Your Questions
Your Questions
Q: Dr. Eppley, I am seeking a witch’s chin correction. My chin sags down like a witch’s chin after my chin reduction ten years ago. Also I would like to remove the neck fat because my jaw is narrow and gets lost in my neck. I would like my profile to be more balanced, so I am hoping that Smart lipo will fix this. The attached x-ray was requested by a surgeon who does facial feminization, even though at this point, I only wanted my jawline and chin corrected. My chin and jaw are off balance, but I don’t want to go through any bone surgery if I don’t have to. My chin midline is slightly off per the surgeon who requested this x-ray.
A: Because you have a witch’s chin deformity from an intraoral chin reduction, your x-rays shows exactly what one would have predicted. You can see the chin reduction which was done which left behind the large chin soft tissue pad which is now unsupported. Your x-rays shows why an intraoral chin reduction does not achieve the desired effect and creates the witch’s chin deformity that you have. This type of chin reduction is ill-conceived and is not anatomically correct. A witch’c chin correction is not going to occur by any form of liposuction. Rather you need tissue resection through a submental incisional approach to make the chin pad tissue match the lesser amount of chin bone support that you now have.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I need information and various options of how to reduce a jawline. (jawline asymmetry correction) I am 23 year old and one side of my jaw bone is larger than the other. As a result my face appears crooked or more angular. I had orthognatic surgery two years ago because one side of myteeth was not meeting and as result I could only chew on the other side. Now I have function on both sides of my mouth to chew food properly. However, the bone on the side of the jaw is larger than the other side and it needs to be balanced. Needless to say, I am not happy with my face and have self confidence issues. I would appreciate it if you can provide any information on what can be done. Thank you.
A: For jawline asymmetry correction, I would need to see pictures of your face from the front and side views to do a proper assessment. However having reconstructed cases just like your description I can speak as to the general issues involved. The question becomes whether the longer side of the jawline needs to reduced, the shorter side needs to be lengthened or whether it is a combination of both to get the best aesthetic result. This can be aesthetically determined by computer imaging. Surgically, the key issue is the location of the inferior alveolar nerve in the bone which often is pulled down lower on the longer side and can limit how much vertical reduction can be done. This question is best answered by a simple panorex x-ray or more ideally by a 3D CT scan.
In most cases of significant jawline asymmetry the combination a vertical reduction on the longer side and a vertical augmentation (by a custom made implant) on the ‘shorter’ side is usually needed.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have had injectable fillers in my cheeks with injections of several popular products over the course of three years now. It is costing a fortune since I metabolize it quickly. (so I’ve been told) I have used Radiesse, Juvederm, and most recently Voluma and love the results for correcting diagonal mid cheek lines and loss of fullness but they do not last more than 4 months. How do I find a surgeon who has sufficient experience in cheek implants ? What is cheek implant surgery downtime? Longevity? Any other cheek augmentation alternatives?
A: Your injectable filler story is not uncommon and many patients will be in your same situation in the years ahead. Injectable fillers are great at doing what they are intended to do most of the time. But despite the good results they provide, many patients have or will find out that the long-term costs of injectable filler ‘maintenance’ will become prohibitive for some patients. Thus seeking a permanent cheek augmentation solution has merits.
Cheek implants can provide a very satisfactory solution provided the proper implant style and size is chosen. Because the cheek area and the cheek implants chosen to augment it defy any exact method of measurement (unlike chin implants for example where the amount of horizontal augmentation needed can be measured) it takes a surgeon with a lot of cheek augmentation experience to get it right the first time. While the concept of cheek implants is simple, it can be difficult to get their placement anatomically correct with good symmetry. This difficulty is imposed on top of how to select the best cheek implant style and size for the patient.
Cheek implant recovery is largely about facial swelling and the time it takes for it to look acceptable. In reality expect that to be longer than one really wants. It takes about ten days to look socially acceptable, three weeks to ‘normal’ and really three months to judge the final result and how one feels about the facial change.
The intermediate step between injectable fillers and implants for cheek augmentation is fat injections. While far simpler and with a very quick recovery compared to cheek implants its issue is how well the fat will survive and how long it will persist. These are unpredictable and can be different for each patient.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in orbital asymmetry correction. I have attached several photos. I believe my right eyeball is smaller in size than my left. I also believe my right eyeball is further back in the eye socket and more deeply set than the left adding to the asymmetry I have. This is probably causing my right brow to drop a bit too. If you look at photos you will see my left eye looks different than in other photos. (same eye just pictures were taken at different times) This only happens from time to time, especially when am really tired I don’t know whether its the muscles in the eyelid reacting or what but as you can probably see it looks very odd. I know am never going to be symmetric but if I could find a solution to help minimize the orbital asymetrys then it would help me massively. Let me know what you think Doctor Eppley and thank you for your time.
A: Thank you for sending your pictures and describing your orbital asymmetry concerns. What you have is rather classic right sides facial asymmetry that affects the entire right orbito-malar region. Your right eyeball is likely not truly smaller than the left but it appears so for the following reasons: 1) the right brow bone sits lower than the left, 2) the right eyeball sits further back in the eye socket than the left, 3) the right upper eyelid has redundant eyelid skin (from the eyeball sitting back further), and 4) the right cheek/infraorbital rim one is smaller than that of the left. The skeletal components of your orbital asymmetry can be demonstrated/proven by a 3D CT scan.
