Your Questions

Q: Dr. Eppley, Our four year old daughter has a flat back of the head due to positional brachycephaly. She has the additional bone growth over her ears that we would consider also having reduced. We want to know our options for building up the flat spot when she gets older. What is the right age? Have you built up flat spots for younger kids? We’d prefer to wait until she’s at least a teen but want to fully understand our options. Does the single step procedure provide enough material to build up the flat spot to the satisfaction of most clients or would you anticipate the two step method where the scalp is stretched to accommodate more material might make more sense? 

A: The timing of elective skull augmentation for a flat back of head is matter of personal preference. In my opinion, it can be done very young or anytime later in life. Building up the bone requires the overlying scalp to stretch and age does make any difference in that regard. Since this is an onlay technique, the hydroxyapatite cement will grow with the surrounding bone so age is not a concern in that regard. I have done a child with unilateral occipital augmentation as young as age 4. The timing is merely a matter of parental and, if old enough, patient choice.

Because your child has bilateral occipital issues with biparietal width increase, the need to reduce the wider bone indicates a need to do it when she is older and the bone is thicker. So the teenage years would be a good consideration in your child’s case. While most cases are done in a single stage procedure, that would depend on how flat it is and how much occipital expansion is needed. If more than 15 to 20mms of occipital expansion is needed, then a first stage tissue expansion would be needed.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had three babies in just under four years. Each time, I was all belly, which was ok while I was pregnant, but it’s left my stomach impossible to flatten again! I’m interested in a tummy tuck and possible liposuction on my sides. I also have an umbilical hernia. Could that also be repaired at the same time?

A: Pregnancy, if repeated often enough and at close enough frequencies, makes numerous permanent changes to the abdomen. Stretched out skin, stretch marks and umbiilical hernias are common sequelae of pregnancy. While losing baby fat and weight can help make some difference, there is no amount of exercise and dieting that can help remove extra skin, reapproximate a rectus diastasis or fix an umbilical hernia. Because of the wide open exposure of a tummy tuck, both the umbilical hernia and the rectus diastasis can be repaired. The removal of extra abdominal skin completes the tummy tuck and can, in many cases, make a woman’s abdomen completely flat again. The amount of loose skin and fat, condition of the rectus muscles and whether a hernia exists or not makes for numerous types of tummy tucks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a mother of  three and have breastfed each baby for about 13 months. I amcurrently breastfeeding my 9 month old. Once I’m done, I’d like to have breast augmentation with gummy bear implants. After breastfeeding, I’m left with very small breasts (embarrassing!). I’ll be probably a small B cup and will want a natural looking D cup. What is the cost of gummy bear breast augmentation?

A: Breast feeding eventually leads many women to consider or undergo breast augmentation surgery. Each child and each round of breastfeeding causes more breast tissue loss known as involution. I have seen many women who after two or more children have virtually lost all of their breast size and with that some of their feeling of being an attractive woman. Breast augmentation is a quick way to restore what was once lost. An important issues is whether you have any sagging after three children and that may necessitate some form of a breast lift with your implants. The other issue is that it is a good idea to have your milk dried up before having the surgery. (although the surgery can still be done with some light milk production) The total cost of gummy bear silicone breast augmentation is around $5500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had two facial problems my entire life, dark circles and retracted lower eyelids. I have always hated my look when I am not squinting and because of that I think that my ower eyelid muscles have become overdeveloped. I have attached pictures of when I squint and when I don’t. This will give you an idea of my orbital/cheek area.

The area circled in the picture was filled with Juvederm already as suggested by a local plastic surgeon to improve lower eyelid projection but it didn’t help at all. Though I do like my cheeks now and I am also thinking about making this permanent with cheek implants to give even better support to lower eyelid. What do you think about this idea? The local plastic surgeon seemed to think that cheek implants were a bad idea.

What procedures would you recommend? Also would canthopexy/canthoplasty address problem with overdeveloped muscle, or would it need to be trimmed with another procedure ? Could all procedures be done together?

A: Your pictures show a large orbicularis muscle roll of the lower eyelid (when squinting), cheek bone hypoplasia and lower eyelid hollows. (with some slight scleral show) I would recommend medium submalar shell cheek implants, a pinch lower blepharoplasty with excision of redundant muscle and fat injections for undereye hollows, all of which could be done as a single procedure. When done locally this is an outpatient procedure but, if from afar, most patients would return home in 48 hours. It would take about 10 to 14 days to look very acceptable without obvious signs of surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley ,I have a question about the Brazilian Butt Lift.  I am wondering with this procedure if the fat could be taken from my stomach? Also is there an extra fee for the liposuction that takes place for the fat transfer to the buttock?

