Your Questions

Q: Dr. Eppley, I’ve been perusing through your blog and I’m curious about forehead augmentation. I would like a more masculine brow bone and forehead. I feel like mine is flat. I’ve attached a profile view. Do you think it would be beneficial to my appearance. What I don’t like is my forehead starts to slope back starting from the brows. I would like it to be more square as if a stick was held against the forehead, more of the forehead would touch the stick instead of only the brow bone. From what I gather, the most economical option is using PMMA bone cement, correct?

A:  Forehead augmentation can be done by using either intraoperatively applied PMMA bone cement or a custom forehead implant. The cost differences between PMMA and a custom implant are not really that different. While PMMA bone cement cost less (the material) than a custom implant, most of that material cost savings is offset by the increased time too place and shape the material. A custom implant costs more than the PMMA material to fabricate but is done in half the operative time, with smaller incision and a lower risk of potential revision due to shape. In the end, both forehead augmentation techniques cost about the same.

In the past, PMMA bone cement was the only forehead augmentation option available. But computer design technology is now making custom implant designs not only possible but affordable.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in the brazilian butt lift. I originally booked the procedure with another doctor. However, he will not be available for the procedure now and he mentioned you as one of the doctors I should see. I am hoping to get the same service as he was providing, which was liposuction of the arms, back, abdomen, flanks and inner thighs with a minimum 1000cc injected into each buttock.

A: I certainly do a fair number of Brazilian Butt Lifts. The key question, however, is whether you have enough fat to harvest that could be filtered and concentrated to be able to inject 1000ccs per buttock. That would be exceptionally unusual. To be able to get 2000cc of injectable fat, you would have to have close to 6,000cc (6 liters) of fat to harvest. That may be possible in you but since I have never seen your body I could not tell if that was so. What most patients don’t understand is that only concentrated fat should be injected not just the liposuction aspirate. Taking the liposuction aspirate and getting rid of the blood, broken fat cells, free lipids and the tumescent solution usually results in a 60% to 70% shrinkage of volume of ‘fat’ that has been harvested. Thus only about 1/3 to 40% of the lipsuction harvest ends up being useable for injection.

For most Brazilian Butt Lift patients, the maximal amount of fat that can be harvested and injected is done as most patients have an overall deficiency of fat for the procedure (based on their goals) rather than an excess. For this reason, I do not promise any patient that a specific amount of fat will be injected as that is an unpredictable number until the fat is harvested. I would have  a good feel for an approximate amount that could be done in looking at one’s body and thus an estimate could be given before surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,I’ve had a bad experience with a primary rhinoplasty making my nose too thin, specially in the upper area where my eyes are (T shaped). I believe the cause of this is overly aggressive osteotomies.  I have morphed a picture where I make the upper third of the nose wider (Y shaped). Would you mind telling me if this is possible with a revision?  Thank you for your time. Looking forward to hearing from you.

A: The nasal bones can not be recut and expanded to create that shape in the upper nose. A revision rhinoplasty using outward osteotomies is not stable and will not hold even if they could be cut to make that shape. Widening the nasal bones is hard enough but to make the nose have a T-shape (or return to it) would be impossible by just moving the nasal bones. The only way to create that shape would be by adding a material or graft to the outside of the nasal bone. That could most easily and assuredly be done by making a small custom implant to fit over the radix to create that exact shape using a 3D CT scan. This is a perfectly safe place for a small nasal implant.  It could also be done using graft materials such as cartilage, bone or acelluar dermis but there are shaping/contour concerns with this type of revisional approach and issues of symmetry and smoothness would be a concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had jaw surgery two times and now have lip damage. Bottom lip seems paralyzed or damaged. (lower lip asymmetry) I saw online and seems others have had the same problem. I have seen it may be hyperplasia of depressor orbis lip muscle or paralysis of lower lip nerve. I don’t know what it is. Do you think it is nerve damage or muscle damage? Is it likely to be permanent damage after jaw surgery or temporary? I has been one year now and still no change. It is less obvious when relaxed but when make ‘O’ shape with lips or kiss shape with lips or smile it pulls down to one side on my right. The left side doesn’t pull down. I did think it was the right side which shows lower teeth when smile which is the problem side but actually I think after research it is the left side which doesn’t show any teeth when smile which is the problem side. I have seen certain solutions are to use Botox but are there any other options? I want something permanent. Can a surgeon correct it with more invasive surgery? Can they maybe correct the problem side or maybe damage the other side so both don’t show lower teeth when smile because personally I think that looks better to only show upper teeth. I really need your help doctor. Please help thanks.

A: What you have is paralysis of the left marginal mandibular branch of the facial nerve. This tiny nerve branch supplies movement to the depressor muscle of the lower lip. With the nerve being paralyzed that side of the lip does not move down normally while the opposite right side does. With no lower lip movement on the left, the normal righth lower lip retraction looks exaggerated and overly pulled down. This lower lip appearance can make one think the side of the lip that moves is the problem when in fact the th higher lower lip side is the culprit of the lower lip asymmetry.

