Your Questions

Q: Dr. Eppley, I am looking to do something for my lower lip asymmetry. My bottom right lip pulls down. It is worse appearing when I smile. What type of lower lip symmetry surgery may solve my problem? Would a corner lift help this? I have had Botox injections, which definitely made it look better but I am seeking something more permanent.

A: Your lower lip asymmetry is caused by a weakness in the marginal mandibular nerve which works the anguli depressor muscle. (which pulls the lower lip down) This is why the left side of the lower lip is higher than the right which becomes magnified when you smile. You said that you were getting Botox to make it more even which I assume is done on below the right lip to weaken the depressor anguli muscle to better match that of the left side?

This leaves you with three options to improve your lower lip asymmetry:

1) Augmentation of the right lip vermilion to raise the lip edge

2) A partial depressor anguli muscle resection (done intraorally) to weaken the stronger right side so it elevates higher

3) left lower lip vermilion resection to lower the left

There are also combinations of any and all of these three.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking to achieve more definition and masculine features. I want a more defined jawline, neck and cheekbones. I actually am even more dissatisfied with how my face looks from the side or profile view. Do you think that liposuction of any area of the neck or cheeks would be beneficial? Or just all implants? I’m slightly hesitant to do implants other than the chin and wondering if you yourself would be able to use fillers instead of something permanent. I have attached some front and side pictures for your assessment.

A: Your side picture clearly shows a more recessed chin that would benefit from a chin augmentation. I think this combined with small jaw angle and cheek implants would provide much better facial definition. But it is clear that you are only comfortable with a chin implant at this time.

When it comes to fat removal, many chin/jawline enhancement patients will benefit from sub mental/neck/liposuction as a complementary procedure. For the cheeks, fat removal is done by a buccal lipectomy procedure which help define or skeletonize the cheek bones better. There is certainly nothing wrong with using injected fat for cheek augmentation. It does not create a sharper or mored defined cheek augmentation effect because it is a soft material and its survival is anything but assured. But for those patients who are a bit skiddish about cheek implants and want to do an initial trial with something more natural (albeit with its own drawbacks), injected fat for cheek augmentation is a good treatment approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I recently had a bilateral sagittal split ramus mandibular osteotomy with a sliding genioplasty. My bottom lip (and perhaps top) have thinned considerably. It seems the bottom lip flips in somewhat. It was always very full and pouty. Can something be done? In addition, my jaw angles used to be much more prominent and I had a longer ramus. What can be done? Will reversing the genioplasty help?

A: Reversing the genioplasty is not the solution for an inward inversion of the lower lip after the procedure. That is caused by disruption of the origin of the mentalis muscle on the bone and it being resutured back together. This can be a source of lower lip tightness, lower lip thinning, and some inward inversion/contracture of the lower lip. Unless you terribly dislike the position of the chin, moving the chin back is not going to solve these soft tissue problems. Rather some soft tissue augmentation is a better approach. This could include the placement of a dermal-fat graft below the vestibule in the lower lip after it is released. (all done through your existing intraoral incision) Fat injections can also be done at the same time into the lips. The take of fat injections is variable but that of the dermal-fat graft assured.

Many BSSO procedures change the shape of the jaw angles, often losing their distinct shape. They often appear less pronounced and higher afterwards when the bone has healed. In some patients, jaw angle implants can restore a more distinct shape and the addition of a little angular width as well.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in getting a body lift. I have had bariatric surgery two years ago and I need to get rid of excess skin. This excess skin around my waistline is causing severe chafing. My insurance won’t cover ‘cosmetic’ surgery. My question is this: can we get insurance to cover it if it is a medical necessity?

A: Insurance in some cases will cover an abdominal panniculectomy but it depends if the abdominal pannus meets several criteria established by the insurance industry. for such coverage. The abdominal pannus must of a certain size as seen in multiple view pictures (hangs down onto the upper thighs), have a medically documented history by a physician of skin rashes/infections that failed to be resolved by topical therapies and one must be of appropriate weight based on their height. (within 20% of their ideal body weight) Fulfilling these criteria is what constitutes ‘medically necessary’ and such information must be submitted to the insurance company for them to pass judgment on whether it is covered or not.

Even if determined medically necessary, insurance will only cover the front half of the trunk (abdominal panniculectomy) and to the back half or the full body lift.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am 38 years old and have horrible bags under my eyes despite good sleep and a healthy diet. Can you tell me what the best option would be to get rid of them and down time for the surgery?