When it comes to treating your orbital asymmetry, the most efficient approach would be the following: 1) right brow bone reduction (raise the lower rim of the brow bone by shaving it), 2) right upper blepharoplasty (use this same incision for the brow bone contouring), and 3) right cheek-infraorbital rim implant augmentation.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. I originally had a chin implant ten years ago. Following an accident in nine years later the implant moved and it was changed with a new implant last year. This new chin implant was much too large for my face and was removed six months later. Following the removal of the implant I developed chin ptosis with too much lower teeth show when I opened my mouth.
I subsequently had a chin ptosis corrective surgery three months ago with bone anchors. The result from the chin ptosis surgery is substantially the same as before the surgery but now my lower lip goes in on the right side when I smile or I speak or when I open my mouth my lower teeth sees too much. When I talk I have trouble to articulating my words, maybe because of the new position of my mouth. I saw the surgeon again last month for this problem again and he did Artecoll to correct the irregularity of the chin and offered me another surgery to remove the extra skin under the chin and to do Botox to correct the defect of the lower lip.
I did not accept these proposals because I want to have first your opinion and advice. The surgery to remove the extra skin under the chin makes me nervous because now when I open my mouth my lower teeth show too much and I fear that this problem will be accentuated with this surgery. Now I really need your advice and your help. I’m sure you could find a solution to restore my chin. I read your publications regarding chin ptosis and possible treatments could be a small implant or 2 or 3 mm osteotomy for support under the chin could help or neck lift. I have seen before and after pictures on your web site concerning this surgery in which you made all this women much more beautiful. Thank you very much for your answer.
A: The first thing is I would not rush into any surgery immediately. It has just been three months and your tissues are still healing. If too much lower tooth show is the primary concern any type of submental tissue removal would not help in that regard. Given your history of multiple chin implants and now being ‘implantless’, it appears that an important part of getting your lip back up may be the placement of a new smaller implant to help drive the tissues upward or possibly even making the vertical length of the chin shorter. Lower lip sag is a very difficult problem that is not easily solved.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in getting injectable fillers for nasal folds and vertical mouth lines I am allergic to many things and wanted to find out how common are allergic reactions and can a test be done prior to the actual full procedure?
A: The majority of injectable fillers today use hyaluronic acid-based materials (synthetic sugars) that are also present in many tissues of the body. Because of their very low risk of hypersensitivity reactions, skin testing has never been recommended or advised with their use in first time patients. This is quite unlike that of the now defunct bovine collagen injectble filler products (Zyderm and Zyplast) from the 1980s and 1990s. That being said the risk of hypersensitivity reactions (aka allergic reactions( is not zero although it is less than 1%.
When in doubt or in a patient with a lot of known allergies it can be convincingly argued that a skin test should be done before even a hyaluronic acid-based injectable filler is done. If there is any doubt or concern, I always perform a skin test which is simple and easy to do. It is done just like a TB test.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I have a question about gummy smile surgery. I’ve always had a long mid-face with significant gum in my smile (5mm with normal smile, 7-8mm with excessive smile). I would be interested in hearing your thoughts about mid-face reduction surgical options.
A: When it comes to gummy smile surgery there are two fundamental treatment approaches. The most common approach is a soft tissue one with a lowering maxillary vestibulopasty and legator myotomies with V-Y upper lip lengthening. This soft tissue approach prevents the lip from retracting upward as much and also drops it down a few millimeters at rest. This is by far the most common gummy smile surgery. The other approach, more historic but still of value in the proper selected patient, is a maxillary impaction surgery. (aka LeFort I impaction) This is the proper gummy smile surgery for those patients that have vertical maxillary excess which is evident by excessive tooth at rest and extreme gum show when smiling. It is not indicated when one does not have excessive tooth at rest. Otherwise a maxillary impaction will bury the upper teeth under the upper lip giving one an aged appearance.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am a male to female transgender patient and I am interested in buttock implants. I have been on hormones for 2 years and have already had facial feminization surgery. I have a flat butt and large rib cage. I also have a little fat around my mid section and flanks. I inquired about a butt lift by fat injections but after an examination they said that I do not have enough body fat. They do not do implants and said that they are extremely painful. Your website said that you do them and that there is not so much pain. Any info would be helpful——Thanks !
A:I have done many buttock implants and the key decisions are implant pocket placement (subfascial vs intramuscular) and the implant size and style. Implant pocket placement has a lot to do with the desired size one is after and the type of recovery what is prepared to got through. I am not sure where you read that buttock implants are not that painful as that would be untrue, particularly the intramuscular location. They do have a modestly long recovery since you do have to sit on the result at some point after surgery. They are uniquely different than breast implants for example because of their anatomic location and their functional significance in the short term. In short, buttock implants can provide a successful buttock enhancement result but it requires a motivated patient who can tolerate the 3 to 4 week total recovery process.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had a question that has made me a bit nervous about a custom jawline implant Originally, i was going to have just jaw implants, but after talking to Dr eppley, I decided to do the full jawline including chin, for a more symmetric look. I was wondering a bit about the implant insertion. With just the jaw, I know that the implants were put in from the inside of the mouth, being placed gently under the muscle. But with the full jawline/chin implant, I didn’t know how it would be inserted and if there are complications. From what I understand, under the chin will be the incision. will the implant be one big piece and slid back on both sides to its final location. Are there any complication with the muscles by inserting this way? Is it easy and safe. Also, is it one piece, or is it 3 pieces that are created together that will be re-attached together at the end (2 jawlines and chin). I’m just looking for a more in depth explanation. Any videos of the surgery you could recommend. Let me know if you have any details you could share for me.