At one year from the injury with no movement, there is no reason for optimism that the paralyzed nerve will start working again. I wouldn’t say it is impossible but very unlikely. There is no method to make the nerve work again other than natural healing. Thus the treatment for lower lip asymmetry from  permanent marginal mandibular nerve paralysis is to weaken the opposite side whose muscular movements are exaggerated. This can be done by Botox injections (temporary) or by partial resection of the depressor muscle from an intraoral approach. (permanent)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to get cheek implants soon. I am also interested in having a hair transplant about 6 months after I have cheek implant surgery. My question to you is do you think it is safe to have a hair transplant after cheek implants? …. Is there any risk of infection to my cheeks implants? … during the hair transplant they will poke the front of my hairline hundreds of times. Can this in any way effect my cheek implants ??

A: This is a thoughtful question that speaks to the potential of bacterial seeding of any implant in the body due to bacteremia (release of bacteria in the bloodstream) after any invasive procedure. I think as long as your cheek implants are well healed and have an intact mature capsule, this potential risk is very low to negligible. It can easily be compared to having a dental cleaning in which one has any implant in their body. This is clearly not a problem of any magnitude given the millions of people who get their teeth cleaned or undergo any dental work and have surgical implants of many varieties and anatomic locations. But to be safe, and this would be done anyway, take an antibiotic starting one hour before the surgery and then for a few days after.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had chin implant replacement done 3 months ago. I had a Medpor chin implant replaced by a silicone square chin implant as I wanted more squareness to my chin and wanted it wider. Today is officially 3 months after surgery and it’s been frustrating for me. Two sides of my chin where the previous wing were removed are still presenting irregularity and swelling. When I touch it it feels kinda soft and tissue like. I’m not sure it’s the capsule or scar tissue still remaining there. It makes the two side of chin still look like swollen and the jawline is not straight at all. But it is definitey improved since the first month after surgery .I’m just really anxious about it everyday now and I’m wondering when will it fully healed? I have searched online and some people says steroid injection can be done. Should I do that? I’m pretty sure the implant placement itself is fine but the capsule or scar tissue is making it look bad. I hope you can help me 🙂

A: Full and complete healing after any facial skeletal surgery can take up to 6 to 12 months after surgery to see and feel the final result. This can certainly be true for revisional chin implant surgery where one iimplant (that is well scarred in) is replaced by another chin implant. The important question is whether the fullness that you see is do to scar tissue/healing or that the implant is simply too wide/big. If it feels soft and tissue like then I would say there is still healing going on and more time would be the appropriate answer. I would not advise steroids as that is an uncontrolled drug treatment that can have adverse soft tissue effects (atrophy and indentations) and thus it can create just as many problems as it may solve. The only injectable treatment to consider is 5-FU injections which can help settle scar tissue but has no soft tissue atrophy effects. Otherwise, if the sides of the chin feel hard, then this is an implant issue where it may be too big or wide

The steps to take now are either 5-FU injections and/or continue to give it more time. At the minimum I would give it at least six months from the last surgery before contemplating anything invasive.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a very very thin Asian male that is looking for buttocks enhancement to get more of a Hispanic or Afro looking buttocks that is more perky and with a lot of volume. Because I am thin I know that fat grafting is obviously not an option so from what I know, implants are my best bet. I am looking for more of a shelf with augmentation in the upper buttocks area but as well as more outward projection to the entire thing…protrusion up and out. I would like to go for bigger implants if possible (that are within reason). I do a lot of physical activity such as dancing, running, biking, you name it. From my understanding placement can be from most superficial to deepest, subcutaneous, subfascia, intragluteus maximus or under the gluteus maximus. I have heard that intramuscular is best for augmentation towards the top but for more actual outwards projection, subfascia is better because the space is larger and because intramuscular would make it close to the sacral nerve which is dangerous. My questions therefore are as follows:

What would you agree is the best placement for somebody of my build with my goals? 

I understand that this is based on softness of the implant, but why would anybody want to have a harder implant over a softer one?

Because I’m trying to aim for more of as a shelf as well as projection additionally, is it possible I might need different implants placed in different spots?

What would be the max size you would put in somebody of my thin male Asian build?

What kind of buttock implant shape is best?

A: Thank you for your thoughtful inquiry and insightfiul questions. A male getting buttock implants is uncommon but certainly not unheard of. There is no question that the best long-term results for buttock implants is in the intramuscular position. (never completely submuscular as this is where the sciatic nerve lives) This follows a general rule that the deeper an implant is placed and the more well vascularized soft tissue cover is over it, the better it is for the implant and the fewer complications that can ensue. But when looking at your aesthetic goals, an intramuscular implant can not achieve the buttock size and projection that you seek. Thus, only a subfascial implant placement will work. This will allow for a larger buttock implant size and it will have more lateral and posterior projection. A round shaped buttock implant is what you want to use. (oval implant can rotate in the subfascial plane which can create an obvious problem)

It is hard to know without seeing you and taking measurements as to the maximum implant size that you should get. But certainly I would not think bigger than 450cc to 500cc

Buttock implants are made of a very soft gel elastomer which feels very much like muscle. There is no reason to use a harder implant durometer.

You never want to place more than one implant for any body area, the buttock region notwithstanding.