A: Despite the fact that you are relatively young, your lower eyelids are a contradiction to your age. They show herniated infraorbital fat pads and some excessive skin. Because your pictures show you smiling (which always makes everyone’s lower eyelids have a lot of wrinkles) I can not fully appreciate how much skin laxity is there or to what degree you may have tear troughs present. Thus it is not a question of whether you would benefit by lower blepharoplasties but what type of lower blepharoplasty. Would it be a fat sparing and transpositional one or should the protruding infraorbital fat merely be excised with the skin tightening? I would need to see a picture of you not smiling to make that determination. Regardless of the type of lower blepharoplasty, the recovery is the same. There will be some swelling and bruising and it will take about 10 days or so to become very presentable in public again. It is not painful nor physically limiting just visibly noticeable for this period of time after surgery.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had an operation on my lips in order to have bigger ones. I had the operation about six months ago. I did not like the result of the operation and two months later I had a second operation. I had scar and asymmetric shape so I did not like the result again. I am regretting my decision for surgery and am missing my previous lips. My problems are the philtrum height is very short, my teeth does not appear because of mucosa and the lips have been stretched too much. I hope you can help in this regard.  I am very unhappy indeed. I want you to remedy this situation soon. I really miss my old thin lips. I have attached some pictures of my lips before and after the procedures.

A: Thank you for sending your lip pictures. You did not say what procedure was done but it appears to have been a lip or vermilion advancement on the upper and lower lips. Unfortunately there is no turning back, so to speak, when it comes to a lip advancement. Once the skin is removed to do the procedure, it can not be replaced later. In essence, you can not reverse a lip advancement procedure. There is no operation to return your lips to their once thinner appearance. The only potential improvement that I can envision is lip edge mucosal resection to achieve a bit of an inner lip roll in and expose more of the teeth.

Your case illustrates why it is always best ti be conservative in a lip advancement. You can always do more but can never do less.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I honestly need an abdominal panniculectomy and need a price. I do have Medicare and Medicaid. I live in Indiana. How much do they cover and how much would it cost out of pocket. I get rashes and yeast infections because of it. It hangs down to lower pelvic area.

A: There are two options to consider regarding an abdominal panniculectomy. It can be done through my private practice on a self pay basis as an outpatient procedure. This is the most efficient method to have the procedure performed, as surgery could be done in a matter of weeks at an outpatient facility. All follow up care is done at one of my private offices. The other route is to use Medicare for the procedure. Medicare is primary over Medicaid so it needs to be approved through Medicare. This would need to be done at my downtown Indianapolis office, where you would be evaluated, photographs would be taken and medical records obtained to document the time and number of treatments done to treat the skin infections. To qualify for Medicare coverage the abdominal pannus must be of a certain size (hanging down onto the thighs), rashes must be present underneath it and there must have been a course of at least 3 months of care provided for the skin infections/rash from your doctor. It would take a few months to determine if you qualify.

I would need to see some pictures of your abdominal pannus to determine if Medicare is even an option and I also need some information about your general medical history.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, How feasible would it be for a healthy 70-year-old female to undergo a “turkey neck, jowl, eyelid” lift?  I’m on Medicare and a fixed income. 

A: Feasibility for any type of facial rejuvenation procedure(s) (such as a lower facelift and eyelid lifts) is determined by two factors. First, age is really an irrevelant issue as long as one has good health. There are many 70 year old and older patients that very successfully undergo these procedures without any problems. The oldest patient I have ever done for a facial procedure (necklift) was a 92 year-old man! So as long as you are healthy and have laboratory studies which are normal, your age is not a limiting factor for the surgery. Secondly, there is the affordability of the procedure. These are plastic surgery operations not covered by Medicare. As such, they must be paid for as an out of pocket expense up front before the surgery. These costs would be affected by what type of lower necklift and how many eyelids are being done. For most patients at any age, the cost of the surgery is usually the determining factor of feasibility. I would need to see some pictures of your face to determine what the feasibility numbers would be for you.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, Two years ago I got lateral supraorbital rim implants made of Medpor.There is only one design of supraorbital rim implants available from this company (Porex/Stryker). They were placed through the upper lid crease. About 4 weeks after surgery the implant on the left side got infected. The pus was drained through a small incision in the lid crease, the wound has been daily cleansed and I have been on Rifampicin and Ciprofloxacin for two months. Because of the incision for the draining, about 2 mm oft the implant surface became visible, but the hole closed soon after the infection subsided. Although since then I have never got any symptoms of infection like swelling, discharge, pus, warming or pain, there is still a quite visible red patch where the pus had been drained. This patch is 7 mm long and 3 mm broad and very adherent to the underlying implant surface… that means it doesn´t move with the upper eyelid. Fortunately it is no problem to close my eyelids. From time to time a thick layer of keratin forms on this patch. Do you think this could still be some kind of infection or could this be a chronic inflammation due to the mechanical friction? What would you advise me to do?

