Your Questions

Q: Dr. Eppley, I had a sliding genioplasty to narrow my chin. I told the doctor that them when I smile, my face looks big at the side of the chin so he mentioned that he’s gonna cut or reshape the bone there and remove some muscles. I’ve attached the photo of the before and after surgery. Because after I did this, every time I smile or not even smiling, I see my line around my chin area looking like someone took a bite out of it and the bone there’s gone. Also I feel like my chin is more narrow not like before. I really don’t mind if it’s making my chin comes forward, but not like before. It is possible to reshape the chin bone in any way. Or just simply just cut the middle and then put the bone in front? 

A: Based on your pictures and the x-rays, what you had done was a sliding genioplasty that brought your chin forward and up a bit as well as had a central wedge taken from it to narrow it. This is clearly evident in the x-rays and by the plate fixation used.  What this has done, and is not uncommon, is to narrow the chin but there is a step off at the back part of the osteotomy cuts. I see where no other bone has been removed…and certainly no muscle or soft tissue has been removed. This has left you with a chin that is now too narrow for the rest of your jawline…hence your interpretation that it looks like a bite has been taken out of the jawline behind the chin. (hollow part)

You have two options to consider for your sliding genioplasty revision. Probably rather than moving the bone back, which can be done, you could simply fill in the bone defects left along the jawline. (provided you are satisfied with the way the front part of the chin looks)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a short lower jaw and feel that it needs improved from front to back. This includes the chin and jaw angles. I am uncertain as to the best way to do it. As a man, I do not lie walking around with a jawline that is not very masculine. My biggest concern about any type of jaw implants is that they might become loose or dislodged if I get hit or participate in any sports. What is your recommendation?

A: There are three different approaches to your type of jawline enhancement and include the following:

1) Standard chin and jaw angle implants (3 pieces)

2) Sliding genioplasty for chin and jaw angle implants (2 pieces)

3) Custom wraparound jaw implant (1 piece)

There are advantages and disadvantages to each jawline enhancement method. Your biggest concern about implant dislodgement would be completely avoided by a single one-piece jawline implant that has a custom fit by computer designing. This is because it is a single implant that with its wrap around effect has more surface area for implant fit and this becomes very difficult to ever move from its custom fit location.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for a surgeon who can help me to decide how to improve my scar. I know it is hard to evaluate a scar from just pictures. I have a small scar 0.5 cm on my chin resulted from squeezing and scratching the spot and I got it infected. It was 10 years ago.The scar was just a very little raised and became white. I had radio frequency treatment done 5 months ago. And after a month the scar became a little more raised. I attached the picture of the scar so you can have a look. It is a slightly hypertrophic scar.

I got a lot of different options from the doctors. Nothing has been done yet, I am very careful as the scar is on the face. A few doctors recommended to me that laser CO2 fractional would be the option for me and some of them said that excision of the scar will give me a more significant improvement and I should have a scar as fine line. Two doctors recommended steroid injection to flatten my scar but it will not reduce the white color.Another doctor said that it could make another complications like pigmentation surrounding skin. I do not want to try laser CO2 as I had radio frequency treatment done on my face and my scar became a little more raised and white.

I would go for excision but a few doctors said that my scar could look worse because of the location. One doctor explained to me why he would not do excision as the scar is on the chin and there is no loose skin so if he cuts it out it will have to be closed under tension which could make my scar worse.

Another surgeon told me something different please read below:

‘The existing scar is not big enough that there should be much tension on the surgical scar. With a good surgeon, and a good post-operative healing process, should leave you with a fine white line. I would place it in a curve or oblique line that parallels the curve of your chin pad – this is called a resting skin tension line (RSTL). The deeper layer of sutures should be dissolving, but the last layer at skin level should be non-dissolving for the best chances at a good result.’ 

Another surgeon told me this:

‘One of the surgeons you have seen is right to say that it does depend a little on how much loose skin there is but in general, there is ample laxity in facial skin to perform an excision of this kind without distortion.  So long as the new scar is placed carefully in relation to the natural lines of relaxed skin tension the new scar should be favorable, but it will still be a scar.’

What do you think about it?

What would you recommend after excision, i need to know your opinion to get the best care after excision.

One of the surgeons wrote me this:

‘I ask my patients to cover their wound/scar with Micropore for the first 3-4 weeks as this provides some mechanical protection to the wound, and traps some sweat and waxes from the underlying skin, which is good for the scar.’

Silicone sheeting is applied after 3-4 weeks, as the scar undergoes a change in how it is behaving. For the first 3-4 weeks, a scar is depositing collagen bundles in a random manner to build up strength. After that 3-4 week,s it enters the remodelling phase, where the scar starts to pull down the random collagen bundles and arrange them in the best possible direction for the scar. At this stage, the body also send in new blood vessels to help that process. This is when scar management such as scar massage and silicone sheeting will help. Starting to do these things earlier than 3 weeks can weaken the scar and cause it to widen.

What do you think about it?

A: The short answer is…if you want to have any chance of a visible improvement in your scar, you have to excise it. There is not an issue of inadequate skin laxity ti close it. Scar revision has ittl chance to make it worse, it is only a question of how much improvement can be gained.

When it comes to scar therapy, I do not believe there is any magic. Given the very small size of the scar, I would recommend topical steroid gel applied at night only.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did lots of research before my jaw angle implant surgery. But I guess not enough to find the difference between lateral jaw implants to vertical implant. I have a high jaw, and I didn’t want it much wider. Just further down with slight wider. I told my surgeon this and he said that there’s only one implant for the jaw. The lateral one. I now can see the width that I will have but of course there’s swelling. The width is too much and it’s not down where I was wanting my jaw to be. So that’s why I would like to do the vertical lengthening jaw implant. I’m trying to see if my doctor can remove it this week. My doctor did not place screws with my implant, he just placed the silicone implant in the pocket of my jaw. I don’t think my doctor was an expert on jawline enhancement and I think that was my first mistake. I’m actually freaking out thinking I just ruined my face. Is it possible to fix my jaw implant problems? Not only did he do the wrong implant, he also went too large.  Please comfort me with info and what I can do.