A primary concern in any buttock implant patient is that they take teh required time to allow the tissues to properly encapsulate the implant befire beginning any strenuous activities. It would be well advised to wait at least four to six weeks before doing so. Seroma formation is the number one complication in buttock implants and a primary cause is too early physical activity.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m wearing braces and the distance between my upper lip and nose is short maybe 1.2 cm now. But I know that if I take off the braces the distance will increase to 1.4 or 1.5cm. I don’t want to do lip augmentation. I want the lip lifting procedure and I want to do it wearing braces. Is that possible?

A: Having orthodontics appliances in place does not impede the ability to do a subnasal lip lift. The question is whether one can tell how much to remove so as not to end up with an overdone result. Subnasal lip lifts that have had too much skin removed have no recoverable strategy…you can’t put back the skin that was removed without a very visible graft under the nose. If your calculations are correct you would do a 3mm skin resection for your subnasal lip lift. If you have do do the lip lift before your braces are removed just make sure it is a conservative amount of skin removed. Removing your braces ma result in the lip lengthenng a few millimeters. But since you have not done that test (remove your braces and measure it), assume that maybe no change in lip length will occur.

Dr. Barry Eppley

Indianapolis, Indiana

Q: D. Eppley, I am contacting you because you are the only surgeon I found that discusses Medpor implants extensively on your blog. I had a rhinoplasty with a tip rotation/refinement using Medpor in my columella topped with ear cartilage. I was healing well; the nose seemed narrowed/slightly more projected. But I was injured and the nose seems to have swollen, derotated, and healed unnaturally. It is more swollen on the left and the entire tip is bulbous.

I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty. He said he could reset the “wings” of the implant that is intended to pinch the sides of my nose closed, remove excess cartilage, and remove “soft tissue”.  

I’m seeking a revision because after the injury the nose changed shape. The tip/dorsum is higher, rounder, and tilts leftward due to prolonged swelling and possible shifting of ear cartilage). I have what appears to me to be pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball away from my bridge. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose with a ball of tissue projected by the implant in my columella. The tissue is soft but fibrous and based on everything that happened I feel I am looking at scar due to prolonged swelling, not curving ear cartilage. The skin on the “injured” parts of the nose is whiter and oiler than the “healed part of the nose which went through no trauma. I make this comparison because there isn’t a surgeon I’ve consulted that sees scar tissue, but I know how the nose was shaped and oriented before injury and don’t know that scar can be removed in a closed rhinoplasty.

Any advice on whether a closed rhinoplasty is really likely to help would genuinely be appreciated. I am caught between the appeal of not going through another open rhinoplasty and the thought that I will pay a hefty price for something that will not actually help much at all.

A: While I have not examined your nose, the question for your revision rhinoplasty is what is the source of the tip problem and what is the best way to solve it. Between the implant and the scar, it is hard to know the bigger source of the problem but in my opinion but need to go. This is best accomplished with an open rhinoplasty with replacement of the implant with a septal cartilage graft.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in surgical scar revision for my box car acne scar. I have undergone microdermabrasion, fractional laser resurfacing, and TCA peel to the area but none of them have had any beneficial effect. It seems like something deeper will need to be done or perhaps just cutting it out. I don’t know as I am not a doctor but none of these other doctors seems to know either.

A:  As you have discovered, none of these superficial treatments are going to work for your type of facial acne scar. This is a problem of tissue atrophy/loss not one of just a more simple surface contour irregularity. Your acne scar surgery options include either excision and geometric scar rearrangement or scar adhesion release and injectable fat grafting. You can first test out how well fat grafting may work by having some injectable filler or even a trial of saline injections done to see if the scarred area will lift up by adding volume by injection underneath it.

Give its size, total excision and a geometric closure is also a consideration. What needs to consider how much tolerance one has for the healing and maturity of a scar on one’s face vs. whether one wants to first try an injection approach before embarking on a ‘bolder’ excisional approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had a subnasal lip lift which I am pleased with the lift in the center of my lips. Now however, it seems to accent the thin corner of my liplips. Aesthetically to balance out the look, I think this is something that should have been done too. Can a corner lip lift be done with local anesthesia?

A: The subnasal lip lift in the right patient is a very effective lip augmentation procedure but it will only affect what lies within the skin excision pattern. By dropping down a vertical line from the sides of the nose to the lip, the lip area improved will only lie within. In essence, it shortens the amount of vertical skin between the base of the nose and the upper lip and only provides accentuation of the cupid’s bow of the upper lip. It would not be rare to a have a lip lift patient turn their focus to the sides of the lip and the mouth corners thereafter.

The key question about changing what was not improved by the lip lift is defining the exact area of outer lip deficiency. This could be either an isolated corner of the mouth lift or an extended corner of the mouth lift that extends further up along the sides of tails of the upper lip. This distinction is critical to understand. An isolated corner of the mouth lift will just change the angle of the corner of the mouth and will not make it thicker. A extended corner of the mouth lift or an outer lip advancement will make the sides of the lip fuller.