A: The fat harvest portion by liposuction of a Brazilian Butt Lift is included as part of the overall buttock augmentation procedure and fee. That is, perhaps, one of the great appeals and bonuses of the procedure. While the amount of fat that will survive after injection is unpredictable, the body contouring effects from the liposuction harvest are predictable and assured.

The stomach is almost always the first place on the body that is liposuction harvested. And for the vast majority of patients it is also the greatest source of donor fat material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley,  I found you from an internet search for “bulging temporal artery”. I have read that you recommend multiple location ligation done in office as the treatment.  I do, however,  have a few questions for you. 

1.  The artery doesn’t always bulge.  I don’t know what triggers it but there are times it’s almost flat. Can a ligation be done ONLY if it’s bulging? (It can be irritated to swell up by rubbing or me crying) 

2.  Are there chances of complications? (loss of hair due to lower blood flow? Surrounding arteries swelling from diverted blood flow?) The internet has scary scenarios!

3.  How would I attend follow up appointments for stitch removal etc since I’m 4 hours away? 

 4) How long is the recovery time and what can I expect in the way of swelling, bleeding or bruising? (take a week off or more?)

A: In answer to your questions about temporal artery ligation of a bulging or prominent temporal artery branch in the forehead/temple area:

1) It is important to be able to find the temporal artery branch to ligate it. So some degree of bulging is needed for the surgical ligation procedure to find the potential multiple ligation points.

2) Other than some very small scars, the risks of the procedure are merely as to how well it works. There is no risk of hair loss and surrounding arteries become dilated as a result of these ligations.

3) The small suture that are placed are dissolveable so there is no need for any follow-up visits.

4) There really is no recovery of any significance. Other than some small swelling at the ligation points, there are other issues of concern.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I was inquiring on if you have any experience with congenital symmastia? It’s something that I’m quite certain I have and something that has always bothered me. I do not think I need breast implants and my breasts are a good size. But I do not like this web of skin that crosses between my two breasts. In bras it looks even worse. How can this be corrected?

A: Symmastia presents in one two ways, either from a congenital basis (like yours) or iatrogenically created by breast augmentation surgery. In congenital symmastia, there is usually a web of tissue between the two breasts. In this web there is fat and therein lies the way to treat it…liposuction. By removing the fat in the web and with postoperative compression, the tissue between the breasts can be made to stick down to the sternum thus eliminating the web. This can be done as s stand alone procedure or combined with breast augmentation. (although by your pictures this is not something that you need)

The success of symmastia correction by liposuction depends on how well the skin will adhere down to the sternum. After liposuction compression is applied but this is a difficult area in which to keep good compression on the skin for any sustained amount of time.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in breast reduction surgery. Next month I am having barbaric surgery with a sleeve done. I have had a lot of female problems. I am having pain in my back and my chest from my large breasts. I do have Aetna Insurance so how does that process work to get a reduction on my breasts and having the insurance cover it?

A: Breast reduction is often covered by insurance and the process to determine if they will pay for it is known as predetermination. This requires photos to be sent as well as documentation that efforts at physical therapy are done (I don’t make the rules, we just have to follow them) for the insurance company to consider coverage. However, if you are going to lose weight, particularly through bariatric surgery, breast reduction surgery should only be considered after the weight loss has occurred. Significant weight loss has been shown to affect breast volume. You may find out that you only need a lift and not a reduction as extreme amounts of weight loss can cause a lot of breast volume to be lost. Wait to consider breast reshaping/reduction surgery until your breasts are in a stable period where your weight is where you want it or the best that it can be.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of a buttock lift. I I would like to have the extra skin/wrinkles removed from my butt. I have hoped to find a procedure that did not include implants. Do you feel I am I a candidate for this surgery procedure?

A: What you are demonstrating is a severe buttock sag with a lot of folds/rolls of skin around the bottom of the buttocks. This often occurs in  very thin women as they age and may also happen after a significant amount of weight loss. While it it true that buttock augmentation would help pick up some of this loose skin, it would take a massively large augmentation to do so. The better approach is to do a lower buttock lift or tuck which removes all the skin folds on the bottom half of the buttock. This places the scar along what should be the infragluteal fold or lower buttock crease. This will not increase the volume of the buttocks, which will still be very flat but it will get rid of a lot of that saggy skin which makes one’s buttocks look a lot older than they really are.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am a 32 year old female interested in having chin reduction surgery. I underwent orthognathic surgery in 2011 to correct a class III malocclusion and to straighten my midline with a bilateral sagittal split mandibular setback osteotomy. I am pleased with the way my bite looks as a result of this surgery, but I am still unhappy with the extent to which my chin protrudes. I am very interested in learning what can be done to reduce the size of my chin and to improve my facial profile. I have attached some frnt and side view pictures for you to review.