A: A custom jawline implant is put in usually as a single piece implant. But it requires three incisions to properly place…two inside the mouth and a front incision done either inside the mouth or from under the chin. The effects on the mentalis and master muscles are the same whether one has a total wraparound custom jawline implant or three separate implants. (chin and two jaw angles) In either case the same subperiosteal pocket must be made.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a frontal hairline advancement. I have no issues with hair loss. My hair hairline simply dips back into in the middle and that’s where I drew a line if that was eliminated on my picture. I have some breakage on the edges from hats and headbands, but nothing permanent. It grows back instantly. Is this possible? I know you are the best at this procedure so I thought I would ask you.
A: Thank you for sending your picture. Where a hairline advancement works the best is exactly where your hairline issue is….in the center of the frontal hairline. Given where you have put the markings for the desired hairline edge I think is a very achievable goal. Scalp elasticity always determines how much the hairline can be moved but a 1 to 2 cm forward movement is possible in most people. It is at the sides of the hairline advancement, the temporal region, where a hairline advancement has the least effect…unless the incision is placed right at the edge of the hairline which would usually not be desirable for most patients. This is a procedure that has a very quick recovery so expect to be back into a normal life within 7o to 10 days after surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin ptosis correction. I originally had a chin implant ten years ago. Following an accident in nine years later the implant moved and it was changed with a new implant last year. This new chin implant was much too large for my face and was removed six months later. Following the removal of the implant I developed chin ptosis with too much lower teeth show when I opened my mouth.
I subsequently had a chin ptosis corrective surgery three months ago with bone anchors. The result from the chin ptosis surgery is substantially the same as before the surgery but now my lower lip goes in on the right side when I smile or I speak or when I open my mouth my lower teeth sees too much. When I talk I have trouble to articulating my words, maybe because of the new position of my mouth. I saw the surgeon again last month for this problem again and he did Artecoll to correct the irregularity of the chin and offered me another surgery to remove the extra skin under the chin and to do Botox to correct the defect of the lower lip.
I did not accept these proposals because I want to have first your opinion and advice. The surgery to remove the extra skin under the chin makes me nervous because now when I open my mouth my lower teeth show too much and I fear that this problem will be accentuated with this surgery. Now I really need your advice and your help. I’m sure you could find a solution to restore my chin. I read your publications regarding chin ptosis and possible treatments could be a small implant or 2 or 3 mm osteotomy for support under the chin could help or neck lift. I have seen before and after pictures on your web site concerning this surgery in which you made all this women much more beautiful. Thank you very much for your answer.
A: The first thing is I would not rush into any surgery immediately. It has just been three months and your tissues are still healing. It would be helpful to see pictures from different angles for a more complete assessment. If too much lower tooth show is the primary concern any type of submental tissue removal would not help in that regard. Given your history of multiple chin implants and now being ‘implantless’, it appears that an important part of getting your lip back up may be the placement of a new smaller implant to help drive the tissues upward. Soft tissue suspension alone appears to have been inadequate.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a reversal otoplasty. I know you have used s small metal spring/clip to help hold the released ear out as an integral part of the procedure’s success. While I know that metal device works I feel uncomfortable with even a very small pieve of metal in my ear. I know you have tremendous experience with resorbable LactoSorb devices and you have probably used that in the past for a similar procedure as a spacer. In an article from 1999, it mentions the use of LactoSorb in rabbit ear cartilage where in 50 percent of the study rabbits suffered auricular skin degradation due to the thinness of the skin and tension on the wound. However it does mention that in order to decrease tissue tension at the implant site, thinner, low-profile more pliable bioresorbable plates have been designed for the nasal septum and are now available for clinical trial.” This article was from 1999 so I hope these other plates have been designed and tested. My questions is this: Would this be a concern for you in this procedure? Also would you know what the thinner, more pliable material discussed would be and if that would be a viable option as well? On a side note I bent the LactoSorb implant you let me take with me to test the pliability and with little pressure, it snapped. This could be a concern if I were to sleep on or press on the implant while healing is taking place. What are your thoughts on this matter? I would love to hear your thoughts on these questions and concerns I have.
A: In answer to your questions about the use of LactoSorb in a reversal otoplasty procedure:
- Such an animal study with that plate size is irrelevant to the human condition. In a mass to tissue ratio that would be the equivalent of putting a 2 x 4 in your arm. That is an enormous polymer load in a small tissue space. With a large load of biodegradable material per surface area of tissue I would expect to see soft tissue changes around the plate. If they really wanted to test it for ‘septal use’, they should have known to use a much smaller polymer load. Therefore, the observed concerns about plate effects on the soft tissue are both misguided and of poor scientific quality. If you want to make a comparative analogy to your clinical situation a LactoSorb device that is .1mm thick, 1mm wide and 5mm long would need to be used in such a study.