A: What you have is a healed sinus or fistula tract and the local sequelae when that occurs in thin tissue. When the implant was infected, the accumulated pus had to go somewhere and it usually goes to the path of least resistance. (along the incision line) This draining tract was a ‘hole’ in the tissues that, once the infection was resolved, collapsed and healed with scar tissue. This scar tissue is thinner and less stable than the normal eyelid tissues. This is why it is adherent, red and undergoes intermittent effort sat re-epithelization. (thick keratin patch)In short, this is not normal skin.

If this is bothersome what I would do is excise the scar, place a small fat graft underneath (to fill in the missing tissue and prevent recontracture of the skin down to the implant) and close the skin over it. This is a scar contracture issue not a chronic implant infection.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am scheduled to have a sliding genioplasty next month and I just wanted to clarify some things. Is there some sort of guarantee I get that this procedure it would improve or completelyy resolve my sleep apnea? Otherwise I don’t see any other benefit other than the profile improvement which would not be worth the surgery risk.

A: The simple general answer to your question is no. There are no guarantees in plastic surgery of any specific outcome. Any surgery is an educated guess that doing a certain maneuver will cause a specific effect. In some surgeries, experience may show that a certain outcome is very likely if not highly predictable. In other types of plastic surgery, the outcomes are less predictable and may, in some cases, be more hopeful than completely predictable.

When it comes to a sliding genioplasty, both sides of these potential outcomes are seen. It is a predictable fact that moving the chin bone forward will change one’s profile and give a stronger chin appearance. Once can debate whether the chin changes net a patient’s expectation but there is no debating that the chin position will change. When performing a sliding genioplasty to help improve sleep apnea, the results are less assured. In theory, when moving the chin forward the tongue is likewise brought forward somewhat due to the attachment genioglossus muscle between the tongue and the back of the chin bone. This is actually the basis of the historic genioglossus advancement procedure done for sleep apnea when a sliding genioplasty is not being performed. To be successful for sleep apnea improvement, the sliding genioplasty movement must usually be significant (greater than 10mms) and one should have a very short or horizontally deficient chin. (indicating there may be posterior tongue prolapse)  Often a lateral cephalometric x-rays will show the position of the base of the tongue to the posterior pharyngeal wall with a narrow airway space. But because the sliding genioplasty moves the front position of the tongue more forward than the back (closer to the point of pull), the amount of chin bone movement does not translate in a 1:1 ratio to what occurs further back at the base of the tongue and the posterior airway opening. This is the anatomic variable in whether a sliding genioplasty will help improve sleep apnea symptoms.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in a chin reduction. have always had a unique chin with over-protruding bone, an excessive soft tissue pad and deep labiomental crease. It almost looks like I have a bottle cap lodged onto my chin. I am very curious as to what you feel would the best approach here. I have had a couple consults with other docs who have suggested a sliding genioplasty and was even shown some pictures of expected results, which I loved, but I am worried about a sagging chin pad after the procedure as they confirmed that they would not do anything to the soft tissue. So I am pessimistic of the accuracy of the pictures they offered. I would definitely prefer an intraoral approach if possible, though I know this could be a complicated procedure that could benefit from an approach via under the chin. Your thoughts?

A: Chin reduction is a much different procedure than chin augmentation due to soft tissue consierations. From a chin reduction standpoint, I would agree that the accuracy of those imaging results is suspect. There is no doubt that the bony chin can be moved back that far, but the question and issue that has to be dealt with in every chin reduction is where is the ‘excess’ soft tissue going to go. With a setback sliding genioplasty, it is not sagging of the chin pad that is the concern as the chin pad soft tissues are not overly detached. It is the tissue under the chin, the submental area, that often can become bunchy or redundant. As the chin moves back, the skin under the neck can bunch up. This is why a submental approach to chin reduction is usually more successful as it deals with the soft tissue redundancies. But I can certainly understand why one would want to try and avoid a submental scar. The good news is that you are fairly thin with no substantive subcutaneous fat so perhaps the soft tissue redundancy concern may be overstated. Therefore one could undergo a setback genioplasty with the understanding that the sub mental tissue issue is unpredictable and may have to be dealt with secondarily if it is an issue. It just depends on how one wants to ‘gamble’…risk a scar revision with the sub mental approach or risk the potential need for a secondary submental tuck up with the sliding genioplasty setback.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am seeking a revision rhinoplasty. I had an open rhinoplasty about five years ago and I am unhappy with the results. It was a very conservative rhinoplasty little to no changes were noticed. Even my friends and family see no difference. I would love to have the tip refined (made thinner and lifted, if possible), a possible reduction of nostrils and even some bony adjustments.