A: Chin reduction surgery must take into account the extent of bone and soft tissue to determine what technique to use. What I see is a central button of bone on the chin which appears to be the primary culprit. It looks like it could be horizontally reduced by at least 5mms and the bone tapered backward along the jawline a few cms. The real question is whether this should be done by a submental or an intraoral approach. It is tempting to do it from inside the mouth but there is always the issue of what will happen with the overlying skin. As tempting as that seems with a smaller chin excess problem like yours, that is  probably a mistake. The submental approach has the added benefit of removing and tucking in any soft tissue excess which complements the bone reduction.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in some form of a tummy tuck. I am 42 years old, totally done with babies,  5’6” and my highest weight was 235 (pregnant) and I’m down to 150lbs and has been that weight for over a year. I’m trying to come down 10 more lbs. Should I get down 10lbs more before I have surgery?  If I do the surgery, will I be okay to lose 10 more and possibly work off that top fullness, or will it look lose again?  I go to the gym three to four days a week and I’ve been working really hard for a really long time.  It’s getting the point where I’m starting to get really discouraged, because the more I lose, the worst my stomach looks. 🙁  I have attached pictures of my stomach from all sides. I did try to get the  best photos possible (I am attaching a back view—just in case) since I’m not sure if I need an extended tummy tuck or the body lift.  Do you think I need it or will the extended TT will be sufficient?  I mean, obviously the hanging belly is the biggest issue, but I really want a good contour.  I am also very self-conscious about my mons area, and hope it will get pulled up (maybe a tiny bit of lipo on it?) in the process.  (It’s totally embarrassing!)  Will that happen?  I really like how your previous patient (2^nd attachment–tummy tuck after) turned out—the scar symmetry, the low profile, and how the mons area looks.  I also have attached another photo from the web that I thought looked similar to me in the before photos.  Do you think I could achieve a result like that?

A: Your pictures were great and show exactly what you need. You definitely do not need a body lift and just a bit of an extend tummy tuck. Your mons will be liposuctioned and lift at the same time as the tummy tuck. Whether any patient can achieve the result that another patient obtained can not be precisely predicted. But if you look similar before surgery, then a similar result may be possible.

If you are within 10 to 15lbs of your weight goal, there is no reason to lose any more. The surgery process will take care of that weight. (what is removed during surgery and the weight loss after surgery during the recovery)

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have loose skin around my belly button after having several children. I went to a plastic surgery consult and was given the option of a mini tummy tuck and moving the belly button lower from the ‘inside’.  I have some concern about the tummy tuck option for my belly. My only hesitation is the aesthetics of having my belly button one inch lower.  Most of my pants/jeans/swimsuits sit just below my bellybutton which, other than the puffy ring around my bellybutton, looks good (generally speaking). I attached a few pics with jeans and swimsuit bottom. I am thinking that it will look “odd” after a mini tummy tuck, such that the bellybutton will no longer be visible with these clothes on and my overall appearance will look “strange”.  Where my belly button sits is between my waist and hip; it seems that the belly button would be moved down around my hip which might appear “not quite right”. Are there any other alternatives for a better appearance of this area?

A: Unfortunately there are no other effective solutions for the excess skin around your belly button other than the mini tummy tuck approach. Unless one puts a horizontal scar across the belly button area (which would obviously be unacceptable) the only way to work out the extra skin is to translocate the belly button lower through a mini-tummy tuck approach

Like just about everything in aesthetic surgery, it is all about the tradeoffs…you usually tradeoff one problem for another. You just have to decide which problem you can live with the best…the skin the way it is around the belly button or less skin around a belly button which is positioned lower. There are no ideal solutions for your problem that don’t have their own drawbacks.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a lip reduction six months ago which, quite frankly, did very little. It may have resulted in a 10% reduction of my lip size. I am now considering further lip reduction surgery for better results but have a few questions.

1) I’m looking for very specific results so I need to be sure you are confident in your ability to perform a reduction of at least 1/2 of the size on each lip? I want results that are very significant and not subtle.