I would need to see a picture of your lip to help you decide what is the correct lip augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m interested in a pinch lower blepharoplasty and am seeing if I am a candidate for the procedure. I took the picture smiling because the wrinkles aren’t as noticeable when I’m not smiling. I have seen a few plastic surgeons about my options. I do have a little fat under my eyes that I’ve been told could be fixed by filler or moving the fat around. That doesn’t bother me as much as the loose skin, and I’m hoping that tightening the skin will help. I will be fifty in November, but I lead a very healthy lifestyle with regular chemical peels.  If I did the recommended procedures, what is the recovery time?

A: The difference between someone who needs a pinch lower blepharoplasty technique versus a full lower blepharoplasty is a function of numerous factors. How much loose skin is present, is there an orbicularis muscle roll, presence of any fat herniation and how much loose wrinkled skin do they have. In addition, the age of the patient and how much facial aging they have is also relevant…as pinch blepharoplasties are generally reserved for early signs of periorbital aging. (less than 50 years of age) Your picture is a smiling one so that obscures some of this anatomic information. But clearly you are young and do not have much herniated fat. Thus based on this one picture, I would say that a pinch blepharoplasty combined with a 35% TCA peel for the rest of the lower eyelids and 8 units of Botox for the orbicularis muscle activity per eye would be beneficial. You can’t get rid of all your lower eyelid wrinkles with any procedure, particularly when one smiles, but this would provide a major improvement with limited downtime. Expect one week or less of a ‘cosmetic’ recovery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I need help in determining what type of revision rhinoplasty I need. I had a tip rotation/refinement using Medpor in my columella topped with ear cartilage. I was healing well; the nose seemed narrowed/slightly more projected. But I was injured and the nose seems to have swollen, derotated, and healed unnaturally. It is more swollen on the left (especially in the tip) than on the right side; the entire tip is bulbous.

I’ve consulted two local surgeons with board certification. One suggested revision with a septal onlay graft/overlay graft in the dorsum. Another said that based on the softness and shape of the nose, he could work around the implant in a closed rhinoplasty (referred to it as a septorhinoplasty). He said he could reset the “wings” of the implant that is intended to pinch the sides of my nose closed, remove excess cartilage, and remove “soft tissue”. 

I’m seeking a revision because after the injury the nose changed shape. The tip/dorsum is higher, rounder, and tilts leftward due to prolonged swelling and possible shifting of ear cartilage (not excess). I have what appears to me to be a pollybeak, especially on the left. Instead of sloping down, the nose sticks out/is projected in a ball someplace away from my bridge, underneath where the tip used to be before it “dropped” filled out due to injury or naturally, like a tube. In other words, the tip is an overprojected bulb following the injury–like the pre-op nose, with a ball of tissue where the nose used to simply droop down flat. That “ball” is projected by the implant in my columella. 

The tissue is soft but fibrous and based on everything that happened I feel I am looking at scar due to prolonged swelling, not curving ear cartilage. The skin on the “injured” parts of the nose is whiter and oiler than the “healed part of the nose which went through no trauma. I make this comparison because there isn’t a surgeon I’ve consulted that sees scar tissue, but I know how the nose was shaped and oriented before injury and don’t know that scar can be removed in a closed septorhinoplasty.

Any advice on whether a closed rhinoplasty is really likely to help would genuinely be appreciated. I am caught between the appeal of not going through another open rhinoplasty and the thought that I will pay a hefty price for something that will not actually help much at all, will have a period at least as stressful, and will cause the same problems in the tip. 

A: The short answer to your revision rhinoplasty dilemma is…have an open rhinoplasty and get the Medpor implant out and replaced with your own cartilage if it is still needed. This is the only to ensure that you can get the best result long-term. A synthetic implant in the tip of the nose may or may not be part of the problem…but I doubt it will be part of the cure. With scar tissue in a revisional nasal tip surgery, visualization and removal of all scar tissue with cartilage reconstruction is the only way to successfully reshape the bulbous and overprojected nasal tip consistently.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, my one month old son has cleft lip and palate on the left side. It is due to be repaired in another few months. Besides the cleft lip, the nose is also very distorted and wide set. Can his nose also be corrected at the same time as that of his cleft lip repair?

A: The initial cleft lip repair is usually done around the age of three or four months after birth. During a primary cleft lip repair, efforts are always made to reshape the distorted nostril and tip of the nose. Some of the nose improvements are natural as the lateral lip element is one and the same with the base of the nostril. So the base of the nostril naturally gets better as the two sides of the lips are brought together and united. But one should not think of this nose effort as a definitive rhinoplasyt or a complete correction. The lower alar cartilages of the nose are still deformed and remain small in development. They are far from completely formed and these initial nasal correction efforts at the time of the cleft lip repair are mainly to improve the width of the nostril base. The nose must undergo further development and additional nasal work will be needed during the early school  and teenage years to more extensively reshape the deformed tip cartilages and correct septal deviations and other nasal abnormalities.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in midface augmentation using malar shell implants but I have not yet had the procedure because of certain concerns. I am concerned about the submalar fullness which I had noticed in photos of female patients who have had the submalar cheek implants placed. Although I definitely have the concavities in the submalar area which would benefit from some augmentation, I did not want “apple” or “cherub” cheeks. (Check out Barry Manilow’s face now). This type of fullness can look artificial and certainly looks better on females than males. I know that the implant can be modified by removing some projection from the underneath side of the submalar portion of the implant.  Of course, a lot would depend upon how much fullness is already present in the submalar area. I am also unsure of whether the implant would make my face look wider and somewhat “chubby” rather than more sculpted (more attractive on males).  I have a round face lacking in strong structural features. But I was not so sure about what the midface augmentation would accomplish .  In addition, the lower eyelid area concerned me.  Actually, I thought that if the midface implant were placed high on the bone close to the orbital rim, it  would have the nice collateral benefit of minimizing the tear trough area, but I did not know how much an improvement this would be, given the design of the implant. 