A: In regards to a revision rhinoplasty, the first question is always what was done in the original procedure. That is not something you would ever know but if you could get a copy of your original operative note from your surgeon that information is always helpful. It is instructive to know from where you started and what was done to know what may be more beneficial in the next procedure. A revision rhinoplasty usually has to do things differently than the first time if a different result is to be expected.

Otherwise, although not uncommon, one just has to await what surprises one may find in there during the revision. (where grafts done?, where was the cartilage harvested? etc)  But in just looking at your photographs, I see room for improvement from the tip standpoint and in nostril narrowing. It is always easier to make a thinner tip when it is being lifted as opposed to being deprojected in thicker male nose skin.

Dr. Barry Eppley

Indianaolis, Indiana

Q: Dr. Eppley, I have facial tics from Tourette’s syndrome. The facial signs that I have are that I blink frequently and occasionally will wrinkle my nose. I have researched Botox for facial tics and would like to know what you’re experience is with this. I can get past the social awkwardness the tics cause at times, but there are flare ups and I would like to stop them. I do not like the long term side effects of medication so I’m looking at this option.

A: Botox can be effective for facial tics as facial tics come from the muscles of facial expression. However, Botox injections for facial tics are done somewhat differently than when it is used to treated overactive muscles from undesired facial expressions and the wrinkles and folds that result.

The location of the facial tics must be precisely located and a superb understanding of the facial musculature is needed. However, many patients with facial tics can not always reproduce them in the office and a description alone is not sufficient for accurate muscular placement. What I like patients to do is to take pictures, or even better a video, of their facial tics in action and bring it into the office. That is the best way to see where the injections should be placed.

Unlike cosmetic use of Botox, injecting for facial tics is a fine balance in getting just the right amount of Botox to control the tic but not causing too much surrounding facial weakness. There is always a trial and error period to find the exact injection location and the right number of units (dose) for the facial tic problem. It is always best to start conservatively with a few injection locations and a small number of units in the first treatment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, you have written that the collagen stimulated by the Sculptra injections disappears once the Sculptra crystals are all gone. Since the effects of Sculptra last on average 2 years, your implication is that the crystals remain on the face for up to 2 years. However, in almost every piece of literature/opinions, I have read that the actual Sculptra dissolves entirely within a few months, leaving behind new collagen. If this is true, then logically this collagen would dissipate no quicker than regular (non-Sculptra stimulated) collagen. Is what I have read incorrect? Are you saying that Sculptra stimulated collagen dissipates faster than our natural collagen? I hope that your theory is correct because I received 2 treatments 2 years ago. I am 26 and underweight and my face is fuller than ever. It’s very upsetting to me. I’m hoping that it’s true that there are still crystals inside my face and that’s why it’s still overstuffed.

A: Any discussion I have ever had on Sculptra is based on the known chemistry of its poly-lactic acid (PLA) particles…which are the crystals to which we both refer. PLA is a very slowly resorbing polymer that often can take up to a year or longer. Most commonly they persist for 9 to 15 months based on the variable resorption patterns amongst different patients although particle resorption may take longer than that in some individuals. The effect of Sculptra comes from the laying down of scar (collagen) around the particles. As the particles are eventually resorbed, the collagen produced will eventually go away as well in most patients. This collagen resorption follows by months after the particles are resorbed. It may also be possible in a few patients that the collagen scar effect may not dissipate although this is very uncommon.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant placed three months ago and I think it is a fine result. However, I would like to make just a few changes to the size and shape of the chin implant portion. Can this be done? Is it a complicated surgery? Recovery time? Can these modifications be made to the original implants or do you believe we need to design a new chin/jaw implant? Thank you and I appreciate all your help.

A: Even with perfect placement and an uncomplicated surgery and recovery, I find that it is not rare that patient’s want to change slightly or modify their custom jawline implant. The good news is that this is a very simple surgery and so much easier than the first time. With an established pocket it is very easy to remove and replace it with very little swelling and no pain. If the initial recovery was a 10, this one will be a 1 or 2. The key question is how to change the implant. It is choice between using the existing one and simply carving it down in the selected areas or making a new one with the new dimensions. Each way has its own advantages and disadvantages being hand carving down the existing one eliminates any new implant cost but requires a good artistic eye to do the changes and keep it smooth. A new implant absolutely ensures smoothness and the exact changes in the right location but incurs the cost of the implant. The difference in the two options is that of the implant cost only.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have severe breast sagging/ptosis I believe. I would like a breast reduction or lift without implants if possible. I have udnergone a 150lb weight loss which has ruined my breasts! I’m 33 years old with 90 year old bags for breasts. They are heavy,ugly sagging breasts. I currently weigh 220lbs with a weight goal of 180lbs. I have read that some surgeons will not preform the surgery on someone with a certain weight or BMI, so I’m working on dropping further weight. I obviously need other areas worked on but right now my breasts bother me the most. Do I qualify for the Lollipop procedure or the one that follows after that? Have you worked on breast this large or severe? Can you help me?