2) I would also like to reduce the bulkiness of each lip, in other words, less meaty.

3) In the technique you do will the scars be visible? What can I expect after everything is healed? Will there be any noticeable scars on the visible/dry part of my lips?

4) Will there be 2 scars, one from the prior surgery and one from this one, or can you remove the tissue from where the old scar is?

A:  In answer to your lip reduction questions:

1) Significant reduction can be obtained but there is a balance between reduction and the location of the scar. The only way to get significant lip reduction is to remove the DRY exposed vermilion not the wet invisible mucosa like you had the last time.

2) You really can reduce the thickness or meatiness of the lip per se. Right underneath the vermilion lies the labial artery which gives the blood supply to the lip as well as the orbicularis muscle which is responsible for some of its movement. Thus you can see that trying to debunk the lip by a deeper wedge excision is fraught with potential problems. All you can do is remove the surface vermilion to have less visible show but really thinning out the thickness of the lips is not surgically advised.

3) as per #1. The key point is…the bigger the reduction the more likely the scar may be visible.

4) The old scar would be removed with the new excision.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m considering getting the custom skull implant for skull augmentation to build up the back of my head. Can you please share your experience of this type of skull implant surgery you have performed?

A: When considering preformed silicone implants for occipital or any skull augmentation, there are two basic methods to do it. Here in the U.S., a custom fabricated implant is always used since there are no preformed skull implants that are commercially available. It is always hard to argue with a custom implant since that is the ideal way to get a perfect fit and have it made to correct any existing asymmetries. That is the approach I have used over eight forehead/temporal augmentations and one occipital augmentations in the past two years. That being said, I have placed a few preformed skull implants (top and back) on international patients who brought the implant with them from overseas manufacturers. (they are illegal to directly import into the U.S. since they are not FDA-approved)

I do think such silicone implants do have role to play in forehead and occipital augmentations for the reasons discussed even if there is a modest increase in the infection rate. (out of 9 such skull implants in the past two years, I have had two infections that necessitated their removal (22%). This is contrasted to over 100 PMMA skull augmentations with no infections seen even in three cases where the implants became exposed due to wound dehiscences. (0%)

That begin said, I am enthusiastic enough about using preformed implants that I am now working with a major manufacturer to create a set of three sizes for occipital skull implants. For many patients this simplifies the procedure, allows for a slightly small incision and creates a moth contour even if it does not have perfect adaptation to the underlying bone.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’m very interested in pursuing skull reshaping surgery to fix a congenital defect involving the right side of my skull. For as long as I can remember, it has been both a cosmetic concern and one of comfort. (causing pain/discomfort with prolonged lying on the right side or with wearing helmets of any sort). From reading your web-based article, I believe I may be a good candidate for your procedure. I’ve attached a few photos of the affected area for your review; of course it’s difficult to capture the magnitude and dimensions of the defect (a bulging, sharply angulated defect) with mere photos. I thank you in advance for your time and consideration.

A: As best I can tell from your pictures, the location you are referring to is the right parietal/posterior temporal region. You describe it as a congenital defect but also call it bulging. I suspect you mean a lifelong bulge in this area which is painful. This is very consistent in my experience with more of a temporalis muscle problem in that area. Most patients and even physicians have little appreciation of how thick the temporalis muscle is in that area and how far back it goes. It always feels like bone but there is a 5 to 7mm layer of muscle under exactly where you point. Having done a far number of temporalis muscle reductions/resections (temporal reduction) in this area for symptoms described just like yours, I can attest that your concerns are more likely muscular based than being a bone problem. A CT or MRI will show how thick the muscle is in this area. However, I often make the decision to do muscle resection/reduction based on the description and physical examination only.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a lip lift. I have very thin lips and a long upper lip. I want them to have more shape and size although I don’t want them to be too big. I have read about lip lifts but am not sure what I really need. I would like your opinion. I have attached a front and side view of my lips for your recommendations.