A: Unfortunately your research on jaw angle implants was indeed inadequate. Of the three decisions you have to make about jaw angle implants, the very first one is whether the implants should be of the lateral width style or the vertical lengthening style. The second decision is what sizes or thicknesses should theses styles be. Lastly, there is the issue of material choice. (silicone vs Medpor)

By far the most common jaw angle implant is the vertical lengthening style with some width. (but usually less than that of the vertical length increase) Pure width (lateral width) jaw angle implants are used in 10% or less of all jaw angle implants in my experience.

You did not ruin your face, the implants can always be converted to the vertical lengthening style at any time. With your facial shape, you likely need a 7mm vertical lengthening and 3mm width style jaw angle implant.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a lot of orbital bossing of the skull which may be pinching the supraorbital nerves causing daily migraine pain. I guess this surgery would be called forehead reconturing/orbital bony contouring/brow bone reduction of that region. I was hoping to get a surgery that could take care of the functional as well as the aesthetic. I have a 3D Ct scan of that region and was wondering what a rough estimate might be for that surgery. Would insurance cover this procedure? I know that the same incision is made across the hairline for both the migraine surgery and the recontouring of the orbital bony area of the forehead. Listed below are descriptions of the surgery I have in mind. Thanks!

1. Forehead reconstruction or cranioplasty where the glabella bone is taken apart, thinned and re-shaped, and reassembled with small titanium wires or titanium microplates and screws.

2. Or the compression technique in appropriate cases where the wall of bone is first thinned and weakened, and then compressed into place. It then heals in the new position.

A: Certainly orbital rim recontouring by brow bone reduction and decompression of the supraorbital nerves can be done at the same time. Only brow bone reduction uses an open scalp incision. Isolated supraorbital nerve decompression for frontal migraines is usually done by an endoscopic limited incision technique. But the open approach does afford great access to the nerves for the best decompression possible.

Most brow bone reductions are best done by an osteoplastic flap technique where the outer table of the frontal sinus is removed, reshaped and then put back in its reshaped form by either resorbables sutures or very plates and screws.

Neither is aesthetic brow bone reshaping or supraorbital nerve decompression for migraines covered by insurance. Prominent brow bones are not a recognized craniofacial deformity by insurance companies. Nerve decompression for migraines is currently viewed as ‘experimental’ surgery without long-term clinical studies to be currently viewed as an approved medical procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. I can not figure out what my face needs to look better. I’d really appreciate you taking your time for this. I have been given different surgery options from doctors here in Australia. However my opinion is that the best doctors are located in America, especially for facial surgery. It has been recommended to me that I have cheek implants, buccal lipectomy and a chin implant. But I want to know your opinion since you are regarded as one of the best surgeons in the world for facial reshaping surgery.

A: In looking at your pictures, your facial reshaping/restructuring goal would be to shorten your longer face and provide some more central projection. You have a more flat paranasal/midface and thus you have to be careful with how you change things to not look worse. I would recommend the following:

1) Chin augmentation but by sliding genioplasty as your chin needs to come forward but should become vertically shorter not longer. (implants tend to make the chin longer or at least neutral in vertical length)

2) Malar/Submalar implant augmentation with emphasis on providing with anterior projection not so much width

3) Avoid a buccal lipectomy. That would be one of the worst things you can do to a face that already lacks projection and could easily end up looking gaunt.

4) Paranasal augmentation to build out the base of the nose and the maxilla. This complements what the dimensional changes of the cheeks and chin and avoids ‘leaving the area between the two behind’.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have read about your custom jawline implants (wrap-around style) on exploreplasticsurgery.com and was wondering if these implants can increase the width of the jaw angle as well as the vertical height or is it just the vertical height that these can change? I’m also trying to establish the drawbacks (apart from cost) of these wrap around implants over the separate jaw/chin implants.

A:  Custom jawline implants can be made to any dimension that is aesthetically desired in either height, width or shape. The actual cost difference between a custom implant and standard implants is much less than one would think, with only about a 20% cost difference at best. While the cost of the custom implant is higher, it takes only 1/2 of the operative time to do…thus explaining why the cost difference is not that extreme. Having done hundreds of combination chin and jaw angle implants, I now find that single custom jawline implant produces a better aesthetic result with a very low risk of malposition/asymmetry compared to using three separate pieces. (1 chin and 2 jaw angles) In fact, it is virtually impossible to have a malposition of a custom implant because of the precision fit and design.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in getting a forehead reduction with the hairline lowering included. However the bossing of my forehead is the entire bone, top middle and down to the bottom over the brow bones. Can these areas be burred and reshape with the same approach you use on the brow ridge and eye orbits sockets as well?

A: The entire forehead can be reduced by burring. The only exception or caution would be over the brow bones where the underlying frontal sinus exists. The bone on the front of the frontal sinuses (brow bones) is usually very thin and may be only 3 to 4mms thick before the frontal sinus is encountered. A lateral skull film x-ray is needed before surgery to measure the thickness of the bone to see how much it can be reduced by burring. If more reduction is needed than just burring can allow, then an osteoplastic bone flap technique is needed to maximize the lower end of the forehead reduction. In a woman this is rarely needed however.