A: There is no question that you have extreme breast sagging and near total breast involution. (loss of breast tissue) Breast sagging or ptosis is classified by where the nipple sits relative to the lower breast fold. When the nipple and the breast mound hangs way below the lower breast fold that is known as a Type 4 breast sagging. (on a scale of 1 to 4) Given how your breast sags I would have to classify yours as a Type 5 sagging which is off the scale!

I have seen breasts just like yours and successfully operated on them. The question that relates to your breast surgery is what type of reduction/lift is needed and the timing of the surgery as it relates to your weight. Understand that every breast reduction incorporates a breast lift. (although not every breast lift is a breast reduction) Your breast lift is way beyond that of the lollipop lift, rather you will end up with a anchor scar pattern due to extreme amount of lifting needed and the amount of breast skin removal. Another consideration would be a partial breast amputation and free nipple grafting technique. This will get you the greatest amount of lift and reduction although your young age and the desire to maintain some volume probably precludes against this more simplest approach. If you were a smoker thisn would have to be the technique of choice. As it relates to your weight, you should be within 25 lbs or less of your weight loss goal to have the procedure.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in having a lip scar revision for my daughter. But I have a couple of questions,. I am really worried about administering anesthesia to her.  Is it safe to do on a child who weighs just 35 pounds?  Since this is a common type of lip scar revision, do you perform this type of scar revision frequently and on children?  Is it better to have the revision now or in a few years after her mouth grows more or when her permanent tooth comes in?  Will it create more internal scar tissue? When I put my fingers in her mouth to massage her scar, I can feel the lump, but sometimes it feels soft.  I try to keep her lips moisturized with aloe and creams.  Also would the revision take place inside her mouth or reopen her scar just above her lip and on her lip? Is it worth putting Claire through this at all?  I really do not want to see any scar or lump if she has this done.

A: In answer to your questions:

1) It is impossible to operative on a child’s face (or body for that matter) without them being under anesthesia. To get a good result, they must be perfectly still to work on them. This is never possible on their face until closer to age 12 if not older.

2) Lip scar revisions are vert common in my plastic surgery practice. As part of the Riley Hospital for Children Cleft-Craniofacial team, I have performed many hundreds of cleft lip repairs and revisions as well as traumatic lip laceration injuries.

3) This is an elective scar revision in which the timing is solely based on when you as the parent think it is appropriate or when she, as teenager, deems it a problem. Age or the state of tooth eruption makes no difference in the timing of the lip revision.

4) No topical therapy is going to alter the scar or help make it better. The firmness of the scar can only be altered by scar maturation which requires time which is several years in children.

5) The scar revision would consist of a vertical elliptical excision staying within the confines of the lip.

6) While no scar revision surgery can guarantee any specific result, it is fair to say with your daughter’s scar that substantial improvement will be seen. Whether it will be perfect with no signs of scar at all is impossible to guarantee and maybe even ti expect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, would the following make me a favorable candidate for migraine surgery? I have a history of chronic migraines for over 15 years. It is well controlled for the past 5 years with Botox injections in four areas (forehead, above ears, back of head, and around eyes) and manual therapy. I have noted a reduction in the effectiveness of Botox injections in the last 18 months.

A: On the surface, a positive response to Botox suggests that migraine surgery can be effective. However it is important to know exactly where the Botox was injected and whether those sites corroborate with the exact anatomic sites of peripheral nerve compression. Where in the forehead and the back of the head exactly? The above the ear and around the eyes are not sites where nerve compression can occur so these may be completely incidental to whatever improvement you may have been seeing to the forehead and back of the head injection sites. (if in fact they were near the course of the nerves) These injections sites sound suspiciously like a very typical ‘wrap around’ the head injection pattern that I have seen done many times by neurologists. Such a random approach is not necessarily indicative that migraine surgery would be effective.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about lip scar revision for my child. She suffered a fall a year ago and had a laceration of the upper lip. It went on to heal  but has done so with a noticeable bump on the lip. I would like an opinion if this could be fixed or do more harm than good if it got fixed..or create more internal scar tissue. Thank you.