A: Thank you for sending the pictures. What they show to me is that unequivocally need a vermilion advancement and not a sub nasal lip lift. Your lips are very thing from corner to corner, has little cupid’s bow shape and there is a long distance between the base of the nose and the upper lip. This is a contraindication to a subnasal or bullhorn lip lift as it will only move up the central third of the upper lip but leave the rest of the lip behind, potentially creating an unusual and unpleasing shape. Only moving the physical location of the vermilion-cutaneous border, from corner to corner, of both lips can you make a significant improvement in the size and shape of your lips. I have attached an example of upper and lower lip vermilion advancements although this patient is older and she wanted a more dramatic change. The change from a lip advancement procedure is adjusted by the vertical size and shape of the skin excision and can be in any degree desired. The ‘test’ of the change a patient wants with a vermilion advancement is done by having them draw on the new border and shape of the lip with an eyeliner pencil. Then that becomes how much lip advancement is done.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in custom cheek implants.  I has severe sleep obstructive apnea and it took maxillomandibular advancement surgery where both jaws were advanced about 8 MM) to finally cure me.  As you can from the attached photos the maxillomandibular advancement surgery changed my face for the worse. Some people do not recognize me, others say I really aged and others say I look totally different. Other people on the internet that had maxillomandibular advancement surgery for sleep apnea say that they got there face back by having cheek implants put in. I would like to augment my cheeks in the best way and have other procedures and/or fillers to get me looking at least as good as I was before the sleep apnea and maxillomandibular advancement surgery.

A: The current state of your facial skeleton/appearance is rather classic when the upper and lower jaws are significantly moved forward when there is no natural malocclusion. These osteotomies are done below the level of zygomas (cheeks) and thus they create a relative state of upper midface/cheek deficiency as there is now a big forward step off between the zygoma and the maxilla as opposed to the reverse step off that normally exists. Cheek and/or cheek-infraorbital rim implants are the logical solution for this induced facial skeletal deformity. There are arguments to be made for either using preformed or custom cheek implants for your midface restoration. But the very altered bing anatomy does make an argument for the custom approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have had rhinoplasty, Medpor jaw angle implants (11mm projection) and silicone chin implant (medium 7mm). But I want a stronger look that is more masculine. I  also want cheek augmentation and I want a stronger chin. But the biggest chin implant I can find only gives 8mm horizontal projection so I’m considering a sliding genioplasy to have both horizontal and vertical augmentation. For the cheek implants iIm considering Design M Malar Implants from Medpor, I think they’re more anatomic than silicone ones, and also Medpor ones augment from zygomatic arch to the cheek bone which I think will give a stronger and masculine look. I would like to know which size would you recommend me to use. (4.5mm or 7mm) so they would look proportional to my jaw angle implants (11mm) I read in the internet that when you use facial implants, you have to consider the soft tissue augmentation that is different from the size of the implant… for example if you have a chin implant with 10mm projection…you’ll end up only with 7mm in soft tissue projection. So if I have cheek implants size of 4.5mm I’ll end up with 3mm augmentation, but if I have the 7mm ones,, I’ll end up with 4.9mm, So i don’t know which ones to use. I read in your blog that when it comes to cheek augmentation you should not over do this specific part because you will look unnatural. I definitely don’t want that. But also I have read that the cheek or zygomatic bone should be bigger than jaw angle.

A: I would take exception with your supposition that there is not a 1:1 correlation with the translation of implant thickness to how much change is seen on the outside. When it comes to any form of jawline augmentation, it is pretty much a 1:1 correlation. In the cheeks it is most commonly a 0.8:1 ratio. However the thickness of the soft tissues in any patient is so variable that no absolute implant size to external change seen can be generalized. Thus I would always assume it is a 1:1 relationship through the skeletal structure of the face. This would be true in my opinion given your relatively thin face.

I would also point out that a little bit in the cheeks goes a long way so I would be careful about going too big here. It is very easy to end up with cheek implants that are too big. Thus, I would lean towards the 4.5mm implants as opposed to the 7mm thick cheek implants.

Lastly, you can certainly do a sliding genioplasty using/keeping the existing chin implant in place  getting the dual benefits of both techniques. However be aware as the slidinjg genioplasty moves forward and down there will be a slimming.narrowing effect on the chin. Thus if you want to end with a more square chin look than you have now, the chin implant should be switched to a square design or even a more square one and not a rounder anatomic style.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I’ve been looking for a more permanent solution for a lip augmentation. I was looking into fat grafting, but I understand that that procedure may not turn out as well as I would like if not done by a surgeon who is very experienced in that procedure. I’ve also been looking into permalip, but I don’t know if that would be for me because my top lip is uneven (as you can see in the picture I’ve attached). In your opinion, which procedure would be better for me? Roughly, how many times have you done each procedure? And what are your prices for both procedures?