That is a long answer to say that a burring technique can sufficiently reduce the amount of bossing of the frontal bone and is often done on conjunction with a hairline lowing/advancement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the Brazilian Butt Lift and would like to know how many procedures you have performed? I have attached two pictures and would like to know what kind of results you would expect with my body type. I am not wanting a big Kim Kardashian booty just some volume to add some shape. Looking at my attached pictures do you think this is achievable?

A: It is a good thing that your Brazilian Butt Lift (BBL) objectives are not like that of Kim Kardashian as you simply do not have enough fat to harvest to achieve that amount of buttock size increase. The success of BBL surgery depends on two important factors, how much fat does one have to give and how much fat will survive after being processed and injected. When you realize that less than 50% (at best) of what comes out as liposuction harvest ends up as buttock volume addition, the reality of what is achievable by the BBL procedure comes into focus.

What one means by ‘just some volume to add some shape’ is open to interpretation, the question is really whether the procedure is worthwhile. There is only one guarantee with the BBL operation and that is the body contouring that results from the liposuction harvest. When one does not have a lot of fat to harvest and process, a realistic buttock augmentation goal should be ‘just something more than what I have’. As that is the only assurity you can get from the procedure.

Many successful buttock augmentation results occur from the combination of reducing what lies around the buttocks and augmenting what lies within…more so than a real substantial buttock size increase. Such would be the case with your body type.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I did not know i could have cheekbone reduction in the U.S.. I had it done in Asia where my friend had that done too. I am of Asian descent and I have wide prominent cheekbones. I had the cheekbone reduction procedure without plates and screws and now I am afraid of non union of the bones, misalignment and dislocation of the fragments of the zygomatic arch. I hear a clicking sound. My surgeon in Korea says it’s normal and will disappear, but I wanted a second opinion from you. 

if you don’t use fixation how you make sure the bones stay in place how you prevent sagging and scleral show after the cheekbone is collapsed. Once you push the zygoma arches in and there are gaps and dents, does new bone is created in years to fill in those gaps or do they remain depressed?

A:  Cheek bone reduction surgery can be compared directly to have a facial fracture…albeit a surgically controlled one. The best way to ensure that the bones stay in the desired position and heal is to use some form of bone fixation. (plates and screws) The clicking you hear is the bone segments that are unstable and are moving with their edges rubbing together.

Since the zygomatic arches are not functionally loaded bones, like the lower jaw for example, one can argue that it is not critical that they are stabilized. They will eventually go on to heal even if it is by fibrous rather than bony union. When it comes to cheek bone reduction, however, the position of the bone is just as important as whether it heals. Sagging or dropping of the bone is associated with soft tissue sag and even potentially lower eyelid sag. This is why some form of bone fixation should be done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After perusing your blog extensively (thank you for it, it has been a tremendous help!), I’ve finally decided to get cheek implants. My issue is that I had a sinus infection 2 weeks ago,and my doctor put me on antibiotics for a week. It has since cleared up and I don’t have any symptoms of sinusitis anymore. As I will be getting my cheek implants in two weeks, will enough time have passed for me to get the implants safely, or will I be an increased risk of infection due to the prior sinusitis?

A: It would be logical to assume that there could be a correlation between cheek implants and maxillary sinusitis. And certainly one should not undergo any elective cosmetic procedure if any active head and neck infection is ongoing. While they are anatomically very close, the placement of cheek implants on top of the zygomatic bones and the sinuses located below and behind the front wall of the maxilla are distinctly separate areas that do not connect. Even an active maxillary sinus infection does not contaminate the tissues where a cheek implant would be placed.

But having a two week period where the maxillary sinusitis is cleared would be prudent. But the typical antibiotics given for facial implants (usually Keflex) is not the type of antibiotics that should be prescribed for maxillary sinusitis since it does not provide adequate antimicrobial coverage.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am in search of a very skilled revision rhinoplasty surgeon and am impressed by your work. 

I had my first septorhinoplasty with right inferior turbinectomy around 18 years ago.  My nose looked wide and had bulbous tip and pinched nostrils on birth and I had breathing problems. During first surgery the doctor took too much of my bridge away. My breathing problems got a bit better but my nose looked totally deformed.  I am of course very depressed due to that and am very much judged by people in life when they see me before I even open my mouth due to my appearance. 

I long to have a normal nose, I would like to have my bridge built up.  These pictures were taken in 2012 just before tip plasty.  I am sending the same pics to you for evaluation as the doctor did not even touch the bridge, only the nasal tip (hook) noted on left profile was made smooth, but everything is the same no difference at all. I did not want my bridge touched at that time as I thought things will get worst but am prepared now to take the plunge with the right surgeon. 

I was told that I did not have any septal cartilage left for grating but never had ear or other cartilage or implant used so far.  What do you think could be done to improve my nose? I do not want any synthetic implants in my nose, thus the only option is my ear or rib cartilage? 

I want to have an elegant nasal bridge, and have the pinched nostrils look better and start to live life better. I would be ever so grateful for your feedback.

A: In looking at your pictures, you do need a dorsal augmentation by a cartilage graft and a rib donor source would be the best and really only good choice in your revision rhinoplasty. This provides an adequate amount and shape of the dorsal augmentation that you need. You would also benefit by alar rim grafts to provide improved support to your nostril rims so they do not collapse downward. Slivers of rib cartilage graft would be an excellent source of the straight thin grafts that are needed here.

Dorsal augmentation would bring the upper two thirds of your nose in better balance/proportion to the tip.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was wondering if you have and do perform surgery on cutis verticis gyrata. If so I was wondering some of the details and and maybe some idea of the length and width of a post op scar.

A: I have performed surgery on this exact scalp condition in the past and can make the following comments about it.

