both the upper lip and left ear deformities well. Both of these pose some of the most difficult challenges in reconstruction of these areas. The upper lip lacks volume and also has a color mismatch of the vermilion of the surrounding lip. While the color and volume problem could be improved by excision of the defect and bringing good tissue in from the sides, that will result in a vertical scar extending up into the currently unscarred upper lip skin. Therefore I would prefer to build up the volume with a dermal-fat graft and then add color by micro pigmentation (tattooing) That would be [referable to me than a vertical upper lip scar. From an ear standpoint, earlobe reconstruction would need to be done by a two-stage procedure. The first stage would be the transfer of a skin flap from the tissue next to the earlobe and  post auricular crease. The second stage would be the release of the skin flap and wrapping it around an ear cartilage graft to form the lobule.

Both upper lip and left earlobe reconstruction could be done at the same time under local or sedation anesthesia.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am trying to figure out if there is a cosmetic surgery that exist for skull reduction. I am a female with a 25.25 inch head circumference and it has been the joke of my life since birth. I already have to have jaw surgery because of my underbite, but I am praying that maybe there is some way to make my bobble head less noticeable. I tried gaining weight so that the weight could bring proportion, but unsuccessful. I know that this may sound silly to some, but this is my life and if I could change this, I will. I don’t expect to ever wear a hat, but I would at least like to face the public without having to cover my head with long hair or look down while walking.

A: There are a variety of skull reduction procedures that can done for just about anywhere on the skull. What is important to understand about them is that they treat selective areas which can be used to change some of the contours of the skull. In rare cases, there is even overall skull reduction by burring. These procedures can not, for example, take a 25 inch circumference of the skull and make it 21 inchs around. But in many cases they can make a visible difference which could provide a psychologically substantial improvement in how the patient sees the size of their head.

Whether these type of skull reduction procedures may be of benefit for you would require that you send me some pictures of your head for my assessment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am a female and interested in a “supermodel” jawline. (female jawline implants)  I would most likely want the wrap around jawline style to create more length across my chin line but I don’t wish to create any additional definition to my actual chin.  I’ve always been picked at, being told I have a long face so I do not wish to have a bigger more define chin. I am just looking to add length side to side.  I’m attaching a pic of my favorite model.  To me, when I flip through the pages of Vogue you can see the focal point of each woman’s beauty is her large jawline.  Tell me if something close to this pic would be achievable on someone like me, and roughly how much a custom wrap around implant could potentially cost.  Also wondering if I fly into Indiana for the procedure how many days/weeks would you recommend I stay there while I heal? Would you be able to link me up with a doctor in the my area who could treat me when I get back home? Flying back to Indiana would be a bit difficult. One more question…does the implant need to be switched out after a certain amount of years?  I was told any implants need to be changed out every 10 to 20 years.

A: When one uses the term for a female of a ‘supermodel’ jaw width, they are referring to a well defined and very angular jawline. In female jawline implants one has to be careful, however, with your jaw width increase so that it does not become too wide for your face. Your long vertical facial length provides some limitations as to how wide you can make the jawline implant. As a general rule the width of the jawline/jaw angles should not exceed the width of the superior cheeks. The model that you favor has a shorter facial length and, as a result, can have a jaw width that actually makes her face almost square. But even in her the width of the jawline is equal to the width of her cheeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a hairline advancement (forehead reduction) surgery one month ago. I’m losing some hair on the scar and was wondering how long will it take before it grows back? Im still not too happy about my head. I don’t feel like I can wear my hair back. I still feel my hairline is high. My husband says it looks good however! Thanks.

A: There are limit to a one-stage hairline advancement surgery based on teh scalp’s elasticity and how much the forehead can be reduced. Hair shafts along the incision line will typically shed in the first few weeks to month after surgery due to the trauma of the surgery. (hair follicles do not like traumatic events) This still leaves the follicles underneath the skin/scar which will regrow hair, at the growth rate of 0.05mm per day (the follicle lies 6 to 8mms under the skin), which will take about 8 to 10 weeks to begin to appear at the skin surface. (1mm per 10 days or 3mms per month) Thus it will take around three months until some hair growth has occurred through the scar. This coincides with when the redness of the hairline scar begins to get better. (less red) Between the hair growth and the maturation of the frontal hairline scar, it will take about 6 months for the appearance to become more normal. It takes up to a year for the scar to fade as much as it is going to and to have enough hair growth length to see the final true hairline location and pattern.

While easy to stay, it takes patience and lot more healing time to really judge your final perception of the surgical result.

Dr. Barry Eppley

Indianapolis, Indiana