A: There are multiple options for lip augmentation from fat injections, implants and mucosal advancement procedures. (V-Y lip lengthening) There are advantages and disadvantages to all of these procedures and none of them are perfect. They all have flaws such an unpredictability of volume retention (fat injections), asymmetry and palpability (implants) and longer recovery. (mucosal advancements) While they all can be effective, it simply depends on which of their flaws you find most acceptable. I have performed many of all of these and I think the ‘safest’ (less risk of complications) is fat injections. Permalip implants are the easiest and can always be replaced by fat grafts should one not like their feel.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a problem with the mentalis “balling up” when I try to elevate my lip after having a genioplasty. Prior to the genioplasty I had an indentation (not really a cleft but a small ridge) in the lower middle of my chin, this since is gone and simply looks like a ball of tissue when I elevate my lip (at rest it looks okay). I did consult with a local surgeon over a year ago who then performed a mentalis resuspension. This showed some improvement but afterwords, due to still having the “balling” found out that he never fully released the mentalis and he’s recommending releasing the entire mentalis and resuspending again. I’ve been doing some research about mentalis resuspension. One technique goes intraorally to do a wide release of the mentalis but also makes a small incision under the chin until the mentalis is completely released. Once the mentalis is fully released it is suspended intraorally and then the chin pad is anchored rom below. Do you think this will work? My main objective is to reduce (or eliminate if possible) the balling effect, hopefully returning that nice indentation (which I feel is the main reason the area balls up) and hopefully reducing my lower teeth show (full competence would be nice however I’d be happy with a mere improvement). Please let me know if this is something that you perform and if it’s something you’d feel comfortable with.

A: As you know there are different variations and extent of mentalis muscle releases. Depending upon how much the mentalis muscle is released will determine how much it can be resuspended. The mentalis muscle has its origin on the bone in the incisive fossa of the incisor teeth superiorly and inserts inferiorly into the skin of the chin. (not really the bone on the bottom of the chin) It is the insertion point of the muscle that actually contracts and pulls the skin upward. Thus when you are talking about a balling up of the muscle when you elevate your lower lip, that suggests that the problem may be exactly the opposite of what you think. I would question with your history if releasing the whole insertion of the mentalis muscle from below is really going to correct this balling up issue. Rather that anatomically suggests that the balled up area of muscle may represent the fact that the insertion point of the muscle in that area has been lost. However given that it is very difficult to re-establish a long-standing disinsertion point of the mentalis muscle (chronic scarred muscle contracture) the only real effective option may in fact be complete mentalis muscle insertion release. This does require a submental incision to really fully release it properly. Once fully released then it would have to be resuspended intraorally.

That is a long answer to say that this full mentalis muscle release and resuspension would be the only hope of eliminating this balling up issue even though it is ‘anatomically incorrect’ when you look at how the muscle moves and its origin and insertion points. That most certainly could be done under a sedation and local anesthesia approach like before.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, After doing some more research, I’ve also wondered about the possibility of facial liposuction or a buccal lipectomy with my vertical chin lengthening procedure.. I know that buccal lipectomy has to be done selectively, because it can cause a gaunt look. Do you think that buccal lipectomy or some cheek liposuction would help me? The fullness of my cheeks bothers me a lot and so I thought the genioplasty would help elongate my face to reduce the roundness or fullness. Basically my question is if some sort of facial liposuction may be a better option, or if it should be done in addition to the genioplasty? (I’ve had one other doctor mention that my chin height isn’t really lacking and that not much vertical height would need to be added). I’m interested in getting your opinion on this.

A: It would not be rare to do further facial derounding by a subtotal buccal lipectomy as a complement to other procedures. A buccal lipectomy produces a subtle effect so it alone would rarely create significant facial slimming. As long as it is not done overaggressively, it will not ultimately produce the gaunt look and will reduce some fullness right under the cheekbones.

By aesthetic measurements, you vertical chin height may be fine. But in the spirit of what you are trying to achieve, vertical chin lengthening is needed. Rather than rely on numbers or what looks right to someone else, use computer imaging to see what facial look is created with and without vertical chin lengthening.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I feel my chin is strong and I like my cheekbones, but they are wider than my jaw rami. I would simply like to add width to the lower third of my face by jaw angle implants. How can that be done? I have attached some pictures of my face so you can see what I mean.

A: I can see by your pictures as to exactly what you mean by narrow jaw angles compared to the rest of your face. Since I do not know what your jawline looks like from the side, I can not tell if it is just a width issue or a combination of width and some vertical lengthening. That distinction is critical in choosing the right style/design of jaw angle implants. Your have stated that you only need width so I will assume for now that is the only jaw angle dimension increase that you need.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, can I get a wrap around jawline implant made of Medpor material?