Cutis verticis gyrate (CVG) is a most unusual although not rare scalp condition of which its cause is unknown. But how it presents with ridges and creases is well known and that the scalp tissue thickens to create it. Treatment options are very limited with the most common approach in limited scalp areas of excision. This may be satisfactory if the rolls are limited to the back of the scalp in a horizontal orientation. But for many cases of cutis verticis gyrata the scarring is likely prohibitive. A more innovative approach is the use of subcision (release) of the creases combined with fat injections. This ‘scarless’ approach has no real downside other than its effectiveness and would be the preferred approach in larger areas of scalp involvement in which excision is not an option.

I would need to see some pictures of your scalp CVG to see which, if any treatment options, may be worthwhile for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in lower eyelid bag removal surgery. I have dreadful eyebags that won’t go away. I have tried all the home treatments and nothing works. I’m a young female at age 28 and the bags last all day. There are two bags under each eye. The past two years everyone has been asking if I’m exhausted or sick. It’s really affecting my self esteem. Can you help me? I am getting married next year and and I don’t want him to lift the veil and see my tired baggy eyes. Thank you for your time.

A: Lower eye bags are the result of fat that is sticking out from under the eyes and pushing out on the eyelids. Because there is a ligament of sorts that normally holds back this fat, when it protrudes it is known as herniated infraorbital fat. Usually it occurs as a result of aging but there are younger people who have it naturally. Known as congenital herniated infraorbital fat, I have seen and treated it as young as 14 years of age. Because you would be normally too young to have this as a result of aging, we can assume this is the result of a congenital weakness in the lower eyelid tissues that can not contain the fat.

This is a very correctable problem. There are two lower blepharoplasty techniques that can be used to eliminate the lower eyelid bags. The first is a transconjunctival (inside the eyelid incision) to just remove the protruding fat. (transconjunctival lower blepharoplasty) This is usually the best approach for younger patients or those that have no excess lower eyelid skin. The other approach is to reposition rather than remove the excess lower eyelid fat done through either internal or external incisions. The decision between the two depends the patient’s anatomy, age and their facial type.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw wiring. I had a back injury about five years ago and then my weight was 130 lbs. Now it is 210 lbs. If I could get down  about 30 to 40 lbs I think I could exercise and really make it work. Does this sound realistic?

A: The eternal question about weight loss is whether any method that provides an immediate and short term effect will provide a sustained weight loss change. The most effective long-term methods of weight loss are significant lifestyle changes in diet and exercise. But that issue aside it is well known that wiring one’s jaws together (e.g., orthognathic surgery) will cause weight loss by the limitations of what one can take in orally. (lack of solid food)

It is important to remember that while jaw wiring can certainly initiate weight loss while they are in place when they come off the onus will then be on the patient. But if you are confident that somewhere between a 20 to 30 lb weight loss over a several month period will help, there is no medical contraindication to doing so. The only question is how long to leave the jaw wiring in place which is usually between 6 to 8 weeks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, When placing a tear trough implant through the eyelid with internal scar and no stitches, are the tissues peeled off the bone as they are with cheek implant placement? I had cheek implants in and removed quickly which left me with mid face sagging and worse eye bags than before, minimal, but the tissues adhered a few millimetres lower than before the operation. Is this a risk with tear trough placement and or removal?, or is a mid face lift usually performed in conjunction with a tear trough implant? Which nerve functions are at risk with this implant?

A: A standard preformed tear trough implant can be placed through a transconjunctival (inside the eyelid) approach. Like all facial implants, it is necessary to make a pocket for the implant which is usually subperiosteal although is can be placed preperiosteal as well. Given the very thin nature of eyelid tissue over the orbital rim, it is best to placed it as deep under the tissues as possible. I would consider the tissue pocket locations between the orbital rim and cheek bones as different as well as the size of the implants that are placed. Cheek implants are placed from below with wide subperiosteal underming and dissection, releasing much of the midface tissues on the bone to place a moderately large implant. Thus it would not be surprising that removal of a cheek implant places one at risk for a subsequent midface sag of some degree. Conversely, the tissue pocket for a tear trough implant is much smaller and is over the medial orbital rim where the detachment of tissues will not cause a midface sag like that of the cheek area.

Tear trough implants pose no risk of nerve injury. The only close nerve is the infraorbital nerve which lies below the orbital rim and where the implant is placed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently looking to have a rhinoplasty later this year. I had a discussion with an anesthesiologist about my needle phobia who advised I speak to the anesthesiologist who will be taking care of me during the procedure. As much as I want to say I don’t have a problem with my needle phobia I do. The last time I had my blood drawn I panicked and passed out. Obviously I don’t want any of that to happen which would make my surgeon’s job harder. He suggested maybe a prescription of Valium before the procedure or something of that nature. I will let you give me your professional advise on this matter. Looking forward to hearing from you.

A: Needle phobia issues are not uncommon in surgery. Known as trypanophobia, it is estimated that about 10% of people have it. While having to get a needle sick is unavoidable since an IV will be needed for your rhinoplasty surgery, there are numerous ways to get past this fear. Your apprehension can be remedied by taking 10mgs of Valium and 25 mgs of Phenergan orally orally one hour before arriving for your surgery. (as there will be someone driving you to and from surgery) Your surgeon can write that prescription for you. Make sure that you have signed your operative consents and had all your questions answered days before the surgery as consent can not be obtained from a mildly sedated patient.

The other management issue that can be done is to apply a topical numbing cream prior to actually putting in the needle. This will minimize needle insertion discomfort.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have lost a lot of weight and the one area that bothers me the most is that of my buttocks. It hangs down with a lot of loose skin onto the back of my thighs. I don’t mind its size now but I can’t stand the loose skin at the bottom. And exercise will not get rid of it. What type of buttock lift do I need?