A: The upper lip scar that your child has is extremely classic for lip lacerations through the vermilion. They often heal with a redundancy of vermilion scar that appears as a lump along the lip line. Such lip scars commonly undergo scar revision by a vertical elliptical excision of the scar and a smoothing out of the lip line. There is no question improvement can be obtained without the risk of doing more harm than good.

While a teenager or an adult would have a lip scar revision done in the office under local, that is not going to work in a five year-old. This would have to be done under anesthesia for patient comfort and anxiety as well as to obtain the best scar revision result and vermilion alignment.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am extremely concerned about sagging after cheekbone reduction surgery. The doctor reduced a large amount of my zygoma, about 6 to 8mms. Would this increase my chance of cheek sagging? I had previous buccal fat and facial liposuction. I am worried that I have a higher chance of sagging now. Also, I am 3 weeks after surgery. There is still quite a bit of swelling in my cheeks although a lot of the swelling has gone down. Could you give some rough guidelines as to when the swelling subsides? E.g,  2 to 3 weeks major swelling, 2 months 80% swelling goes down etc.? I greatly appreciate your input. Many thanks!

A: The proper time to asssess the result after any type of facial skeletal surgery, such as cheekbone reduction, is three months. My general guidelines is that 50% of the swelling goes down in 10 days, 70% by 3 weeks, 80% to 90% by 6 weeks and 100% by three months after surgery. Reducing your zygoma width by 6 to 8mms has a high chance of having some cheek sagging afterwards. Done bilaterally that is removing a lot of the cheek tissue support for the middle of the face. But time will tell. No one can say now whether it will or won’t.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in jaw angle implants. I’v attached some photos of my face. As you can see my jawline narrows inward as it comes down from my cheekbones. With that being said, I do not want the big, thick, extra wide looking jawline. I would like slight width and definition. I would ideally want more of a masculine, defined, bony look with hollowness between the corner of my lips to my cheekbones, kind of like a male model. I don’t want a big change, I would rather have a more inconspicuous outcome. I do understand; however, that there will be a difference in my look. From what I have seen online, the normal outcome is a thicker/ widened look. I don’t necessarily want that. I have attached images of Tom Cruise and a photo of Johnny Depp to show you examples of my desired outcome.

A: Jaw angle implants can produce a variety of jawline changes based on the style and size of the implant but the facial shape and tissue composition also has a major influence on the outcome. While many men do not have the facial shape to come close to those jawline goals, you actually do because you do not have a lot of subcutaneous fat. You have to have a pretty thin face to pull that off.  So while I think you can achieve it, it is not going to be able to be done with any of the standard shaped jaw angle implants. You need a special shaped jaw angle implant that just sits on the back half of the jaw angle and has a significant lateral flare to it that is concave as it flares out. This way it gives no thickness to the jawline and only adds the angle accent. That could be done by either a semi-custom or custom implant approach. A semi-custom approach is where standard jaw angle implants are hard carved before surgery to create the desired shape. A custom approach is where the jaw angle implants are computer-designed off of the patient’s 3D CT scan.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in migraine surgery. I have been suffering from disabling, chronic migraines since 1991. However, I have been suffering from migraines daily since 2011. My neurologist prescribed different types of medicines, but nothing helped. The neurologist also performed several tests including MRIs and CTs but could not find the cause of my migraines. In 2012, I began seeing a headache specialist but that too was unsuccessful. In 2013, I began seeing an acupuncturist/chiropractor. This helped very little in that I still suffer from migraines daily and the pain is even worse during my menstrual cycles. I can no longer depend on pharmaceutical short term fixes that do not and the harm it has done on my body. I’ll try to explain the location of my migraines the best I can. I usually feel my migraines right underneath my eyebrows and between them. During a migraine, I press whatever tissue that is inside my eye sockets (the area closest to the middle of my eyebrows). Doing this can take pressure off but only while I continue to press. Also I can feel a difference in the amount of swelling in the tissues of that area when my migraines are at a ten plus. There are also some rare times when my migraines are in the temple location. I hope I explained in a way that was not confusing to you.

A: Your migraine history/story is fairly classic from my perspective as patients often seek surgery as the last measure. The place to start is to define a patient’s migraines by location…where do they start and spread to. What makes some migraines improveable by surgery is if they come from a point of peripheral nerve compression. Your description sounds similar to what migraine patient’s experience when they have peripheral nerve compression of the supraorbital/supratrochlear nerves as their trigger point. This strongly suggests that migraine surgery consisting of nerve release/decompression through an open hairline approach could be effective for migraine relief.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I had a custom jawline implant (done by Implantech) placed last year, but there are some areas that haven’t been addressed adequately. Assuming that the design file is still available, can I just check if it would be possible to modify the previous implant design? Also, would it end up costing as much as getting a brand new custom implant made, or will the cost of modification be lower?