A: There are two basic types of wrap around Medpor implants depending upon how you choose to have them preoperatively prepared. There are preformed implants (a variety of chin and RZ angle styles (also known as the Matrix system) and then there are custom implants. Due to the extremely high cost of custom implant fabrication from Stryker ($15,000) I do not consider that a practical option for most patients. Thus with Medpor it is a matter of selecting amongst the various preformed ‘parts’ to create a wrap around jawline effect. A true custom wrap around jawline implant prepared off of a patient’s 3D scan can only really done today economically if it is made of a silicone material.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I came across your website in search of a surgical procedure that would add more volume to the back of my head. (occipital augmentation) I have essentially a flat head, and would like to change that. My question is; what is the average price (I know they are not all the same) for this procedure.

A: The typical occipital augmentation procedure uses about 60 grams of bone cement (which is just about the extent that the scalp can stretch to accommodate the underlying bone expansion) placed over the flat area on the back of the head through a scalp incision. In most cases of occipital augmentation this produces a satisfactory result. However there are a minority of cases where this volume addition may not meet the aesthetic expectations of the patient based on the degree of flattening that they have. Thus it would be helpful to see a picture (side view) of your head to determine if this one stage approach would be enough. In more severe cases, a two-stage approach can be used but obviously we would like achieve a good enough improvement that only a single surgery is necessary.

As a general number, the average total cost of a cone-stage occipital augmentation procedure (all expenses included, surgeon’ fee, operating room and anesthesia and bone cement material costs) is around $8500.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I would be pleased if you could tell me if in my case whether an endoscopic midface lift would help to get rid of the sagging face after cheekbone reduction?

A: I have read through many explanations of facial sagging and its causes and treatments after cheekbone reduction surgery and find very little of substance there that is helpful. It only tells what is already known…that if the osteotomized bone segments are not stabilized by plate and screw fixation (particularly at the zygomatic body) the natural contraction force of the masseter muscle will pull the entire cheek segment downward including the attached soft tissues. In addition, over release of the masseter tendon from the zygomatic body will have the same effect even if the bone is properly stabilized in an inward and superior position. Fixing this type of msuculofascial sag is not going to be helped by any overlying skin repositioning maneuvers such as any type of facelift procedure that merely pulls on the skin. Thus, while any sort of midface lift may be of some help, it does not fully address the root cause of the facial sagging…musculofascial contraction.

For all intents and purposes, it is not really possible to reattach or lift scarred masseter muscle. This is why some form of skeletal cheek augmentation is usually needed with the lift to volumize the submalar cheek zone. This could be done with either implant or fat augmentation.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have thought about liposuction a long time on my abdominal area which has always had a roll, even as a child. I would like to consult on liposuction and perhaps breast augmentation. I am going on vacation by the middle of June and did not know if it is even possible to schedule with you prior to that time.

A: It is very common to perform breast augmentation with any number of other body contouring efforts. Coming breast implants with a little bit of liposuction would not extend that recovery to any significant degree. Given that you are going on vacation in the middle of June, I would recommend that you have this surgery at least six weeks in advance of that event so you can be fully recovered, have few if any twinges of discomfort/soreness and be able to be completely in the the benefits phase of the surgery with little body ‘memory’ of the actual surgery. Thus it would be ideal for you to have this surgery no later than the end of the month. We strive to service our patients in an expeditious manner so I can see that happening on our end. I will have my nurse contact you tomorrow to find a convenient consultation time as soon as possible.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, from my research and various consultations, I believe Medpor facial implants is the way to go. I have heard that with silicone it will eat away the bone’s density as it has shown on my latest CT scan. (which was sent to you also)  Over years will the bone keep deteriorating from the silicone? What is your opinion on both types? pros/cons?

A: Whatever you have heard about silicone facial implants is both inaccurate and untrue. It does not cause any deterioration of the bone. That is an occasional passive phenomenon in the chin where the implant may settle into the bone from the pressure of the overlying muscles if the implants are placed too high on the chin bone. It is a simple passive phenomenon and not an active inflammatory process, It is never seen beyond the chin area in my experience.