A: When it comes to large amounts of weight loss, the buttocks like every other area of the body is not spared from an overall deflation effect. The deflated buttocks loses both volume from fat loss and exaggerated amounts of sagging due to such volume loss. Buttock reshaping after weight loss can include either volume addition, tucking or lifting the sagging skin or some combination of both.

Buttock lifts can be separated into a true buttock lift (done from above as part of a circumferential body lift) or a lower buttock lift. (which is really a tuck after excision of overhanging skin.

A lower buttock lift is a lower excision/tuck procedure that is done along the infragluteal crease. (or makes a new one) It removes excess tissues and creates a new higher and more tucked in fold. It is not a difficult procedure to go through nor to recover from it. The biggest issue is to just not stress the incision lines (like bending over far) for a few weeks as the area heals. All sutures are under the skin and dissolvable so no suture removal is needed. The incision lines are heavily taped for support and serve as the only dressing. One can shower the next day and only strenuous activities need to be avoided for awhile until the incisions are more fully healed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am searching for a facelift opinion. I know you are an expert so I would value your opinion. Can a facelift correct this droopy mouth and marionette lines? I have lots of sag and volume loss. My skin seems firm with good elasticity but aging and gravity does take its toll. Is a long lasting correction possible? There are so many options for facelifts these days I don’t know which is the right one. Every doctor seems to have their way to do a facelift and they all claim their way is the best. I will only be able to financially do this once, so I’m looking for the best information to get the best outcome for me.

A: You are correct in that there seems to be many ways in which facelifts are done. And any time there are so many ways touted to do something you can be assured that there is no one single best way to do it. Nor does one facelift method work best for everyone as today’s facelift patients range anywhere from 35 to 85 years old…and simple logic would indicate that the facial aging concerns and anatomy amongst patients are quite different.

Facelifts fundamentally differ in three ways, extent (incisions and dissection), degree of SMAS manipulation and adjunctive procedures done at the same time. Putting together all these areas is what makes facelifts different and customized for each patient. But what does make them somewhat similar and serves as the basic elements of a facelift are the amount of skin flap dissection and SMAS redraping. With significant marionette lines and a droopy mouth, it is clear that you need a fuller type facelift with long skin flaps as opposed to a short scar or more limited type facelift. (e.g., Lifestyle Lift) SMAS manipulation is handled differently by various plastic surgeons but suffice it to say that extensive redraping of it is needed.  Such manuevers are needed to help get rid of the marionette lines and improve the jawline and neck.

What a facelift will not do is correct droopy mouth corners. As a result, a separate small procedure will be needed with your facelift that directly treats this problem…a corner of a mouth lift.

When it comes to a ‘lasting correction’, it is important to understand that a facelift essentially buys time. It is not a permanent procedure and its effects will last years, perhaps 8 to 10 years, but eventually some or much of the correction will be lost. Facelifts help reverse the clock but they can not stop it.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had cheek implants recently and developed right after a weakness of my right upper lip and nostril. I was reading up on people that have had similar issues like mine and what other doctors have recommended and can across this (read below). I’ve also read the longer you wait to get the issue checked out the worse the outcome will be if your trying to fix it. So I’m torn on waiting if it lowers my chances of resolving the problem. I’m terrified this is permanent and was wondering if conducting a nerve test would be a smart thing to do. Maybe the nerve just needs to be decompressed, or if it was damaged or cut then nerve grafting would be the way to go. But the longer I wait the less my chances are to fully recuperate to the way I was before. 

What do you think?

‘The usual risks have been well presented by the other physicians. However, based on observed cases, there is a risk for temporary weakness of a cheek or upper lip especially with the larger implants which have to be placed beneath a branch of the facial nerve which is stretched. When and if this happens , Botox therapy can be used for symmetry until the nerve function returns.’  

A: Facial nerve injury is a very rare occurrence after cheek implants as the dissection is done under the muscle where the nerves supply them. But it can happen. In almost all cases complete nerve recovery would be expected.

I would be very careful about what you read and try to interpret about facial nerves injuries…as they are quite different based on where the injury to the nerve occurs and what type of injury that it is. Most of what you are reading refers to a proximal injury to a facial nerve branch, whereas what you have is a distal or terminal branch type of nerve injury. In essence if you draw a line between the corner of your eye and the corner of your mouth what lies towards the ear would be considered proximal and what lies on the nose side of that line is distal. Distal facial nerve injuries, where the nerve fibers are smaller than a human hair, are not treatable by any surgery or other therapy. Time and healing is all that can be done for them. This is particularly true for the distal branches of the buccal nerve which supply the upper lip and nostril. The buccal branch has a particular propensity to recover, unlike many other facial nerve branches, because there is considerable cross connections between these terminal nerve fibers. So even if one little branch is injured, the cross connections will allow other signals to supply what has been lost. This is particularly true in stretch injuries. (which is the only type of injury you could have) Thus it is not true that the longer you wait the worse the chances of recovery are. Waiting is the treatment and the longer you wait (there is nothing else to do) the better the chances of recovery will be. This is a process which is unknown as to how long it will take…it could be days, weeks or even months. Although I would guess some improvement will start within four to six weeks, it could take longer and complete nerve recoveries have been seen out to even a year after the event.