A: In looking at your face and all the current styles of performed midface implants, none would be appropriate for what you are looking for. You are correct in assuming that your face would get wider  and would dimensionally change you in the wrong direction. What you need is more anterior or forward projection across the orbital rims and down onto the face of the maxilla. This is actually the ‘missing’ zone of facial augmentation in regards to current implant designs because it is concave facial area and not a convex one.

What you really need is an orbito-maxillary facial implant that improves midface projection but not malar width. This can only be properly designed through a custom implant approach based on a 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in numerous body contouring procedures since I have lost 130 lbs. But I did not achieve this weight by bariatric surgery so would it be possible for me to have multiple procedures in one day? I have a lot of loose skin from my arms to my thighs so I need a lot of work done and the quicker I can get it off the better.

A: The origin of one’s weight loss has little impact on how any number of body contouring procedures are done in a single operative event. Actually extreme amounts of weight loss achieved by non-bariatric means, diet and exercise, are ‘safer’ since there are no metabolic issues to consider. (unlike a gastric bypass) There really are few differences between body contouring after weight loss and bariatric plastic surgery considerations when it comes to the type of body reshaping procedures considered and how they are put together. The key issues in doing multiple  body contouring procedures is the length of time to do the surgery and what period of recovery time does the patient have. As all body contouring involves considerable trauma to the body if you just consider the size of the body surface areas being treated.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a wide chin and am interested in a chin narrowing procedure. What is the best way to make the chin bone more narrow? 

A: The benefits of chin narrowing is very clear as you do have a boxy square chin. To obtain substantial chin narrowing there are two basic techniques, bony genioplasty wedge (sliding genioplasty with central wedge reduction) and lateral tubercle ostectomies. (cut off the corners without down fracturing the chin) There are advantages and disadvantages of each method of chin narrowing. Having done them both numerous times, they both can work but there are subtle differences between them that can carry aesthetic consequences. The advantage of the bony genioplasty wedge reduction method is that it does not strip off all the attached soft tissues so the risk of the soft tissues not adequately reattaching afterwards is minimized but it is a ‘bigger’ operation due to the need to down fracture the bone  and the bone cuts come closer to the exit of the mental nerve from the bone. (risk of numbness) The lateral tubercle ostectomy method merely cuts off the corner of the boxy chin and does not need to down fracture the chin bone and thus there is no need for plates and screws to put it back together.  Its bone cuts stay further from the mental nerve so the risk of lip numbness is less. Its disadvantage is that it may not produce as significant a chin narrowing effect and detaches more of the soft tissue.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been opening your website and reading your articles for a while. I think your website is very informative. I would like to thank you for creating this website. Without any doubt i can say your are one of the world’s best and most skilled plastic surgeons. I wish I was very wealthy, I would have flown to USA and set an appointment with you, but unfortunately I don’t have a strong budget at the moment. I intend to travel locally for a chin osteotomy or implant and jaw angle implant. I want to make my face look very masculine and angular. I am attaching my photo to have your viewpoint about the type of jaw angle implant. I want to do something permanent and long lasting. I think my jaw needs a thick implant but I don’t know which shape and type is better. Thanks in advance.

A: While most commercially available silicone jaw angle implants provide only width, the vast majority of men who seek a stronger and more defined jawline need vertical lengthening of the jaw angles as well. Thus a more masculine jawline usually needs a combined vertical and width dimensional change to have a more pronounced flare to their jaw angles. Your pictures certainly show that to be true. The only question is how much vertical and horizontal thickness in millimeters would look best.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have been self conscious about my deficient chin my whole life. If I so much as look down, I develop a double chin despite being 5’7″ and weighing only 114 pounds. I used to diet often thinking that this would decrease the roundness/fullness of my face but it wasn’t until recently that I realized it is really the lower 1/3 of my face and its overall deficiency that is causing my face to look round and short.

As you can see, I have a very horizontally as well as vertically short chin. The reason I would like the sliding genioplasty vs. a chin implant is to add vertical length to my face as I feel its shortness makes me look younger than I am and also meek/shy which decreases my confidence in my daily interactions with others.

I’ve done the research on sliding genioplasty vs. chin implant, and one of the questions I have is: If I would like a little extra width added to my actual chin (You can tell in the pictures, especially the one head-on picture, that it is not only short vertically and horizontally, but it is narrow), I have read that only an implant can widen at this area, and that a genioplasty by nature of cutting the bone and advancing it will actually serve to further decrease the width of the chin. Is this true? I would like to decrease the odds of this happening if at all, although perhaps adding width to the chin would not even be as beneficial as I think given my facial size in general and would throw everything out of line aesthetically?