- Polymer plates stand little deformation and they will react from a biomechanical perspective like a piece of plastic. They have little room for elastic deformation when acute loading forces are placed on them. That being said, bending them between your fingers is not an analogous situation to being implanted in human tissue. In human tissue that are somewhat mechanically protected by the tissues that are attached to and they develop greater resistance to deformation through hydrophilic nature. (water absorption) However as I mentioned in the office this is a concern that is completely obviated through the use of a metal spacer technique.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a facelift and jaw angle implants. Does it make a difference if they are done together or separately? If they need to be done separately which one should be done first? I have already scheduled my facelift but my gut feeling says that the jaw angle implants should be initially done first. My questions are:
1. Since I should have the implants first…how long after should I schedule my facelift?
2. Do you do jaw angle implants and facelift at the same time? (If I decided to have the facelift with the implants).
3. Would submitting pictures help decide which way to go/
Thanks for your help!
A: While jaw angle implants and a facelift can be done at the same time, I think it is better to stage them doing the jaw angle implants first followed by the facelift three months later. Jaw angle implants cause a fair amount of swelling in front of the ear and jaw angle area. That swelling would seem counterproductive to the pull of a facelift and would work against what the facelift is trying to accomplish. You do not want to stretch out the very skin and tissues that have just been pulled up. (if the facelift is done before and at the same time as jaw angle implants) While I think the two procedures are complementary (both help create a much better jawline), they just should not be done together and the sequence of the staging (implants before lift) is important.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am writing a paper for my school on becoming a plastic surgeon and I need your help.Thank you so much for taking your time to do this…especially so promptly. Out of five plastic surgeons surgeons in my area all of them have practice managers who are like guard dogs to their doctors. I could not get a single one to return my calls or emails. You are amazing for doing this for me. You’ve definitely helped to save my grade and sanity! I am only in my second year to starting my path towards this career. I have a lot to learn yet on what all it will take, but I have my mind set to be a plastic surgeon regardless. If you have any other words of advice I am all ears!
Thank you SOOO much! You are a lifesaver! Alright here we go…
1. What made you chose this profession? Did you know before med school that this is what you wanted to do?
2. What are some of the benefits and drawbacks of your position?
3. Your experience with all of your schooling is really impressive! How long did it take you to complete all of it?
4. What are some of the benefits to becoming board certified? Would you recommend it? and what is involved in doing so?
5. If you had to do it over again would you still become a reconstructive surgeon?
6. What are the most important skills to obtain for this career?
7. What advice or information do you wish you had known when you were premed?
8. Is the compensation worth all of the expenses that it took to become a surgeon?
9. Was money coming in slow when you first started your career? Or were you able to start right out of school at a comfortable pay?
10. What was is like when you first tried to find a job? How long did it take you to become comfortable performing different procedures?
11. What is your typical day like?
12. About how many surgeries do you perform in a week? What are the most common procedures?
13. Are there ever any surgeries that make you nervous? if so, which one(s)?
14. What was the hardest part to becoming a surgeon?
15. What do you think about the current status and future of this occupation?
16. Would you recommend this career to someone who was interested?
For my own personal information…was it hard to get accepted to medical school? I think that is my biggest fear. I stink at interviews and I am scared that they will pick me apart and I won’t know how to respond to their questions. One last question, so my absolute dream is to make money doing the elective surgeries then be able to do pro bono work for individuals who have been in accidents or have had something happen and are not able to afford to “be fixed” is that a completely unrealistic thought? Or is it something that I could expect to be able to afford to do while still living quite comfortably myself?
A: In answer to your questions:
1) My background is different than most plastic surgeons. I went to dental school first and then medical school. I was trained as an oral surgeon and then progressed through further training to become a plastic surgeon. So yes by the time I was in medical school I knew I wanted to be a plastic surgeon.
2) Like all surgeons, the personal and financial rewards are high but it is a lifetime commitment that can be all consuming being responsible for patients and the surgery they have.
3) Leaving high school until entering plastic surgery practice was 20 years.
4) You have to be board-certified today, it is not an option to not be. You will not be paid by insurance companies for surgery performed if you are not board-certified. Board certification is an additional written and oral testing after have you have completed plastic surgery training.
5) Life is full of many interesting vocations. While plastic surgery island has been my life, it would always be interesting to see what else would have been out there to do for a living.
6) Like all careers, persistence and focus are the keys to success. Nothing succeeds more than persistence dedication to a focused goal.
7) Nothing really. Education and the creation of a career is an evolving process than often takes one down different roads than one envisions. Keep focused on getting the best education with a propose is what I knew then and is what I would tell any college student today, a medical career notwithstanding.
8) Money is only a measure of educational costs and the services ultimately provided from using it. The worth of that education and career is really based on the joy one gets by the process of achieving it and then using it. One should never measure their success in life by a monetary yardstick. The value of the process is what it makes you as a person.
9) Comfortable pay is a relative concept. As long as the money coming is ore than your expenses, one should be comfortable. But yes working is more financially comfortable than training is.
10) I never had trouble find a job. Work was available as soon as I finished my training.
11) I start the day at 5:30AM in the office and usually get home by 7PM at night.
12) I perform between 10 to 15 surgeries per week. Since I do such a varied number of aesthetic and reconstructive plastic surgery procedures there is not really one common procedure. The procedures range anywhere from cleft lip and palate repairs, cosmetic breast augmentations to custom skull and facial implants.