I have used plenty of both silicone and Medpor facial implants in both primary and revision work. I could detail all of the advantages and disadvantages of each but, in short, if I never could place another Medpor implant I wouldn’t. (I still do when patients want but I have yet to see any advantages with its use and there are plenty of disadvantages) It costs more, has a higher rate of infection (as any textured surface implant does anywhere), is difficult to place, requires longer incisions to insert, is harder to modify, and poses a real problem when it comes to revisional surgery. (and remember even with custom implants the revision rate is not insignificant in the young male face patient) Whatever benefits they may be to some tissue ingrowth are overwhelmed by all of these disadvantages and screw fixation easily eliminates its only one advantage. (tissue ingrowth = implant stability) Over the years I have come to one conclusion about Medpor… it is an implant material that is really a poor choice for facial implants but it has been around so long and is an alternative to silicone that doctors keep trying to make it work.

But some patients are very emotional in their decision for Medpor although the logic of its use does not meet the scientific test for being any better than silicone. (and is a much worse handling material) But if that is what the patient wants, I will use it most of the time unless I feel it really compromises the ability to get the desired result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I really need an opinion on what I should do to correct facial sagging or ‘bulging’ around my perioral area. I had upper jaw surgery six months ago which was a maxillary impaction. Since then, the left side of my face looks normal but the right side looks ‘pouchy’ and droopy to me. I’m glad I did the jaw surgery for my bite, but the way the right side of my mouth looks makes me feel old and ugly. I had a tiny bit of Juvederm injected in my cheeks and near the corner if my right lip a few weeks ago, but it hasn’t made any difference whatsoever to the problem. What do you recommend?

A: When you think about the mechanics of this type of facial skeletal surgery, it is perhaps no surprise that some facial sagging can occur in a few patients. When the maxilla is vertically shortened and the lower jaw rotates more upward in a new bite relationship, the overlying soft tissues have not changed. Thus there may be a relative ‘excess’ of soft tissue to bone. (bone is removed but the soft tissue is the same amount) While this is theoretically true, it rarely poses an aesthetic problem. But this can be a source of the tissue sagging…a relative soft tissue excess compared to the vertical length of the facial bones.

The options for improvement could be simple perioral mound liposuction on the fuller/sagging side or attempt to lift the sagging tissues by a variety of cheek augmentation methods. Which one may be best for you I can not say based on just this one picture and how you feel about the rest of your midface.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a cranioplasty. I have a depression in my forehead for the past twelve years. I am twenty-two years of age and this depression started showing around age ten and has just been there ever since. It makes me feel alien, I don’t like taking pictures, I only comb my hair in one style to cover it kind of and I really think that I would be a more confident person had I have a normal forehead. I desire a “normal” forehead, without a sink in it :(. I have attached pictures of what it looks like.

A: In looking at your pictures, what you have is a classic case of what is known as linear scleroderma which creates a deformity known as the ‘coup de saber’ (cut of the saber) effect when it appears on the forehead. It is a condition that usually develops as a child and causes a loss of fat and an indentation in the bone. It is progressive and the tissue atrophy effect eventually burns itself out by the time one is a young adult in most cases. Its causes is not really understood and is currently felt to be related somehow to the nerves. When it appears on the forehead, it usually follows along the line of the first division of the trigeminal nerve. (supraorbital nerve which comes out of the brow bone and extends vertically upward into the forehead) This is why you have a very groove going upward from your brow bone, hence the description ‘cut of the saber’.

I can not tell completely from the pictures about the quality of the overlying skin, which usually is thinned and mottled in color although your skin along the groove does not appear so. (but the pictures are fuzzy) Treatment could consist of fat injections, a minimal incision endoscopic cranioplasty for bone augmentation or a combination of both. I would know exactly what to do by feeling it but I suspect it ail requires a combined fat and bone augmentation technique for optimal forehead augmentation contour improvement.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about temporal muscle reduction surgery. My husband’s temporalis is very prominent when he chews and I was wondering if this is something to be worried about. He’s a healthy 25 year old and has no symptoms. Can this be fixed?

A: Having prominent, large or hyperactive temporalis muscles is not something to be worried about for any medical reason… unless one is having chronic muscle pain or spasm from their large size. Many men in particular have prominent temporalis muscles which can become very prominent in its convexity on the side of the head. The larger the lower jaw, the bigger the muscle has to be to open and close it. Thus, the bigger the muscle the more prominent it will be seen when in use from chewing when it maximally contracts.

Whether one should reduce the size of the muscle ‘(fix it’) by temporal muscle reduction surgery is an aesthetic concern not one of medical necessity. Some of the most prominent portions of the temporalis muscle can be reduced/thinned to reduce its bulging appearance (make the area above the ears flatter and not convex) without any effects on jaw opening and closing in my experience with this type of surgery.

Dr. Barry Eppley

Indianapolis, Indiana