In addition, I have read that only a sliding genioplasty can add vertical height to the chin in addition to horizontal projection, but in other more recent publications I have read that there are new implants manufactured now that can be tailored to the patient and add vertical height as well. Would this be an option for me as it is more cost effective or is sliding genioplasty exclusively the way to go given my individual anatomy?

I am anxious to hear back from you, and thank you so much for taking the time to review my pictures!

A: Many of your perceptions about chin augmentation surgery are correct as it relates to the differences between a sliding genioplasty and a chin implant. Historically, it was true that only a sliding genioplasty could add vertical length to the chin but that is no longer true. There are new performed vertically lengthening chin implants (actually they move the chin position out at a 45 degree angle thus adding both length, projection and width) and custom implants can be made from the patient’s 3D CT for any amount of differing chin dimensional changes.

While a one-piece sliding genioplasty particularly if it adds vertical length can make the chin more narrow, that can be solved by modifying the bone  That can be managed by doing a midline split/expansion genioplasty technique and widening the bone as it comes forward and down.

As you can see there are a number of ways to accomplish what you are after for our chin. But the first place to start is to precisely determine what exact chin dimensional changes you need. I will have to do some computer imaging but my initial guess is that about 5mms forward and 5mms vertically longer would be about right. I doubt if your chin should be made any wider as you want to get away from a round and short look and even a slightly more narrow chin in and of itself makes the face look longer.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a lot of deep saucer-shaped scars and indentations on my face. I recently read about the use of GalaFLEX and would like to know if this product could be used to smooth out the appearance my face. I once had a doctor in California who suggested using sheets of a “derma” product to place between the skin and the underlying tissue to smooth it out.  When I read about GalaFLEX it appears to be the same type of product. Perhaps you can give me your thoughts on it.

A: The concept of an interpositional material between the skin and the underlying fat/SMAS is an interesting one. As of today there are over a dozen allogeneic and synthetic matrixes/scaffolds that are currently available for use. So this concept is not new and Galaflex just represents one of the synthetic options to consider. All of these have been developed primarily to support the lower pole of the breast in breast reconstruction and in treating bottoming out of the breast in aesthetic breast augmentations. Of the synthetic options, the one I would consider is SERI Silk mesh as opposed to Galaflex since it is currently FDA-approved while Galaflex remains under FDA clinical trials.

Moving beyond the materials, the real question is whether placing an interpositional material under the skin would help smooth out the face. That part is unknown since this is not what it has been studied for and I have know of no patients who has been so treated for that facial skin problem with this method. But I guess there is always a first time in the right patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If ever you need a guinea pig for studies in regards to the use of liposuction and fat transfer for treating deformities from black market butt injections, please contact me. Sadly, I was one of the many young, naive, stupid girls (1000’s from what I now know from doing so much research) whom underwent this black market procedure of silicone (now don’t know what it really was, but the devil was calling and I fell to his vanity trap and oh boy am I paying for it now) butt injections which has completely ruined my life. I am consumed with anxiety, depression and regrets for my ignorant, immature and impulsive decision for trying to look better to be able to compete with other women for attention that I wasn’t getting at home after losing 80 lbs. I have become not only unhappy but overwhelmed at what my life has become over some very stupid decisions. I am only reaching out because I want to know what the average cost is for this procedure, but also to tell you that there are so many women on forums that are seeking help from professionals, willing to pay thousands because they have the money, but doctors say there are no procedures to help us.

A: The problem of deformity and hardness from the scar and granulomatous reactions from black market butt injections of silicone and other unknown substances is a difficult problem for which there are no certain cures. But the use of liposuction and fat injections is one potential treatment option that has some biologic merit. While the injected material can not be substantially removed, breaking up the scar tissues using liposuction cannulas and then introducing fat may create a softening effect while maintaining volume. One has to have enough fat to harvest to do the procedure but not to the volume that would be needed in a traditional buttock augmentation procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would like to accomplish a chin with less harsh of a labiomental fold, preferably no fold at all. But have the area more smooth. Maybe somehow add vertical volume to the chin area or adjust the mentalis muscle to achieve the desired result. I would like to here your thoughts on what procedure you would recommend to achieve the most attractive chin possible.

A: Altering the labiomental sulcus or crease is the hardest portion of the chin to change. This is because it is a fixed anatomic structure that correlates to the depth of the anterior mandibular vestibule intraorally and the upper attachment of the mentalis muscle beneath it. It is simply not possible to completely get rid of the labiomental sulcus. It may be softened a bit by various injection and implant materials but the operative word here is ‘a little bit’. If the chin is lengthened vertically by a bony genioplasty method, it may appear  slightly less deep because the chin is longer and the labiomental fold is stretched out. That lessening effect may be enhanced by the simultaneous placement of a small fat graft.