Additionally, I’m looking to get my philtrum augmented. Would any existing implant work (Peri-pyriform?), or should I consider fat grafting?

A: This is not the first time I have had a patient inquiry about changing a custom jawline implant to a new or tweaked design. I can assure you that your original design file is still available and the previous jawline implant design can be modified. There is some reduction in a new implant design cost fee which is about 15% from the original pricing. (as per the manufacturer) The other good news is that replacing an existing jawline implant with a new one is substantially easier than the first time with a very quick recovery.

I believe when you refer to philtral augmentation, you mean paranasal/upper lip augmentation. That is what is illustrated in the link you have provided. True philtral augmentation is philtral column augmentation done by placing cartilage grafts or small implants in the philtral columns of the upper lip right under the skin to give enhanced ridge lines. There are advantages and disadvantages to either injected fat or placing implants along the nasal base. (paranasal-premaxillary region) In general, implants are going to give a more assured and permanent augmentation effect.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am interested in forehead augmentation as well as temporal and back of the head augmentation. I like the way I look when I have hair, but sadly my hairline has began to recede. My forehead slopes back and I feel my head lacks the mass to balance my face (forehead and all) out. I’m interested both widening my temporal region (starting at about the ear back) with custom formed implants AND correcting relatively flat back. Can one incision be used for all three adjustments (left and right temporal and the back of the head)? And if so how large of incision would be needed and where would it be located? 

A: I commonly have performed combined forehead augmentation and occipital augmentation. Dual access to both the back of the head, temporal and forehead regions can be done through a single scalp incision. It is known as a coronal scalp incision and runs across the top of the head from ear to ear. It effectively allows a ‘clamshell’ approach to be taken to skull rehabbing surgery and provides a 360 degree access and view of the entire head above the eye and ears. While it sounds and looks dramatic, it heals very well and quickly When looking at the patient the very next day when the dressing comes off, it is hard to image that type of surgical exposure that was done just the day previously. Patients also have a surprisingly minimal amount of discomfort afterward.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am wondering if I am a candidate for custom chin implant as I want both vertical and lateral projection (as opposed to simply lateral with most implants) Also if I decided to go ahead with a large chin implant would jaw angle implants be needed to add balance?

A: There is now available a type of chin implant that produces a combined vertical and horizontal lengthening to the chin so a custom chin implant may not absolutely be needed. This is a new type of chin implant that provides a vertical length increase to the chin that has never before been part of any chin implant. What size of vertical lengthening chin implant you would need depends on how much of a chin change you were looking for. The largest vertical lengthening chin implant creates a 7mm horizontal advancement with a 7mm vertical lengthening effect, creating a 45 degree angulation to the chin.

If you lengthen the chin to any degree, I would suspect that jaw angle implants would be needed to balance out the new jaw length. That could be confirmed by computer imaging.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am looking for some insight as to what to do with my undereye hollows. I am 50 years old and starting to show a little hollowing under eyes.  I think the fat has shifted and there is less volume. I’m looking for ideas as to the best and least invasive way to improve it. I had a lower blepharoplasty about six years ago. I have heard conflicting views on using temporary synthetic fillers (Radiesse, Juvaderm, etc) vs. fat injections. If I did something, I would prefer permanent, rather than a touch up every 6 months or so. Perhaps you could comment on fat injections and whether its a reliable way to correct this. I do have some creepy skin underneath and would like to know about skin resurfacing, laser, etc… No knives and cutting for me. 

A: When it comes to under eye hollowing, it is an issue of volume addition. But there is no under eye filler approach that can guarantee smoothness or permanency. Fat is the only injectable option that may achieve some permanency but it has the risk of unevenness or small lumps. While they would likely not be seen, they may be felt. It is just the nature of a filler that does not have linear flow coming out of the end of the injection cannula. If you particulate the fat into a liquid that will have linear flow, then there will likely be 100% absorption of the injectate.

The best approach to undereye skin tightening is fractional laser resurfacing which can be done in the office under topical anesthesia. Because of the very thin skin of the lower eyelid, one has to be careful to be too aggressive to avoid a burn injury. Thus it may require more than one fractional laser treatment to get the best result.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I have a very deep labiomental fold that I seek improved.  That is what I am seeking your opinion about. What labiomental fold reduction procedure do you recommend? If so do you believe this procedure would bring long term improvement for me. Also, have you successfully performed this procedure in the past?  Your credentials speak for themselves and I value and will follow your lead.