Botox injections can be done on the opposite side for facial symmetry, although if recovery on the affected side starts weeks later, the facial asymmetry will persist until the Botox wears off. (around 4 months) Since facial nerve recovery is usually progressive (starts working a little at a time), I would wait a few weeks or month to see if the nerve will slowly start coming to life. If not, then you can get Botox on the opposite to provide some temporary improvement in facial symmetry with smiling.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I hate my breasts! I am just 20 years of age and my breast looks like they are 85yrs. They sag and my nipples are huge. Due the weight I have lower back pains and my shoulders hurt. I can’t where certain clothes. For once I would to be able to a strapless bra or even not have a wear a bra at all with my clothes. I need a breast lift!

A: Large hanging breasts, even in young women, can be both aesthetically unattractive and cause symptoms of back, neck and shoulder pain. A breast lift with areolar reduction, and a little breast tissue removal, can create a dramatic improvement in their shape and reduction or elimination of their associated musculoskeletal symptoms. The trade-offs for these dramatic breast changes are scars in the classic anchor or inverted T shape. One has to decide whether these changes are worth it but most young women would say so. It is also important to understand that breast shape is variable over one’s lifetime particularly when one is still very young. Pregnancies and weight gain/loss will negatively affect the result of any breast lift/reduction procedure with the most common changes being further breast tissue loss (involution) and skin sagging. (pseudoptosis)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in intramuscular buttock implants. I don’t really feel comfortable with the subfascial pocket for them. Having said that if I go with intramuscular and 350cc or less in implant size, then which shape you would recommend? Can I get away with a round implant? Oval or anatomic? I would also like to have some liposuction for a better shape. Do you recommend to do them at a different time or together with the buttock implants?

After my first liposuction, I noticed that I have developed some fat around my bra area (bra rolls) that I hate. Here I attached some of my pictures with some assimilation on where I like to have the liposuction done. Can you please kindly let me know if they are relatively doable?

A: The most common intramuscular implant that I place is a 330cc anatomic implant that has a lower profile and more tapered edges than a traditional round or tear drop implant. This creates as more natural contour to the buttocks and will definitely avoid a rounder and more fake look. As most of the patients who undergo buttock implants are about your size (because they are not good candidates for BBL surgery), this implant volume is the right and maximum size that can be placed. Trying to ‘stuff’ a bigger implant than this in an intramuscular space is prone to causing other problems and even more prolonged recovery.

In regards to liposuction, you should definitely do it at the time of buttock implants due to the convenience of intraoperative positioning. You need to be in the prone position for the buttock implant procedure and this is the best way to liposuction the bra rolls and flanks as well. This fat could be used to fill in some of your indentations which would not likely go away with the push out of the implants way below them.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in correcting my coup de sabre involving my forehead and eye. What would be an approximate cost of correcting my linear scleroderma.

A: There are three approaches to treating your left forehead/orbital scleroderma (linear scleroderma en coup de sabre); forehead bone augmentation with bone cements, fat injections and the insertion of a dermal-fat graft. Which one would be appropriate for you would depend on how the tissues feel (skin stuck to bone with complete loss of fat) and whether there is an underlying bone defect on the orbital rim and in the frontal bone. (which almost always there is) Since there is usually both fat and bone defects along the line of scleroderma the most common surgical approach would be bone augmentation by bone cements combined with fat injections, either done together or in two separate stages.

To determine the ideal treatment needed for your linear scleroderma, a combined physical examination and a 3D CT scan is the best way to know exactly what to do. In many cases, these procedures are covered by insurance. But, at the least, fat injections can be done on a cosmetic fee basis and this is the most economical approach and would be part of any ideal surgical approach anyway.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 5’3” and 115lbs, 48 years old, healthy, and work out regularly. I have tried the Brazilian Butt Lift surgery (BBL) but not only didn’t it work but it also made my buttock shape more square than round. It also gave me some indentations. I am now very interested in buttock implants. I consulted with a plastic surgeon in South America and one in Los Angeles. They are both saying intramuscular for the buttock implant location. One is using highly cohesive gel implant called from Silimed and the one in Los Angeles uses semi solid silicone. They are recommending 400cc round or 480cc oval. As I was researching I came across your site. I noticed that you don’t recommend anything bigger than 350cc. I appreciate if you could share your opinion with me. I like the softness of cohesive but safety of solid ones. I love round looking butt, not too big or too small. Thank you for your time and feedback.

A: Let me provide you with some basic information about buttock implants. All buttock implants used today, regardless of the manufacturer, are made of soft flexible solid silicone elastomer. In essence they are all highly cohesive semisolid silicone gel. There is really no difference in their material composition. There are some minor differences in the durometer of the semisolid gel used (slight differences in stiffness) between the manufacturers but tis is really of no consequence to the patient.

Buttock implants can be placed either inside the gluteus maximus muscle (intramuscular) or on top of it. (subfascial) There are arguments for and against each implant location. If there was one perfect location for buttock implants, that would be what everyone would use. Intramuscular buttock implants are technically harder to perform, have a significant recovery but have the lowest incidence of long-term complications. There is also a limit, no matter what a surgeon says, as to the size of buttock implant that can fit into the intramuscular space. In someone of your size, that is going to be about 350cc or less. I can not see how any buttock implant of 400cc or greater can truly fit into the tight intramuscular pocket…at least with someone of your small size. It is not a recommendation that I make, it is simple function of what the anatomy will accomodate.