13) No surgery makes me nervous anymore ayer having seen and done thousands of plastic surgery procedures. The only thing that makes me ‘nervous’ is my hope that each patient gets the best result and the outcome takes them to a better place.
14) Working when you feel too tired to do so.
15) Plastic surgery is such a diverse surgical specialty that it will always have a bright future. When the possibilities are so endless the future is only limited by the imagination and creativity of those who are trained to do it.
16) Interest in plastic surgery alone is not enough to make it a career. Passion about it is what is important. For that is what it takes to get through the process to becoming a plastic surgeon.
Getting into medical school has little to do with how one interviews. Just like college it is really all about the numerics, the grades and test scores.
While it it is not completely unrealistic to be able to do pro bono surgery, the reality is the medicolegal and social media risks of so doing will usually make that thought secondary in the real world of practicing surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in umbilicoplasty surgery. (technicaIly umbilical scar revision after a tummy tuck) I just recently had a tummy tuck 6 weeks ago and my belly button is off to the left a little… I want to correct this but I wasn’t sure how long to wait? And if this is something you can do?
A: If you have had a fully tummy tuck and your belly button is off midline, it can be moved back closer to the midline through an umbilicoplasty procedure. But there may or or may not be a residual scar out of the ring of the belly button scar based on how far it needs to me moved over. I would need to see pictures of your abdomen to better answer your question. Most likely when you say a little I would imagine it is probably no more than 1 to 1.5 cms at most. It is possible that just excising a crescent of skin towards the midline on one side of the bellybutton may be the type of umbilicoplasty (umbilical scar revision) that you would need. I would certainly vote for that approach even if it can’t be gotten completely to the midline because to will keep the scar confined to the circumferential existing scar around the belly button.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in skull reshaping as well as jawline reshaping. Would insurance cover my surgery since it is due to congenital plagiocephaly? Also, any doctor in my area that you know of that could do the same surgery that I need? Thank you for everything you do.
A: Thank you for your inquiry. In answer to your questions:
1) It would be impossible to answer any of your questions without knowing what exact procedures that you need. What I could envision what they may be, I would need to see pictures of your face and a more specific description of the skull and facial asymmetries that you have. Skull reshaping and jawline reshaping are broad terms that apply to a variety of different procedures.
2) Only the insurance company can say whether any of the proposed procedures would be covered. To make that determination the treating physician would have to file a predetermination letter complete with a 3D CT scan (to show the deformities) so they can pass judgment on the operative plan. At best, it would be a 50% or less chance that they would cover any of the procedures.
3) Without knowing the exact problem and the needed procedures, I could not say what expertise exists in your geographic area. Skull reshaping and jawline reshaping are very specialized areas in plastic surgery that very few plastic surgeons do.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in facial asymmetry surgery. I developed facial asymmetry over past five years and it gets worth each year. I have very low self esteem and would want the least invasive procedure to correct this. I am interested in knowing the causes for this and learning more on options to correct. As you can see in this photo the right side of my face seems to droop. It is not as toned as the left side. To me it seems to be pronounced when I talk and less pronounced when I smile. The concern I have is why–about 5 years ago I didn’t notice this extreme droop at all and over the past few years it seems to get worse. I have always had a lazy eye and that never really bothered me but now that it has advanced to my lip it does concern me. What are causes for this? I get my eyebrows done and the technicians have told me it’s hard to get them to match because they are just different that is when I really began noticing. It just seems like the two sides of my face are totally different. I appreciate your time.
A: Your facial asymmetry is congenital where the entire right side of your face sits lower than the left. Yo have known this inadvertently for a long time because of the eye asymmetry (‘lazy eye’) but it has become more apparent now as the entire right face is dropping as you age. That is why it is much more apparent now and gets better when you smile since smiling picks up the sagging tissues.
There are no ‘minimally invasive methods of facial asymmetry correction. This is a problem that will respond only to surgery. The simplest and most effective approach to your facial asymmetry surgery would be a combined right endoscopic brow lift and right lower facelift/jowl tuck up procedure. This will resuspend the tissues up higher so the right facial droop is corrected and better matches the left side of your face.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in occipital augmentation surgery. My 5 year old son has a flat spot on the back of his head. We consulted out pediatrician about it from an early age and were told it would “round out”. It didn’t so at 18 months we paid out of pocket for a helmet and got minimal results because of he was passed the age of best results.
This has caused a lot of pain and regret for us even though my son doesn’t have a clue that anything is wrong. At what age is it safe to consider doing something about the issue? We don’t want him to face any social issues because of bad advice from our pediatrician and late action on our part. What are our options?
A: The aesthetic correction of unilateral occipital plagiocephaly by occipital augmentation can really be done at just about any age in my opinion. Correction involves building out the bone with hydroxyapatite bone cement (at at early age) or a custom made implant at older ages. Whatever is placed on the bone will grow with the slowly expanding skull growth. I think hydroxyapatite cement is most appropriate for young children since its the inorganic mineral content is most similar to bone. The decision and timing for occipital augmentation surgery at this point in your son is a personal one and is most appropriately done when you and your wide deem it most psychologically protective.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My eyes are too wide- apart which is the biggest regret in my life. I have normal to level 1 of hypertelorism (advised by one doctor before) and I think I am close to no deformity. I would like to know if orbital box osteotomy can be performed in non-deformed patients through milder approaches, like via infra-orbital or oral incisions since my inter-pupillary distance is not as wide as the deformed cases. In my home county and East Asia, there is very rare information about this procedure. I would like to know if any osteotomy procedures can be done to my eyes. Much appreciated and awaiting eagerly for your response. Many thanks doctor!