A: Even though it is a small area, labiomental fold  reduction is challenging. Having tried synthetic fillers, injectable fat and Gore-tex, silicone and allogeneic dermal implants for the severely inverted V shaped labiomental fold, they simply can not lift the retracted skin edges. Internally the labiomental fold sits over the lower lip vestibule so it is not a bone influenced soft tissue structure of the upper chin. It requires release by making an incision along the depth of the crease (there is a skin fold there anyway), undermining and lifting up the skin edges, placing a dermal-fat graft and then closing the skin edges over it. A dermal-fat graft will completely survive and provide a permanent solution to the inverted labiomental fold.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am currently 21 years old, and wear around a size 36 H.  I am 5’1 and weight roughly around 210 pounds. The women in both sides of my family have large breasts. Both my aunt and my mother had breast reduction surgery. I do have discomfort while sitting which has caused me to have really bad posture. The bad posture has caused a pretty decent size hump on my lower neck/back. Would I be a good candidate for a breast reduction?

A: By your description I could not imagine a better candidate for breast reduction surgery. Your musculoskeletal symptoms and posture indicate that your breasts are too heavy and hung too low for your body frame to support it. You have already seen the benefits (and the scars) from breast reduction in your relatives so you are well aware of both the benefits and the trade-offs of the procedure. You age is not a limiting factor for having the surgery. While you are overweight for your height, that is also not an excluding factor in having successful breast reduction surgery. Weight loss will most likely make your breasts smaller but will not correct the sag which is often as much a culprit as their weight.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, I am inquiring about how to get rid of some injectable filler I had placed. I had two rounds of Sulptra to my cheeks and upper face last year that produced a subtle but pleasant change. I then went in a third time for lines around my mouth and was injected with a 1/2 vial of Sculptra into my lower cheeks and in front of my ears. The creation of volume started at just three weeks and has continued into this 6th week. I just wanted a couple lines filled near my mouth and specifically told her no more volume, but I realize there was either a miscommunication or she hasn’t had someone react so strongly on the 3rd vial. I know that most doctors say that Sculptra is irreversible and I might just have to wait two years, but a few others have suggested collagenase, 5FU and Kenalog injections to reduce it. One even suggested Ulthera therapy. I’m confused, but if there is something I can safely try, I really don’t want to go two years waiting for it to wear off.

A: The effects of Sculptra are magnified each time you use it as the body is reacting to the polymer crystals that are being implanted. So much like an immune response, each exposure to it (as well as the volume placed) can create an even more profound effect. Its effects are created by the scar/collagen reaction to the implanted material. The volume effect goes away when the polymer crystals finally dissolve and the scar tissue created by them eventually wears off…a period of between 18 and 24 months. In very rare cases, the volume effect does not go away.

Since it is very likely that time will solve the problem, you don’t want to do anything that may have its own adverse effects. For this reason, injectable steroids (Kenalog) would be excluded no matter how dilute. Collagenase is an option but is a small percentage of patients they can develop a reaction to the enzyme. 5FU has really known side effects although it is less effective than either steroids or collagenase. External skin tightening therapies such as Ulthera or Exilis can have some facial slimming effects because of the radiofrequency heat they produce which could cause the reactive subcutaneous scar tissue to dissipate. They are well known to cause fat absorption at high energies or repeated treatments.

The safest options in my opinion would be 5FU injections combined with Exilis. It may require more one treatment but conservative improvement with no downsides would be a prudent approach.

Dr. Barry Eppley

Indianapolis, Indiana

Q: Dr. Eppley, If I had you take out my chin implant, would I get my original chin back, or will it look somewhat deformed from all the carving you have to do and all the ingrown tissue that has been produced since it was put it one year ago.

A: What happens to the chin with chin implant removal depends on numerous factors. What is the size of the implant, what is the composition of the implant (silicone vs Medpor) how long has it been in place, and what is the nature of the soft tissue pad sitting on top of it. By far the most important of these issues is the size of the implant and the material. Small sized chin implants composed of silicone material are the most likely to have a chin return to its original shape. Large implants, particularly those composed of Medpor which are more ‘destructive’ to remove, are less likely to have the chin return to its original shape. Usually it is not a bone change issue, but the stretch of the overlying soft tissues that poses the potential issue. In many cases managing the soft tissue by tightening or suspension helps solve any soft tissue deformity that may have been caused by the implant.

Dr. Barry Eppley

Indianapolis, Indiana