Subfascial buttock implants are technically easier to perform, have a shorter recovery and permit implants of larger sizes to be placed. It would be no problem to placed implants of 400cc or greater in the subfascial space. You have one important issue that may make this buttock implant location more favorable than it might be for others…you have had a prior fat injection procedure. While it may not have accomplished your overall buttock augmentation goal, it has provided some increased tissue and vascularity to the buttock tissues. I think given your desire for a very round looking buttock of intermediate size, you are likely better off with subfascial buttock implants.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a young man with symptoms of moderate plagiocephaly. The left-back side of my head is flat, the left eye and cheekbone is slightly higher and more prominent, my right eyebrow is lower and the eyelid sags heavily compared to the left, my right ear is pushed outwards and pulled back compared to my left one, and my jaw is wider on my right side. I noticed this completely about a year ago but most of my life I have felt like there was something off about my face. I’ve never been “bullied” by my appearance but I’ve been told from friends that I have a weird head or crooked eyes. Most people probably don’t notice right away but I feel like it is holding me back from completely enjoying my life and being content with my appearance. For example I cannot wear glasses because they look crooked when I put them on and I’m afraid to get a haircut because it is very noticeable how much larger the right side of my head is than the other. 

A few potential surgeries in helping my appearance maybe be augmenting the left back side of my head, reducing some of the thickness on the right side by burring the bone and removing some temporalis muscle, adding prominence to my right cheekbone and filling out my left jaw. I’m not looking for perfection, but I feel that adding and taking away from the right spots and micro-adjusting my features would help me look a lot better. 

I’ve done quite a bit of research on my condition but I cannot find any clear answers on what would help me. I would greatly appreciate any input you have on how I could improve my facial balance and asymmetry and bring out the natural good looks I believe I deserve to have.

A: Without seeing pictures of you I could not make any specific recommendations, but all the face and skull procedures you have mentioned are classic ones for correcting craniofacial plagiocephaly issues. (crooked face and skull) Occipital augmentation of the flat side of the back of the head and burring reduction of the contralateral protruding side of the back of the head are good skull reshaping options. Unilateral cheek augmentation and unilateral jaw angle augmentation are good facial ershaping options. Since you have identified those areas they would undoubtably all be collectively beneficial for improved craniofacial symmetry.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in making some changes to my face and I would value your expert opinion on what needs to be done for this type of facial reshaping. My face does not seem very proportioned and I can’t completely put my finger on why or how to change it. I have attached some pictures of my face from various angles to help you in this assessment.

A: I have taken a look at your pictures and have some changes to the following facial features based on what I see are their disproportions/imbalance.

1) Forehead = high hairline with forehead that slopes backwards at a severe angle. Treated with hairline advancement and upper forehead augmentation to shorten and round out the forehead.

2) Nose = high bridge, protruding tip and bifid tip (wide with split and separated dome cartilages) Treated with open rhinoplasty to lower bridge, deepen nose/forehead junction, shorten and narrow tip, and decrease nostril width.

3) Chin = vertically short chin, protrusive chin pad and deep labiomental fold. Treated with vertical lengthening bony genioplasty.

Attached are some predictive images of all of these potential facial changes put together for their overall composite facial reshaping effect. Together they make for a significant change.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I first contacted you in March and have taken awhile to get a consultation scheduled. I am now down to Breastfeeding once a day, so even though my breasts don’t look exactly like they will once I’m completely done, I thought maybe I would still be able to get a good idea about what I need/want. As you’ll see in the pics, my right one is bigger. It is by far my dominant breast where Breastfeeding is concerned. I didn’t realize just HOW bad they look until I took these pictures!! Talk about being even more depressed. Lol. Anyway, I’ve been looking at doctors who offer the Rapid Recovery Breast Augmentation as I have a 1, 3 and 5 year old. I see now from the pictures that I may need a lift as well as implants. I’m very interested in the teardrop shaped moderate profile textured gummy bear implants. Ones with a warranty is preferred.  Also, will I be screened prior to the surgery to make sure there are no cancerous lumps or anything? Any info you can give would be great!  

A: In looking at your pictures, if you go large enough with the implants I am not sure that you absolutely needs a lift. But you has a lot of skin and it will take substantial volume to fill it out. If you go with a ‘small’ breast implant size, then some type of lift/skin reduction will be needed.

In regards to our breast asymmetry, while two different size breast implants can be used, you are going to have to accept that there will always be some asymmetry between your breasts. Implants alone will not completely solve most breast asymmetry issues.

Rapid Recovery Breast Augmentation uses a combination of early arm range of motion with intraoperative muscle injections to return the patient back to their normal life as soon as possible after surgery.

All breast implants have warranties that come from the manufacturer. These include lifelong implant replacement for device failure and a ten year from surgery contribution towards surgical cost ($3600) plus free implant replacement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had very prominent brow bossing which I had burring done on by a physician who doesn’t perform these procedures frequently. After the burring, my brow ridge looked better, but I am left with strange indents on my forehead. My surgeon attributes this to scar tissue forming from where he burred the bone down, so he injected steroid into two spots on my forehead, which have resulted in additional dents. He has said he will fix the steroid dents free of charge but I really just want someone’s opinion who performs forehead procedures. I’m so bummed my forehead looks worse than before 🙁 is there any way, preferably the most conservative available option, to correct this? Thx so much for your time.

A: It has been my experience on any type of forehead or skull reshaping by burring that the final shape seen on the outside is a direct reflection of how the bone looks underneath.(particularly when adequate healing has occurred after three months) Scat tissue forming irregularities is not something I have seen. Even though the forehead and scalp tissues are quite thick, it will not hide even the slightest irregularity on the underlying bone when it is fully healed. Injecting steroids is not going to solve these irregularities (because they are bone based) and has a high risk of making them worse by shrinking the fat under the skin.

The only minimally invasive way to try and fix these forehead contour issues now is injectable fat grafting. But the unpredictability of fat take after injection has its own issues when trying to correct relatively small forehead contour issues.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been doing some research and I found some info on Refine Suture lift and mesh lift with fat grafting.  I was wondering about these procedures and if you would suggest this over the traditional lift with implant. I have read that these help with the lifts lasting longer and upper pole fullness, but wanted a professional opinion.