A: Orbital translocations, aka orbital box osteotomies, can only be performed through a coronal/scalp incision with a frontal bone flap craniotomy removal. There are no effective more limited ways to do an orbital hypertelorism procedure. The only less invasive way that the eyes can be made to appear closer together is with some camouflage procedures such as nasal bridge augmentation and/or medial canthoplasties/medial epicanthoplasties. These small changes to the nose and inner eyes, particularly if done together, can often have major influence on how close the eyes may appear.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am looking for a surgeon who has proper training to do “mandible angle reduction”surgery. (This is a form of plastic surgery, aesthetic not reconstructive, to reduce the square jaw angles for patients who do not have jaw angle deformities but just wish to reduce square jaw angles.) However, I am not sure what training a doctor should have to perform this type of surgery.
a) Is it enough for a plastic surgeon to attend a 3 day forum for “ Surgical-Orthodontic Approach to Dentofacial Deformity”, to perform “mandible angle reduction”and cut people’s square jaw angle bones?
b) Would attending a 3 day forum on “Surgical 0rthodontic Approach to Dentofacial Deformity” be RELEVANT to equip a plastic surgeon to perform “mandible jaw angle reduction?
c) I cannot find information on line about “Orthodontic Approach to Dentofacial Deformity” so I have no knowledge/understanding. What is this about? Orthodontic is a branch of dentistry so I cannot quite see how this 3 day forum relates to doing mandible jaw angle reduction.
d) What training should a plastic surgeon have, which would be relevant or adequate to perform “ mandible jaw angle reduction” ?
A: The question you are asking about what qualifies a surgeon to perform jaw angle reduction surgery is not a simple one as that training/experience could be gathered from a variety of different experiences. Any surgeon that would perform this procedure would be trained and very experienced in facial bone surgery. This could come from a plastic surgeon with craniofacial surgery training or an oral and maxillofacial surgeon with good orthognathic surgery experience. Jaw angle reduction surgery, while simple in concept, is technically challenging as is all surgery of the mandibular ramus due to the limitations of surgical access.
I can speak about the forum you have mentioned in the context of your question since I have not seen or attended the program. Although that is clearly a course in orthognathic surgery of which aesthetic jaw angle reduction would not typically be a part of that course curriculum.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I would like to get some information about the PRP hair injections for hair loss. I have been diagnosed with Telogen Effluvium. I believe it may be CTE now as its going on a year. Will this treatment help stop the shedding as well as help with growth?
A: PRP (platelet rich plasma) has had good success with a variety of medically induced hair loss problems, not just for androgenic male hair loss only. (PRP Hair) Since telogen effluvium is a reactive process and not genetically induced it should theoretically respond to a variety of stimulatory agents. PRP contains platelets which are concentrated sources of high levels of growth factors. Such growth factors are known to stimulate a variety of cells including the follicle cells in the hair bulb. For hair loss PRP is mixed with other hair growth agents such as niacin to maximize its effects. It is administered through a number of small droplet injections throughout the scalp using a very small 30 gauge needle. While there is no guarantee for response in any patient, the autologous nature of PRP has no downside to its use. PRP hair treatments can also be combined with other hair regrowth methods such as minoxidil for a synergistic effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in chin reduction surgery. Here are my questions:
1. What is your recommended approach for me…burring down vs. cutting the bone, intraoral vs. submental, etc? Just the chin or the jaw also? Changes to the fat/muscle/skin?
2. What can it achieve (can you simulate it with a digital image)?
3. What are its limitations and possible side effects?
4. What are the risks and how do you minimize them?
5. What can I do to ensure the best results possible? Are there limitations on travel?
6. Can you share before/after photos of women who have undergone this surgery?
7. Your site states $6500 for chin reduction – does this include anesthesia, operating room, surgeon’s costs? Does the cost differ by surgical method?
8. How much time to I need to plan to take off work and/or work from home?
9. How many trips would be required? (pre-op, surgery day, post-op/follow up?)
10. Would you recommend doing rhinoplasty and chin reduction at the same time or separately?
11. What are your Care Credit terms (6,12,18 months no interest?)
12. Do you require dental x-rays or some other type of imaging?
13. Would liposuction be effective in achieving a more defined chin/jawline? Is this considered a separate procedure from the chin reduction? Is there enough fat in your estimation that re-injecting it to my cheeks would produce a good result? Would a future pregnancy alter the results?
A: Thank you for sending the detailed questions about chin reduction. My answers to your questions are as follows:
1) If vertical chin reduction is all that is needed than an intraoral wedge bony genioplasty approach would be used (this would include narrowing the chin if desired) But all other chin dimension reductions are best done by a submental approach.
2) Computer imaging is always done before any facial reshaping procedure. Chin reduction is no exception.
3) Scar (if submental approach is used), asymmetries, uneven jawline, soft tissue redundancies are all potential risks and complications from chin reduction surgery.
4) As you can see in #3 the risks are essentially aesthetic in nature. Knowing how to manage the soft tissues in a chin reduction is actually more important than the bony reduction part of the operation.