More aggressive labiomental fold reduction can be done but this requires a skin incision and the subcutaneous placement of a dermal-fat graft under the released skin edges.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am considering having a cranioplasty and/or temporal shell implant. I recently had a cranial CT done, and was wondering if you would be able to recreate that into a 3D CT scan in order to make the temporal shell implant, or at least to get a better idea of which areas are deficient in the cranium in order to better place the PMMA cement. Could you please let me know the costs associated with translating the CT scan into a 3D format, and if this would help you even with a PMMA cranioplasty without temporal shell implant?

A: Unless the original CT was taken in high resolution cuts (1mm or less), you can not get it converted into 3D CT images.

When it comes to what you are calling a temporal shell implant, I need to know exactly the temporal area to which you refer in terms of augmenting. There is skin only area between the temporal hairline and the eye which is where preformed temporal shell implants are used to augment. I am going to assume this is the temporal area to which you refer. A regular or 3D CT scan is not helpful in addressing the volume needs of this area since this is a muscular augmentation area and not bone. A CT scan, particularly a 3D one, only shows bone.

The only reason to get a 3D CT scan for the forehead is if one is getting a custom temporal implant made. If one is using PMMA bone cement, the scan is not really helpful as this is artistically applied and shaped during surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 26 year old female, I am very self conscious about my forehead and have been for years. I am so tired of feeling embarrassed and having to hide it and limiting what I can and cannot do for fear of it showing. I’ve been researching transplants to lower my hairline. I’ve ran into your website and was wondering if you do hair transplants to lower hair lines? If so a round about cost to have it done? I’m really hoping you can help me and I can get this done and feel 110% more confident with myself.

A: Lowering the hairline, as you may know, can be done by either scalp flap advancement or hair transplants. There are advantages and disadvantages with either approach and neither one is perfect. So let me review these with you. The advantages of hair transplants for lowering the hairline is that it does not create a fine line scar along the frontal hairline (although it will create a scar in the back of the head from the harvest site) and does not involve a true surgical procedure under general anesthesia. Its disadvantages is that it will take at least two hair transplant sessions and close to eight hours of procedure time to get the new hairline properly filled in and up to six to nine months to se the final result. A scalp advancement for hairline lowering creates an immediate hairline lowering in a fairly simple procedure under anesthesia. (like a reverse browlift) It disadvantages is the fine line scar along the frontal hairline and the possibility that some hair transplants may be needed along the scar line for better camouflage. (may or may not be needed)

When comparing these two, it is also important to look at the costs differences between the two. Two hair transplant sessions will definitely cost more than a surgical hairline lowering procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in facial reshaping surgery. I am a female with a recessive lower chin and a minimal jawline. I have had orthognathic surgery twice now, which has improved my teeth but not the balance of my face. I still have a very convex facial profile with an extremely long vertical jaw angle. Here are some images of my face. I hope these will help you to assess my situation. My last surgery was 11 months ago in which my upper and lower jaw were brought forward to correct an overbite and an open bite. I do feel that my upper jaw (between nose and upper lip) is more elongated than before. As you will see from the photos it is difficult for me to close my lips. I realize that this cannot probably be fixed, however I would like my face to look less long and narrow and my jaw line  more defined. My jaw is rather vertical in angle. Any advice very much appreciated.

A: The forward positioning of the maxillomandibular complex has placed a strain on your lip closure as this was not the bony relationship that your lips were ‘designed’ to function over. Along with the upper lip lengthening, these are not rare changes that occur with such maxillomandbular forward movements. In addition, loss of the jaw angle can occur with sagittal split ramus osteotomies (SSRO) of the mandible particularly when the lower jaw moves forward. This can be accentuated in females who may already have a thin and slightly high vertical has angle position initially.

The way to make your face look less vertically long and not so narrow is through a combined sliding genioplasty and jaw angle implants. Small vertically lengthening jaw angle implants (7mm vertical length and 3 to 5mms width) will create more defined jaw angles but not over power the upper face. A sliding genioplasty of the movements of 3mms forward and 6mms vertical reduction would shorten the chin length and also help push up the soft tissue chin pad. This may provide some potential benefit also to reducing the lip strain through a better lower lip position at rest.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am researching tummy tuck surgery and trying to see what can be done for me. I have attached pictures to help you see my severe abdominal overhang problem. I would like your professional opinion on which course of action would be best. 

A: It is important to realize that there are different kinds of tummy tuck surgeries depending on the nature of the abdominal problem. While traditionally divided into a mini and full tummy tuck, that historic classification by today’s methods is too simplistic. I divide tummy tuck surgery into six different types and levels which vary based on the amount of tissue removed, the location and extend of the incisions and whether liposuction plays an additive role in improving the result.