A: Your research and questions into these developing methods of breast reshaping are timely and insightful and merit a full explanation to put them into perspective  and how they may or may not apply to you and your breast reshaping goals.

While implants for volume increase and lifts for repositioning the breast mound and nipple upward are the traditional and time-proven methods of reshaping the deflated and sagging breast, they rely on a synthetic implant and scars to create their effects. So understandably alternatives have long been sought for either a more natural result (non-implant) and breast lifting methods that create less scars and more resistance to any lower pole breast relaxation.

Historically these searches for improved breast reshaping methods have been met with disappointment. But the three techniques you have mentioned (fat grafting, Refine anchors and internal mesh supports) have recently come into play and are promising…although they are still in various stages of development. Thus their use does not have a long track record so the initial enthusiasm must be viewed with guarded optimism.

Fat grafting can work in restoring volume to the deflated breast but what it can only achieve moderate volume increases. Fat grafting can not create large increases in breast size. This translates into an implant volume of about 200cc or less. If one has enough fat to harvest, then fat grafting can be a good substitute for this low volume increase which is usually perceived as ‘just adding a little extra upper pole breast fullness’. The only caveat about fat grafting is that its volume retention is not assured. As a genera statement, the volume of injected fat into a breast that survives and is maintained is around 50%…but some may have more or less volume retention.

Refine suture anchors for internal breast tissue suspension (internal breast lift) is based on placing a matrix of sutures with small plastic anchors that pull up the breast tissue upward and help anchor it to the upper pectoralis muscle fascia. As one of the few Refine-trained plastic surgeons in Indiana, I am very familiar with this device and its use. For small amounts of breast lifting, particularly in conjunction with fat grafting, it can have a useful role in breast lift surgery. But it will not provide a major lift when the transposition of the nipple-areolar complex must be moved significantly upward. In addition, its long-term effects are not well known as the device remains in clinical trials with long-term follow-up data yet to be reported.

The long-term stability of a breast lift is largely based on the skin tightening of the lower pole of the breast. This naturally relaxes to some degree in many breast lift patients, particularly when the breast mound is not supported by an underlying implant. The concept of adding a sling of support across the lower pole of the breast during a breast lift is both logical and has been tried in the past. But the use of non-resorbable synthetic meshes (hernia repair mesh) in the past has been met with wound healing and infectious complications. The concept has enjoyed re-emergence today because of a wide variety of cadaveric dermal slings and resorbable synthetic meshes. The two resorbable synthetic meshes currently available (GalaFlex and SIRI scaffold) offer a very adaptable thin mesh-like scaffold that be easily sutured across the bottom pole of the open breast lift patient. They are resorbable and are eventually replaced by new collagen tissue. Their use is gaining in popularity with good results and few complications and probably better long-term breast shape results. But they will not attain use in every breast lift patient as the cost of the mesh is around $2000 per breast. This adds substantially to the overall cost of the surgery which currently limits their use to the high-risk or revisional breast lift/implant placement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 25 year old male. I am interested to coming to see you for some procedures to help me get the model look. I have some areas of my face I am unhappy with. One being the width of my face (too wide) and the other being the contour of my forehead/supraorbital rim/temple/eye area. I read a method of making wide face slimmer by zygomatic osteotomy. I read bone heals itself in new position after zygoma osteotomy so I wondered is it possible to do zygoma osteotomy and shift the entire zygoma arch upwards slightly (and also inwards)? I believe this would give a good high but narrow cheekbone appearance, as I don’t want flat cheekbones. 

My next problem is my forehead/eyes/temple area. My temples are very hollow and I have asymmetrical supraorbital rims. The supraorbital rims protrude which are more apparent due to hollow temples. My forehead is very backward sloping, despite it being protruding and having prominent frontal sinus area. 

I had considered options of frontal brow bossing reduction and then adding custom made implant on the forehead extending from forehead to supraorbital rims or to the temples. I always wanted supraorbital rim implants because I like the look of small squinty deep set eyes. I do not want to look feminine. I have added pictures of my forehead and eyes and pictures of how I want my eyes/forehead to be. I had an endoscopic browlift as an attempt to create the model look few years ago (because the surgeon said it would create a model look) but I feel it didn’t and needs to be reversed. I can’t work out what makes male model have eyes like that? They have strong foreheads, and is it the supraorbital rim that makes them have that model look? Along with a more hooded eye, and supraorbital rims that blend into the temple area? I really would appreciate your expert advise on this because you seem to be so knowledgable on your field.

A: I think there is no question that what makes for the so called ‘male model look’ is facial skeletonization…meaning an enhancement of facial skeletal areas such as the forehead, brow bones, cheeks, chin and jawline/jaw angles. As for the forehead in general, a backward sloping forehead angulation is not desirable regardless of what degree of brow bone prominence one has or does not have. A fuller more vertical forehead shape that allows for a noticeable brow bone break is the most masculine of all forehead shapes.

A endoscopic brow lift would work exactly against this type of male look as brow elevation and retro movement of the frontal hairline, particularly in a forehead that already has a backward inclination, will usually make it more feminine appearing. You may have discovered that in your own experience.

Blending the supraprbital rim/forehead into the temporal regions would be relevant for the high anterior temporal one but for the low one or the classic zone of temporal hollowing. That is much more effectively treated by standard subfascial temporal implants.

As for the zygomatic bones/arches, I do not feel that yours is wide and there would be little benefit to try to move the bone to accomplish any external aesthetic benefit. If you want further enhancement at the anterior zygomatic or high zygomatic arch levels, that would need to be done with a custom designed implant. That would be far more effective, predictable and have a much more rapid recovery.

Dr. Barry Eppley

Indianapolis, Indiana