5) Preoperative choice of the correct chin reduction procedure is the most important step to ensure the best result.
6) Because of patient confidentiality, there are very few before and after pictures that can be shared. And this is coming from someone who has done a lot of them.
7) This is a logistical question for my assistant Camille. Until we know the exact chin reduction procedure she can not give you an absolute number.
8) Recovery is all about the swelling and when you feel comfortable being seen in public. Everyone is different in that regard. It could be one week for some and three weeks for others.
9) One trip for the surgery is all that is needed. All followups can be done electronically.
10) Rhinoplasty and chin procedures are commonly done together. That is a personal choice.
11) Another economic question for Camille.
12) No preoperative x-rays are needed unless one is getting an intraoral bony genioplasty.
13) Liposuction rarely, if ever, can make a more defined jawline. Such changes are a reflection of what happens to the bone not the soft tissues. Any fat injections done would need a harvest site not from the neck. The amount of fat needed exceeds what can be obtained from the neck. Chin reduction surgery will not be affected by pregnancy.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, what is the difference between the effects of cheek implants and a cheek lift? In looking at pictures cheek implants looked more subtle than the lifting of the cheek tissues. The cheek implants themselves looked more obvious than the cheek lift, however. The cheek lift appears to pull on the face and make the nose a bit wider and even lift the lip. So the overall change to other facial features with implants seemssubtle while there were more changes to other facial features with the cheek lift,despite the cheeks themselves looking more natural. Am I correct in this assessment?
A: You are quite accurate in your assessment of the influence of the cheek lift vs cheek implants and their effects on the face. Cheek implants push the tissues more out and forward while a cheek lift pulls the tissues more up and back. Thus their effects on the cheeks are different. A cheek lift can widen the nose and pull upward on the lips. Conversely cheek implants have no effect on the nose and the lips.
This is why a cheek lift often creates a bigger change on one’s face while cheek implants have a isolated effect on just the cheeks.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I am interested in a forehead implant. What would the duration of the stay after surgery need to be? How long is it going to take to make the forehead implant? Also what is the maximum you can fill the forehead outward just for reference? How large are the implants able to go? Mine won’t be a very large one I don’t believe, but I’ll send you a picture as requested. Its more the upper part of the forehead I’d like to add volume to and maybe the brow area also if you can do that. But it is mainly the upper forehead so I have more even side profile and not a slanted forehead.
A: With a 3D computer designed forehead implant the dimensions of it can be just about whatever one wants. Given your descriptive requirements there does not appear to be a limit to the thickness of the implant particularly at the upper part of the forehead which usually never needs more than 7 to 8mms of thickness. The implant fabrication process takes about three weeks from design to having the sterile implant arrive for surgery.
You would likely not need to be here after surgery for more than a few days so ou feel comfortable traveling home after your forehead implant surgery.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I contacted you six months ago about cheek implants. I had gotten cheek implants placed, removed, and then a cheek lift. I promised a six month update. Wow, what a difference six months post op can make. My desire for to have implants reinserted (in this present moment) has vanished along with all of the swelling that previously existed. Swelling can play serious tricks on the mind, and it’s unfortunate that many people don’t realize this. I had mentioned that I wished I had waited the full 6 months to see the cheek implant result, and that still rings true, but not much can be done about that now. I’m sure as a plastic surgeon you must go batty trying to help people understand what is just swelling and to wait out the full six months before judging the final result.
Anyway, things are great for now, but moving forward, if several years from now I am interested in getting implants reinserted, I will definitely keep you in mind. Thank you very much for your help regarding my cheek implant issue.
A: One of the hardest things for facial reshaping patients to understand is the time it takes for all swelling to subside, soft tissue contraction to occur and one to psychologically adjust to the new facial look. The patience it takes to go through these phases is highly variable and some patients are more tolerant if it than others. There definitely is a tendency for some patients to want to reverse their result in the early phases of healing for the comfort of what they used to look like.
Cheek implants are no different in this regard and the tendency is to think they are too big early after surgery. When months later had they waited it out it may be just fine…or in some cases not enough of a cheek augmentation effect.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, What I don’t like about my nasal implant is that it looks stiff and sits on top of the bone rather than conforming to the natural contours of the bone. The frontal view looks nice but the side view not as good. From the side view I prefer more of a “ski slope” look. Is rib cartilage as stiff and firm as the implant? Can rib cartilage still warp? Is rib placed in the bridge area the same way the implant is? Does the nose have to be cut open to place rib? I was also wondering if tip surgery is generally less expensive without an implant in my nose? Thanks for the info.
A: Rib cartilage is stiffer and more firm than a nasal implant. Unlike a nasal implant, rib grafts do have the risk of warping although that is largely related to the shape of the rib graft harvested and how it has been carved. Like nasal implants rib grafts are put in the same way which is best done through an open rhinoplasty approach. The cost of a tip rhinoplasty would be the same regardless of whether a nasal implant already was present in the nose.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I’m a healthy 32 yr old man who previously had a successful rhinoplasty one yr ago. One week ago I had Radiesse (1,5 ml x 2) injected in my cheeks and I loved the results immediately after. But since the inflammation has gone away, I lost that chiseled male model look I am going for. It still looks good but not as good and not that chiseled look anymore. I can’t afford to inject my cheeks with Radiesse every week so I need a permanent result. The problem with off the shelf cheek implants is that they only provide a 4 mm thickness and the post op pictures look too subtle for me. (because I want to be a model). I have low body fat and a narrow face with thin cheeks so I feel that I have the anatomical prerequisites to achieve that attractive look with the help of a skilled surgeon like yourself. What is your opinion on this? I have attached 2 photos from before and immediately after my Radiesse injections. I also attached photos of three male celebrities with the chiseled look that I am looking for.