There is no question you would get tremendous benefit by an extended tummy tuck. (level 5) This is a tummy tuck where the removal of excess tissue wraps around the side of the waistline or encompasses about 300 degrees around the waistline. (it does not cross the midline in the back like a full circumferential body lift does) If you do not chase the excess skin around the waistline (a traditional or level 3/4 tummy tuck stops at the hip bones) you will be left with big dog ears of skin  and protruding tissue over the hips. In addition, it is important in any tummy tuck particularly when there is an overhanging abdominal pannus (apron) that a simultaneous pubic lift be done. This is often overlooked because it is hidden underneath the pannus but will become unmasked when the pannus is removed. Thus the excisional pattern of the tummy tuck should incorporate the design of a simultaneous pubic lift in its pattern. I have attached some picture showing a before and after an extended tummy tuck with a pubic lift. Note that the resultant tummy tuck scars wraps almost completely around the waistline.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I am interested in gynecomastia reduction surgery. I’m a 36 year old who has had man boobs my whole life. I’ve tried dieting and exercising to try and get rid of them with no success. They’ve caused great embarrassment for me over the years. I won’t swim in public and am very unconfident when it comes to dating and any sort of relations with the opposite sex. 

A: Your feelings of embarrassment and some degree of social restriction is not rare and exactly replicate what many men with similar problems state about their gynecomastia problem. Once gynecomastia has formed, there is no diet or exercise regimen that is going to get rid of it. While in extreme weight loss cases, breast tissue can be lost in a male, many men with gynecomastia do not need extreme amounts of weight loss. Gynecomastia reduction surgery can be very effective and is usually most effective when open excision is combined with liposuction. This is an outpatient procedure done under general anesthesia that takes about two hours to perform.

The success of gynecomastia reduction surgery is based on how completely the removal of breast tissue is done. There is always the risk of removing too much breast tissue causing a crater deformity or not taking enough leaving a residual areolar protrusion after all the swelling has gone down. This is the delicate balance plastic surgeons walk when performing this type of male chest surgery. For these reasons, there is about a 15% to 20% risk of desiring a revisional or touch-up surgery to optimize the chest contour.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I want to hear your expert opinion on whether a chin implant or a sliding genioplasty or some other thing is more appropriate for my jaw. I have attached pictures from 3 angles of my lower jaw, at a default, relaxed face. Notice my big jowls and rounded face. I have been told (by a few oral/maxillofacial surgeons) that a sliding genioplasty would probably be better than a chin implant because, as one surgeon put it,….an implant usually doesn’t create the angles I would need for the roundness to soften up a bit and for significant loose skin to pull. I don’t mind a slightly round face, I just don’t want to look like a balloon on the lower half of my face.

In your experience, how true is this???

A: A properly designed chin implant can create more angles than than a sliding genioplasty. A sliding genioplasty brings the chin forward but will make it more narrow in doing so. That is fine if that is the frontal change that you want….which usually works well for a female. Most males want a more square chin as it comes forward with a genioplasty which will not create that effect unless the bone is split and widened. But in doing so there will be a dip behind the chin in the jawline. Many bone-based facial surgeons often know how to do one chin approach (sliding genioplasty) but often do not have much experience with the array of chin implants, preformed and custom, that are currently available. Both implants and a sliding genioplasty are effective chin augmentation operations but their effects can be dimensionally different. It becomes imperative to know what each of them can aesthetically do and then apply it to the aesthetic needs of the patient.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have this grinding type noise when I open my jaw on my right side. I have had orthodontic treatment years ago and have a underdeveloped lower jaw. I consulted my orthodontist about the grinding noise possibly being linked to my underdeveloped lower mandible. He told me that my jaws are lined up correctly and I should do nothing about this grinding noise. At the beginning if my orthodontic treatment a lower mandibular advancement was recommended, however I decided at that time that I would just have orthodontic treatment without surgery. After orthodontic treatment I have a clearly recessive jaw with extra skin around my lower jaw area. As a craniofacial and maxillofacial surgeon I would highly consider your opinion in what my next step should be.

A: Many people have asymptomatic grinding noises which emanate from their temporomandibular joints. This is usually caused by the disc in the joint which may catch on opening as the mandibular condyle comes forward.  Underdeveloped lower jaws with Class II malocclusions (orthodontically corrected or not) have a greater propensity for these disc noises. But as long as one is having no pain in the TMJs or any difficulty with opening, there is no treatment indicated. For the recessive jaw and loose skin around it, this can be aesthetically addressed by either a sliding genioplasty or a chin implant. Either approach has certain advantages and disadvantages that must be assessed based on each person’s anatomy and aesthetic desires. The first place to make this determination would require an assessment of pictures from the side and front views.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Please help me I have flat head from the back and it looks ridiculous and people are laughing at me . And I’ve been suffering for over 22 years. I want to ask do you you have plastic surgery for the back of my head and please tell me the solution. I have attached a picture for you to see how bad it is.

A: Thank you for sending your picture. I will admit, and I have seen many flat back of the heads, that you do have an impressive one. It is one of the flattest back of the heads that I have ever seen. There is no question there is improvement to be had with flat back of head surgery, it is just a question of how much and what effort do you want to put into it. There are two basic approaches, either a single stage or a two stage approach. In a single stage approach, a custom implant or PMMA bone cement is use to create a moderate improvement. In a two-stage approach, a first-stage tissue expander is placed to stretch out the soft tissues. Then a custom implant or bone cement is placed to get a more significant change. (at least double that of the one-stage) Either way, you definitely can get a positive improvement from the very flat back of the head that you have with these occipital augmentation.

Dr. Barry Eppley

Indianapolis, Indiana