A: Injectable filler treatments can be a good test to see the effects of cheek augmentation but are clearly not suitable for a sustained and repeated cheek augmentation approach over time. If an injectable filler treatment gave you very pleasing results then I am certain that a bone-based cheek implant can do the same if not better. Cheek implants do come in thicknesses greater than 4mms so I am not certain that a preformed standard cheek implant of the right style and size would not work for you. There is, of course, always the option to make custom cheek implants.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, My question is about the limits of a lip lift and the use of one in a postoperative Lefort patient. In most of the pictures I’ve seen it looks like a surgery that merely helps make the vermilion more visible but it doesn’t really “lift” the lip if it’s really hanging. I received orthognathic surgery years ago to make my face shorter and since then my upper lip has been hanging lower than usual. It also looks flat and dead instead of curled up and reactive to facial tension. I was wondering if a lip lift could help in this case and if one with muscle hemming (a technique that I rarely see talked about) would be a better option. Thanks.
A: Your correct in that a subnasal lip lift primarily exposes more vermilion (and reduces the skin distance between the nose and the lip) bit does not lift the bottom edge of the lip vermilion any higher. A subnasal lip lift is largely a static procedure not a dynamic one. Many upper lips after an intraoral vestibular incision used for a LeFort 1 procedure become somewhat less animated due to the stripping of the collateral muscle attachments. I can’t see, however, how a muscle hemming procedure of a subnasal lip lift would improve that problem. It would likely cause other adverse effects on upper lip movement and smiling which is why it is not written about much and is largely shunned today.
If you want to raise the upper lip with a subnasal lip lift it should be combined with a horizontal horizontal mucosal resection on the inside of the lip.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, I had eyebrow transplants done 3 weeks ago with 50 FUEs to each brow area, I’m looking to get a rhinoplasty with a silicone implant done a month from now. Can I just check and see if it will be fine to do so or will my grafts be damaged if I get a rhinoplasty done so soon after? My surgeon says it is fine but I wanted to get some additional expertise from someone of your professional caliber.
A: The follicle of a hair transplant has taken by two to three weeks after being placed. The hair shaft will have exfoliated by then but the transplanted follicle lies deep to the skin surface where it will be unaffected by any external forces. It will cause no harm to recently transplanted follicles to have a rhinoplasty done one month after the hair transplantation procedure. In fact hair transplantation could be done at the same time as a rhinoplasty if it were not for several logistical issues. (e.g. time of the procedure and the typical environment (office ) where most hair transplantation procedures are done) Rhinoplasty even using a silicone implant will have no negative impact even on hair transplants that are so new.
Dr. Barry Eppley
Indianapolis, Indiana
Q: Dr. Eppley, Three years ago I had a functional rhinoplasty with adenoids were removed and turbines shrunk which has dramatically changed my voice. My nose and face have changed. The flesh all around my nose, the triangle from under my eyes down my cheeks and under my nostrils / tip of my nose has completely sunk. It is fixed and depressed against the bone of my skull. My top lip has flattened and hangs lower over my teeth. The nose tip is also thinner and lower. I am interested in a pyriform implant a surgeon here recommended that might support the base of the nose off of my skull again and lift the flesh up with it. It is a concave depression right now I keep poking out with my tongue over my teeth. Also my cheeks have sunk either side of the nose so I have folds and have lost my natural volume over my naturally high check bones. I had a young face but have aged over night. My eyes look sunken and everything pulled down as if the implants fixed my cheeks inwards and down. I have seen different surgeons and there is no consensus between implants or fat grafting but I also feel as if my cheek and lip muscle around my nose need lifting back into place. I keep being told I am attractive and too young for a face lift. I feel as if no one is listening. I seem to be researching similar treatments as cleft palate patients. Between the nose and lip and around the nostrils up to the eye are indented.
Please find attached some pictures for your review. You can see how my lips jutting out under the lip and the front of the cheeks is flat, particularly indented on either side of the nostrils and where the mouth cheek folds are. I look forward to hearing from you.
A: Thank you for sending all of your pictures. You have a classic central midface deficiency. It is really a combined per maxillary-paranasal-maxillary deficiency which is commonly seen is certain ethnic groups. (e.g., Asians) The whole central part of your face is flat. While a peri-pyriform midface implant will be somewhat helpful it is inadequate in both design and size for your needs and its benefits alone will be woefully inadequate. By itself it will not provide fullness (more like bumps) to the side of the nose. What you ideally need is a custom midface implant made that will build up the entire deficient mid facial area from around the base of the nose up along the sides of the nose and out onto the maxilla. In addition the tip of the noses not going to be lifted up by any augmentation done at the bone level including the premaxillary region. Deprojection and lifting of your nasal tip will require a tip rhinoplasty to do so.
Dr. Barry Eppley
Indianapolis, Indiana
